Every finding on record at Home Sweet Home Health Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: January 28, 29, 30, February 2, and 3, 2026 Active Census: 40 At this Emergency Preparedness survey, Home Sweet Home Health Care was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: January 28, 29, 30, February 2, and 3, 2026 12-Month Unduplicated Skilled Admissions: 8 Partially Extended on 01/29/2026 at 2:15 PM Abbreviations: CM Clinical Manager HHA Home Health Aide RN Registered Nurse SOC Start of Care QR 2/9/26 A2

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observations, record review, and interview, the agency failed to ensure patients were provided with the hours of operation to place a complaint with the department of health for 3 of 4 home visit observations (Patients # 1, 2, and 4). 410 IAC 17-12-3(b)(2)(C) 1. A review of the agency patient admission handbook failed to evidence the hours of operation for the Indiana Department of Health. Page 1 of the handbook included the “State Hotline” phone number but did not include the hours of operation. 2. A review of the “Patient Rights and Responsibilities” section of the handbook included the patient right, “To be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies ….” Further in the handbook patient rights and responsibilities the handbook included “Complaints, you have the right: … 3. To be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies. The State Hotline number is 1-800-246-8909 and the days/ hours of operation are [no information listed].” 3. During a home visit observation on 01/29/2026 beginning at 09:30 AM with Patient #1, the review of the home health agency binder in Patient #1’s home failed to include hours of operation for the state home health complaint hotline. During the home visit, RN 3 was unable to locate the information about the state department of health’s hours of operation in the handbook. 4. During a home visit observation on 01/29/2026 beginning at 10:30 AM with Patient #2, the review of the home health agency binder in Patient #2’s home failed to include hours of operation for the state home health complaint hotline. 5. During a home visit observation on 01/30/2026 beginning at 06:00 AM with Patient #4, the review of the home health agency binder in Patient #4’s home failed to include hours of operation for the state home health complaint hotline. 6. During an interview on 01/29/2026 at 02:20 PM, the Alternate Clinical Manager indicated the hours of operation for the state department of health were not included in the patient handbook and she did not know the hours of operation for the state department of health.

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 observation, record review, and interview, the home health agency failed to ensure medications were accurately assessed for 1 of 2 unskilled home visit observation patients (Patient #3). Findings include: 1. Review of the undated Medication Reconciliation policy indicated “… At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client prior to admission. This will include all over the counter, prescribed, and PRN [as needed] medications. Documentation of these medications will be listed on the Medication Profile and include name, dose, route of administration and frequency. The home care nurse should also review ALL medications in the home and identify duplications, expired medications, like medications with different names… By asking the client to bring you the bottles of all prescription and non-prescription medicines they take, you are initiating the process of getting the most accurate list… If the client continues to receive home care after the first 60 days, the clinician doing the reassessment will again review all medications client is taking, update the records… Medication reconciliation will be completed at all Starts of Care, Recertifications, Resumptions and at discharge… Medications will be reviewed with the client on each home visit to determine if other prescription or non-prescription drugs are being taken…” 2. A home visit observation was conducted on 01/30/26 at 9:00 AM to observe HHA 2, who was also the Patient’s family member and primary caregiver, perform care for Patient #3. Observed Ramelteon (a prescription sleep medication) 8 milligram tablets, Trazodone (a prescription medication used as an antidepressant or sleep aid) 25 milligram tablets, and Topiramate (a prescription medication used primarily to treat epilepsy) 25 milligram tablets in the home. During an interview on 01/30/26 at 9:56 AM, HHA 2 relayed Patient #3 had been taking half of a Ramelteon 8 milligram tablet at bedtime for about one year, a 50 milligram tablet of Trazodone at bedtime for about a year and a half, and one and a half Topiramate 25 milligrams tablets three times per day. 3. Review of Patient #3’s medication profile provided by the home health agency on 01/29/26 failed to include Ramelteon, Trazodone, or Topiramate which Patient #3 was taking. The medication profile included Allegra Allergy Children’s Oral (an over-the-counter allergy medication), Benadryl Allergy Children’s Oral Liquid (an over-the-counter allergy medication) as needed for allergies, Cortef Oral Tablet (a prescription corticosteroid used to treat a variety of conditions), Clobazam Oral Suspension (a prescription medication used to treat seizures), Detrol Oral Tablet (a prescription medication used to treat overactive bladder), Epidiolex Oral Solution (a prescription medication used to treat seizures), Fintepla Oral Solution (a prescription medication used as an add-on treatment for seizures), Fycompa Oral Suspension (a prescription medication used as an add-on treatment for partial-onset seizures), Hydroxyzine Hydrochloride Oral Solution (a prescription medication used to treat allergies and asthma), Levothyroxine Oral Capsule (a prescription medication used to treat low thyroid hormone levels), Motegrity Oral Tablet (a prescription medication used to treat constipation), Pregabalin Oral Solution (a prescription medication used to treat certain types of seizures), Prozac Oral Solution (a prescription medication used to treat depression and anxiety), Singulair Oral Tablet (a prescription medication used to treat asthma and allergies), Zofran Oral Solution (a prescription medication used to treat nausea and vomiting), and Zyrtec Children’s Allergy Oral Solution (an over-the-counter medication used to treat allergies), all with the route listed as oral or by mouth. The medication profile failed to indicate the medications were to be administered via gastric tube. The medication profile included Baclofen Oral Tablet (a prescription medication used to treat muscle stiffness and spasms), Cefdinir Oral Suspension (a prescription antibiotic used to treat infections in the body), Erythromycin Ethylsuccinate Oral (a prescription antibiotic used to treat infections), Melatonin Oral Liquid (a supplement used to treat trouble sleeping), and Ocuflox Ophthalmic Solution (a prescription antibiotic used to treat infections of the eye). The agency failed to remove Baclofen, Cefdinir, Erythromycin Ethylsuccinate, Melatonin, and Ocuflox from the medication profile when Patient #3 was no longer using it. The medication profile included Cortef Oral Tablet 5 milligrams with a dosage and frequency of 2.5 milligrams 2 times daily as needed for fever, illness, or surgery. Cortef Oral Tablet 5 milligrams was again listed with the dosage and frequency of 1.25 milligrams daily as needed for fever, illness, or surgery. Cortef Oral Tablet 5 milligrams was again listed with the dosage and frequency of 7.5 milligrams 3 times daily as needed for fever, illness, or surgery. The medication profile failed to include the correct dosage and frequency of 2.5 milligrams twice per day and 1.25 milligrams in the evening. The medication profile included Epidiolex Oral Solution 100 milligrams per milliliter with a dosage and frequency of 1.4 milliliters 2 times daily. The medication profile failed to include the correct dosage of 1.7 milliliters 2 times daily. The medication profile included Fintepla Oral Solution 2.2 milligrams per milliliter with a dosage and frequency of 1.4 milliliters 2 times daily. The medication profile failed to include the correct dosage of 1.7 milliliters 2 times per day. The medication profile included Levothyroxine Sodium Oral Capsule 62.5 micrograms with a dosage of 62.5 micrograms in the morning one hour before food. The medication profile failed to include the correct dosage of 75 micrograms daily one hour before food. The medication profile included Pregabalin Oral Solution 20 milligrams per milliliter with a dosage and frequency of 5 milliliters at bedtime. The medication profile failed to include the correct frequency of 5 milliliters 2 times per day. The medication list included Onfi which was a brand name for Clobazam. Clobazam was already on the medication profile with the same dosage and frequency. The medication list also included Somatropin (prescription human growth hormone) which was another name for Norditropin which was already included in the medication profile with the same dosage and frequency. The agency failed to ensure the medication list did not contain duplicate entries of the same medication. 4. During an interview on 01/30/26 at 9:56 AM, HHA 2 relayed she managed Patient #3’s medications when she was not on the clock as an HHA. HHA 2 also relayed Patient #3 took only Klonopin (a prescription medication used to treat seizures and panic disorder) by mouth, and all other medications that would normally be administered by mouth were administered via gastric tube. HHA 2 also indicated Patient #3 had not taken Baclofen since April of 2025, had not taken Cefdinir since September of 2025, had not taken Erythromycin Ethylsuccinate in about six months, had not taken Melatonin for about a year, and had not used Ocuflox since about August of 2025. HHA 2 also relayed Patient #3 had been taking Cortef at the dosage and frequency of 2.5 milligrams twice per day and 1.25 milligrams in the evening for two years. HHA 2 also relayed Patient #3 had been taking 1.7 milliliters of Epidiolex 2 times daily for about a year. HHA 2 indicated the Fintepla dosage and frequency had changed to 1.7 milliliters 2 times per day about 2 to 3 months ago. HHA 2 relayed Patient #3 had been taking 75 micrograms of Levothyroxine daily for approximately 8 months. HHA 2 indicated Patient #3 had been taking 5 milliliters of Pregabalin 2 times per day since about April of 2025. HHA 2 also relayed Onfi was the brand name for Clobazam, and Somatropin was another name for Norditropin. 5. During an interview on 01/30/26 at 3:08 PM, RN 3 relayed medications were reconciled at every recertification visit or as needed if there were changes. RN 3 indicated this would include looking at the pill bottles in the home. RN 3 indicated Patient #3 took all their pills and liquid medications through a gastric tube except for the Klonopin wafer. 6. During an interview on 02/02/2026 beginning at 4:28 PM, RN 3 indicated all the medication profile errors had been corrected after the home visit and prior to the interview, including but not limited to, those related to Baclofen, Cefdinir, Cortef, Epidiolex, Erythromycin, Fintepla, Levothyroxine, Melatonin, Onfi, Pregabalin, Somatropin/Norditropin, Ramelteon, Trazodone, and Topiramate. Findings include: 1. Review of the undated Medication Reconciliation policy indicated “… At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client prior to admission. This will include all over the counter, prescribed, and PRN [as needed] medications. Documentation of these medications will be listed on the Medication Profile and include name, dose, route of administration and frequency. The home care nurse should also review ALL medications in the home and identify duplications, expired medications, like medications with different names… By asking the client to bring you the bottles of all prescription and non-prescription medicines they take, you are initiating the process of getting the most accurate list… If the client continues to receive home care after the first 60 days, the clinician doing the reassessment will again review all medications client is taking, update the records… Medication reconciliation will be completed at all Starts of Care, Recertifications, Resumptions and at discharge… Medications will be reviewed with the client on each home visit to determine if other prescription or non-prescription drugs are being taken…” 2. A home visit observation was conducted on 01/30/26 at 9:00 AM to observe HHA 2, who was also the Patient’s family member and primary caregiver, perform care for Patient #3. Observed Ramelteon (a prescription sleep medication) 8 milligram tablets, Trazodone (a prescription medication used as an antidepressant or sleep aid) 25 milligram tablets, and Topiramate (a prescription medication used primarily to treat epilepsy) 25 milligram tablets in the home. During an interview on 01/30/26 at 9:56 AM, HHA 2 relayed Patient #3 had been taking half of a Ramelteon 8 milligram tablet at bedtime for about one year, a 50 milligram tablet of Trazodone at bedtime for about a year and a half, and one and a half Topiramate 25 milligrams tablets three times per day. 3. Review of Patient #3’s medication profile provided by the home health agency on 01/29/26 failed to include Ramelteon, Trazodone, or Topiramate which Patient #3 was taking. The medication profile included Allegra Allergy Children’s Oral (an over-the-counter allergy medication), Benadryl Allergy Children’s Oral Liquid (an over-the-counter allergy medication) as needed for allergies, Cortef Oral Tablet (a prescription corticosteroid used to treat a variety of conditions), Clobazam Oral Suspension (a prescription medication used to treat seizures), Detrol Oral Tablet (a prescription medication used to treat overactive bladder), Epidiolex Oral Solution (a prescription medication used to treat seizures), Fintepla Oral Solution (a prescription medication used as an add-on treatment for seizures), Fycompa Oral Suspension (a prescription medication used as an add-on treatment for partial-onset seizures), Hydroxyzine Hydrochloride Oral Solution (a prescription medication used to treat allergies and asthma), Levothyroxine Oral Capsule (a prescription medication used to treat low thyroid hormone levels), Motegrity Oral Tablet (a prescription medication used to treat constipation), Pregabalin Oral Solution (a prescription medication used to treat certain types of seizures), Prozac Oral Solution (a prescription medication used to treat depression and anxiety), Singulair Oral Tablet (a prescription medication used to treat asthma and allergies), Zofran Oral Solution (a prescription medication used to treat nausea and vomiting), and Zyrtec Children’s Allergy Oral Solution (an over-the-counter medication used to treat allergies), all with the route listed as oral or by mouth. The medication profile failed to indicate the medications were to be administered via gastric tube. The medication profile included Baclofen Oral Tablet (a prescription medication used to treat muscle stiffness and spasms), Cefdinir Oral Suspension (a prescription antibiotic used to treat infections in the body), Erythromycin Ethylsuccinate Oral (a prescription antibiotic used to treat infections), Melatonin Oral Liquid (a supplement used to treat trouble sleeping), and Ocuflox Ophthalmic Solution (a prescription antibiotic used to treat infections of the eye). The agency failed to remove Baclofen, Cefdinir, Erythromycin Ethylsuccinate, Melatonin, and Ocuflox from the medication profile when Patient #3 was no longer using it. The medication profile included Cortef Oral Tablet 5 milligrams with a dosage and frequency of 2.5 milligrams 2 times daily as needed for fever, illness, or surgery. Cortef Oral Tablet 5 milligrams was again listed with the dosage and frequency of 1.25 milligrams daily as needed for fever, illness, or surgery. Cortef Oral Tablet 5 milligrams was again listed with the dosage and frequency of 7.5 milligrams 3 times daily as needed for fever, illness, or surgery. The medication profile failed to include the correct dosage and frequency of 2.5 milligrams twice per day and 1.25 milligrams in the evening. The medication profile included Epidiolex Oral Solution 100 milligrams per milliliter with a dosage and frequency of 1.4 milliliters 2 times daily. The medication profile failed to include the correct dosage of 1.7 milliliters 2 times daily. The medication profile included Fintepla Oral Solution 2.2 milligrams per milliliter with a dosage and frequency of 1.4 milliliters 2 times daily. The medication profile failed to include the correct dosage of 1.7 milliliters 2 times per day. The medication profile included Levothyroxine Sodium Oral Capsule 62.5 micrograms with a dosage of 62.5 micrograms in the morning one hour before food. The medication profile failed to include the correct dosage of 75 micrograms daily one hour before food. The medication profile included Pregabalin Oral Solution 20 milligrams per milliliter with a dosage and frequency of 5 milliliters at bedtime. The medication profile failed to include the correct frequency of 5 milliliters 2 times per day. The medication list included Onfi which was a brand name for Clobazam. Clobazam was already on the medication profile with the same dosage and frequency. The medication list also included Somatropin (prescription human growth hormone) which was another name for Norditropin which was already included in the medication profile with the same dosage and frequency. The agency failed to ensure the medication list did not contain duplicate entries of the same medication. 4. During an interview on 01/30/26 at 9:56 AM, HHA 2 relayed she managed Patient #3’s medications when she was not on the clock as an HHA. HHA 2 also relayed Patient #3 took only Klonopin (a prescription medication used to treat seizures and panic disorder) by mouth, and all other medications that would normally be administered by mouth were administered via gastric tube. HHA 2 also indicated Patient #3 had not taken Baclofen since April of 2025, had not taken Cefdinir since September of 2025, had not taken Erythromycin Ethylsuccinate in about six months, had not taken Melatonin for about a year, and had not used Ocuflox since about August of 2025. HHA 2 also relayed Patient #3 had been taking Cortef at the dosage and frequency of 2.5 milligrams twice per day and 1.25 milligrams in the evening for two years. HHA 2 also relayed Patient #3 had been taking 1.7 milliliters of Epidiolex 2 times daily for about a year. HHA 2 indicated the Fintepla dosage and frequency had changed to 1.7 milliliters 2 times per day about 2 to 3 months ago. HHA 2 relayed Patient #3 had been taking 75 micrograms of Levothyroxine daily for approximately 8 months. HHA 2 indicated Patient #3 had been taking 5 milliliters of Pregabalin 2 times per day since about April of 2025. HHA 2 also relayed Onfi was the brand name for Clobazam, and Somatropin was another name for Norditropin. 5. During an interview on 01/30/26 at 3:08 PM, RN 3 relayed medications were reconciled at every recertification visit or as needed if there were changes. RN 3 indicated this would include looking at the pill bottles in the home. RN 3 indicated Patient #3 took all their pills and liquid medications through a gastric tube except for the Klonopin wafer.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all medical equipment the patient used in the home was included in the POC for 1 of 2 unskilled home observation patients (Patient #3). Findings include: 1. Review of the undated Plan of Care policy indicated “… The Plan of Care shall be completed in full to include… Need for/presence of home medical equipment and assistive devices…” 2. A home visit observation was conducted on 01/30/26 at 9:00 AM to observe HHA 2, who was also the Patient’s family member and primary caregiver, perform care for Patient #3. Observed a stander device, suction device, and oxygen concentrator. 3. Review of Patient #3’s POC failed to include a stander device, suction device, oxygen concentrator, or shower chair. 4. During the home visit observation on 01/30/26 beginning at 9:00 AM, HHA 2 relayed Patient #3 had a shower chair used to assist with showering and a stander device to assist with exercise and range of motion. HHA 2 also relayed Patient #3 had a suction device and oxygen concentrator that were used as needed while waiting for emergency services if the Patient had a bad seizure. 5. During an interview on 02/02/2026 beginning at 04:28 PM, RN 3 indicated oxygen concentrator and suction machine were added to the medical equipment list after the home visit on 01/30/2026.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to update a plan of care that was consistent with assessment findings for 1 of 1 patient with SN and HHA services who had a home visit observation (Patient #2). 1. An undated agency policy, “Client Reassessment/ Update of Comprehensive Assessment,” indicated the purpose of a comprehensive assessment was to “… modify the plan of care….” The policy further indicated the comprehensive assessment determined the “Need for continuing home care services.” 2. An undated agency policy, “Plan of Care, indicated “The Plan of Care is based on a comprehensive assessment….” 3. During a home visit observation on 01/29/2026 beginning at 10:30 AM with Patient #2, RN 4 prepared to fill Patient #2’s pill boxes for two weeks. When asked what would happen if the RN was unable to fill the pill boxes as scheduled. RN 4 indicated the patient could fill his/her pill box. When asked, Patient #2 indicated they could fill their own pill box. When asked, RN 4 indicated she filled Patient #2's pill box "for his ease. He doesn't have to remember to do it." 4. Patient #2’s clinical record included a comprehensive assessment completed on 01/01/2026 by RN 4. The assessment identified a patient strength as “… compliant with care and taking medications.” The assessment included a “Skilled Nursing Care Plan” which identified the services as “supervisory visit every 14 days and Recertification assessment every 60 days.” The assessment nursing care plan failed to include filling Patient #2’s pill boxes. 5. The assessment indicated Patient #2 did not have a “… poor understanding of the disease, management, and/or med.” The clinical summary and general notes indicated Patient #2 understood their medications and side effects. Additionally, the summary indicated Patient #2 maintained compliance with medications. During an interview on 02/03/2026 beginning at 10:09 AM, RN 4 indicated Patient #2 had nursing set up their pill boxes since SOC on 09/13/2024. During the same interview, the Alternate Clinical Supervisor indicated Patient #2 was referred to the agency for medication assistance. As no referral information was available, the SOC comprehensive assessment done on 09/13/2024 was reviewed. The management of oral medications assessment indicated Patient #2 was independent in managing oral medications. The assessment indicated Patient #2 did not require someone to set up medications for him/her. RN 4 indicated the documentation of Patient #2’s need for medication setup “could be better.”

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observations, record review, and interview, the agency failed to ensure patients were provided with the name and contact information for the Clinical Supervisor for 4 of 4 home visit observations (Patients #1, 2, 3, and 4). 5. During a home visit observation on 01/30/26 at 9:00 AM, reviewed Patient #3’s agency binder which named the Alternate Clinical Supervisor as the Clinical Supervisor. The binder in the Patient’s home failed to identify the correct person as Clinical Supervisor. 1. A review of the agency patient admission handbook evidenced the name of the Clinical Supervisor as [Alternate Clinical Supervisor]. The handbook failed to identify the correct Clinical Supervisor. 2. During a home visit observation on 01/29/2026 beginning at 09:30 AM with Patient #1, the review of the home health agency binder in Patient #1’s home identified the wrong person as the Clinical Supervisor. 3. During a home visit observation on 01/29/2026 beginning at 10:30 AM with Patient #2, the review of the home health agency binder in Patient #2’s home identified the wrong person as the Clinical Supervisor. 5. During a home visit observation on 01/30/2026 beginning at 06:00 AM with Patient #4, the review of the home health agency binder in Patient #4’s home identified the wrong person as the Clinical Supervisor. During an interview on 01/30/2026 beginning at 02:20 PM, the Alternate Clinical Supervisor indicated she was listed as the Clinical Supervisor in the patient handbook.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure HHA supervisory visits were conducted at least every 14 days for 3 of 3 active patients receiving both SN and HHA services (Patient #2, 5, 6). Findings include: 1.Review of the undated Home Health Aide (HHA) Supervisory Visit Policy indicated “… Frequency of Supervisory Visits… Skilled services present: Every 14 calendar days… Visits must be documented in the clinical record…” 2. Review of Patient #5’s clinical record included a POC for certification period 11/28/25 to 01/26/26 with orders for SN services one time per every 14 days for medication set up and HHA services 14 hours per day, 7 days per week for personal care and assistance with ADLs. The record included an HHA supervisory visit note for 12/03/25 with no further HHA supervisory visit notes until 12/31/25, 28 days later. Patient #5 received daily HHA visits between 12/03/25 and 12/31/25 except for 12/17/25, 12/18/25, and 12/19/25. The record failed to evidence HHA supervisory visits were conducted at least every 14 days. 3. Review of Patient #6’s clinical record included a POC for certification period 12/31/25 to 02/28/26 with orders for SN services one time per 14 days for medication set up and HHA services four hours per day, five days per week for personal care and ADL assistance. The record included an HHA supervisory visit note for 01/15/26 with no further HHA supervisory visit notes until 01/30/26, 15 days later. The record indicated Patient #6 received HHA visits on 01/20/26, 01/21/26, 01/22/26, 01/23/26, 01/24/26, 01/25/26, and 01/28/26. The record failed to evidence HHA supervisory visits were conducted at least every 14 days. 2. Patient #2’s clinical record included orders for SN services one time per every 14 days for medication set up and HHA services 9 hours per day for 3 days per week for personal care and assistance with ADLs. The record included an HHA supervisory visit note for 12/11/2025 with no further HHA supervisory visit notes until 01/01/2026, 21 days later. The record failed to evidence HHA supervisory visits were conducted at least every 14 days. During an interview on 02/03/2026 beginning at 10:23 AM, RN 4 indicated supervisory visits were required every 14 days. RN 4 indicated she did not do a supervisory as it would have been due on Christmas day. When asked, RN 4 indicated she did the supervisory visits to correspond with her regular visit dates and when the HHA was present. When asked, RN 4 indicated she could have done a telehealth supervisory visit or asked another RN to do the visit. During the same interview, the Alternate Clinical Supervisor indicated the supervisory visits needed to be completed with the HHA present once per month and the visit could have occurred the week before Christmas. 4. During an interview on 02/02/2026 beginning at 3:37 PM, RN 1 relayed HHA supervisory visits were conducted every 30 to 60 days. RN 1 indicated Patient #3 did receive HHA visits between 12/03/2025 and 12/31/2025 but no HHA supervisory visits were conducted between those dates. 5. During an interview on 02/03/2026 beginning at 10:09 AM, RN 4 relayed the most recent HHA supervisory visit for Patient #6 was on 01/30/2026 with the one prior being on 01/15/2026.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient's needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN performed HHA supervisory visit every 60 days for 1 of 4 active patients receiving aide only services (Patient #4). 1. An undated agency policy, “Home Health Aide (HHA) Supervisory Visit Policy” indicated supervisory visits for patients with aide-only services must occur every 60 days. 2. Patient #4’s clinical record included orders for HHA services and SN visits every 30 – 60 days for supervisory visits. The clinical record evidenced a supervisory visit 09/22/2025. A supervisory visit note indicated a visit on 11/19/2025, however, the note was incomplete as it was not signed. As of 01/29/2026, the clinical record failed to evidence a completed note for a supervisory visit since 09/22/2025. The agency failed to ensure supervisory visits were completed every 60 days for patients who received aide-only services. During an interview on 02/02/2026 beginning at 03:37 PM, RN 1 indicated supervisory visits were every 30 – 60 days. Alternate Clinical Supervisor indicated aide-only patients required supervisory visits every 60 days and that did not occur for Patient #4.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical documentation included an electronic signature and date for 1 of 4 active patients with aide-only services (Patient #4). 410 IAC 17-15-1(a)(7) 1. An undated agency policy titled “Clinical Documentation Summary” indicated “Clinical documentation must be: Accurate and complete, Timely.” 2. Patient #4’s clinical record evidenced a “Supervisory Visit Note” with a visit date of 11/19/2025. The note had an electronic date of 11/24/2025 at 03:13 PM. The note failed to evidence the electronic signature of RN 6. The Alternate Clinical Supervisor brought a copy of the visit note that now included RN 6’s electronic signature and electronic date and time of 02/03/2026 at 11:53 AM. RN 6 failed to complete and sign the document according to the policy. During an interview on 02/03/2026 beginning at 01:01 PM, the Alternate Clinical Supervisor indicated she had RN 6 sign the document on 02/03/2026. The Alternate Clinical Supervisor indicated documentation was to be completed within 5 days and the note was not completed within that timeframe.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: February 8, 9, and 10, 2023 Facility Number: 014208 Provider Number: 15K166 Unduplicated skilled: 6 During this Emergency Preparedness survey, Home Sweet Home Health Care was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR: 02/14/23, Area 2

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: February 8, 9, and 10, 2023 Unduplicated skilled admissions: 6 Census: 19 The survey was partially extended on 02/09/2023 at 2:00PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR: 02/14/23 Area 2

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 all plans of care included the psychosocial status, nutritional requirements, medications, hospitalization risk, patient and caregiver education, and information related to advanced directives for 5 of 5 active records reviewed (Patient #1, 2, 3, 4, and 5). Findings include: Review of an undated agency policy titled "Medication Reconciliation" stated, in part, "... the clinician doing the reassessment will again review all medications ... update ... the plan of care ...." Review of the record for Patient #1, start of care 1/6/2022, evidenced a recertification assessment which included a section on advance directives. In that section, the assessment identified the presence of advance directives of DNR [do not resuscitate], living will, and medical power of attorney. Review of the record for Patient #1, certification period 12/21/2022 – 2/18/2023, evidenced a plan of care which included an advance directive section. That section evidenced the statement, “No advance Directives….” During an interview on 2/10/2023 at 12:35 PM, the Administrator confirmed advance directive information was incorrect on the plan of care. Review of the record for Patient #3, start of care date 1/27/2021, certification period 1/17/2023 – 3/17/2023, evidenced a plan of care which stated, “There is no data for this section” regarding the presence or absence of advance directives. During an interview on 2/10/2023 at 12:35 PM, the Alternate Clinical Supervisor confirmed the plan of care required information on advance directives. Review of the record for Patient #5, start of care 1/11/2022, certification period 1/6/2023 -3/6/2023, evidenced a plan of care which failed to address psychosocial status and risk for hospitalization. These sections stated, “There is no data for this section.” Additionally, the plan of care identified medications, including, but not limited to, “Ativan [used for anxiety ] 0.25 mg [milligrams] at bedtime, buccal [administered in the cheek area]” and Morphine [for pain] 0.5 mg twice daily buccal.” Review of the medications from Entity A, responsible for the entire care of Patient #1, evidenced a medication list including, but not limited to, “lorazepam intensol [active ingredient in Ativan in a liquid concentrate] 2 MG/ML [milligrams per milliliter] 0.5 mg as needed every 4 hours ….” During an interview on 2/10/2023 at 12:35 PM, the Alternate Clinical Supervisor confirmed psychosocial status and hospital risk should be on the plan of care. The Administrator confirmed Entity A had the most current medication orders and that Entity A managed all medications for Patient #5. Record review of Patient #2, start of care date 10/31/2019, included a plan of care for the certification period 12/14/2022 through 02/11/2023. Patient #2 diagnoses included, but were not limited to, morbid obesity (severe) due to excess calories and type 2 diabetes. The plan of care indicated “… nutritional requirements … Regular [any food can be eaten with no restrictions] … Heart Healthy … Low Fat … No Concentrated Sweets ….” The plan of care failed to evidence the correct diet for Patient #2 and failed to evidence patient and caregiver education. Review of an agency document titled “OASIS-D1 [Outcome and Assessment Information Set is a patient-specific, standardized assessment] Recertification” signed and dated by RN #1 on 12/13/2022 indicated “… diet type … NCS/low fat/health heart ….” Review of an agency document titled “Skilled Nursing” signed and dated by RN #1 on 12/21/2022 and 02/01/2023 indicated “… diet type … NCS [no concentrated sweets]/low fat/healthy heart ….” During an interview on 02/09/2023 at 2:30PM, when asked if a regular diet includes NCS, low fat and heart healthy food, RN #1 indicated regular diet means the texture is regular. When asked where the caregiver and patient education can be found in the plan of care, the alternate clinical supervisor indicated education documentation is in the OASIS and 60-day summary but with the recent electronic medical record system update, education may not have transferred to the plan of care. Record review of Patient #4, start of care date 05/20/2021, included a plan of care for the certification period 01/10/2023 through 03/10/2023 that indicated “… psychosocial status … no data for this section … hospitalization risk … no data for this section ….” The plan of care failed to evidence documentation of patients’ psychosocial status and hospitalization risk. During an interview on 02/09/2023 at 2:30PM, when asked where the documentation for the psychosocial status and the hospitalization risk was located in the plan of care for Patient #4, the alternate clinical supervisor indicated that information did not transfer from the OASIS into the plan of care.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the registered nurse (RN) failed to ensure the home health aide (HHA) care plan included the frequency for completion of tasks for 1 of 1 records reviewed with skilled nursing and HHA services (Patient #2). Findings include: Record review of Patient #2, included an agency document titled “Care Plan for Patient #2,” signed by RN #1 and dated 12/13/22, and included the home health aide tasks, but not limited to, the activities permitted, safety precautions, and application of skin lotion which failed to evidence the frequency to provide these tasks. During an interview, on 02/10/23 at 12:35 PM, when asked, the alternate clinical supervisor indicated there were no frequencies for the home health aide tasks of activities, safety precautions, and application of skin lotion.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aide notes were included in the medical record in 1 of 5 active patients receiving home health aide services (Patient #3), with the potential to affect all home health aide patients. Findings include: Review of the record for Patient #3, start of care 1/27/2021, for the certification period 01/17/23 – 3/17/23, indicated home health aide visits were completed on 01/17, 01/18, 01/21, 01/22, 01/23, 01/24, 01/25, and 01/29/2023. The clinical record failed to include documentation of the care provided for these dates of aide services. During an interview, on 02/10/2023 at 11:17 AM, the Alternate Administrator confirmed the documentation was not in the medical record. 410 IAC 17-15-1 (a)(4)

This visit was for the federal and state investigation of 3 complaints at a home health agency Complaint Numbers: IN0031964: substantiated; with findings IN0029763: substantiated; with findings IN0029785: substantiated; with findings Survey Dates: 09/22/2021-09/24/2021 Facility Number: 014364 Provider Number: 15K166

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure all staff followed standard precautions and infection control for 1 of 1 home visits observed (#4). Review of an undated agency policy, titled “Infection Control Plan Purpose B-401” indicated “Covid-19 Control Plan … caregivers are to wear facemasks when in direct contact with their client or within 6 ft [feet] of their client ….” Review of an undated agency policy, titled “Handwashing/Hand Hygiene D-330” indicated “… indications for hand washing and hand antisepsis … between tasks on the same client …." Review of the Centers for Disease Control and Prevention (CDC) web page reference, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html, indicated “… Do wear a mask that … Covers your nose and mouth and secure it under your chin … How NOT to wear a mask … under your nose ….” A home observation visit was conducted with HHA (home health aide) G on 9/23/2021 at 9:05 AM, with patient #4. HHA G was observed wearing a cloth face mask below nose while within 6 feet of patient. HHA G was observed picking up a tube of patient’s medication and squeezing onto patient’s hand without performing hand hygiene. During an interview on 9/23/2021 at 2:30 pm, when asked if field staff (staff working with patients outside of office) are to wear face masks, clinical manager indicated face masks were required for field staff when providing personal care or within 6 feet of a patient.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure office staff followed an infection control plan for the prevention, control, and investigation of office staff infections. Review of an undated agency policy, titled “Infection Control Surveillance B-402” indicated “… outbreak surveillance-specific infections or infection clusters within multiple individuals at the same time … agency will implement a process of identifying all infections in … employee population … evaluate effectiveness of current control measures or identify an action plan to improve incidence of infections ….” Review of an undated agency policy, titled “Coronavirus (COVID-19) Office Policy” indicated “… employees are to wear facemasks when unable to socially distance at least 6ft [feet] apart from other staff … this coronavirus policy applies to all of our employees who physically work in our office ….” Upon entrance to agency office on 9/22/2021 at 9:45 AM, observed staff congregating at entrance not wearing masks. Note posted on front door of agency indicated to stop, don mask, temperature, sanitize and keep 6 feet distance. When asked receptionist if Covid screening needed to be done, receptionist did not answer. During an interview on 9/22/2021 at 10:05 AM, the administrator asked the surveyor if he/she should wear a mask. In turn, the surveyor asked the administrator what the Covid-19 protocol was for in the office staff. The administrator indicated 6-foot distancing was required and if not vaccinated, then staff had to wear a mask. During an interview on 9/23/2021 at 2:30 PM, when asked about the four staff in office who tested positive for Covid-19 on 9/3/2021, the clinical manager indicated over half the office staff were sent home and Covid-19 testing was completed on all office staff. When asked who was to complete Covid-19 screening when entering the building, the administrator indicated anyone who entered. When asked why no screening was done upon entrance to the agency office, the clinical manager indicated the receptionist was nervous and didn’t do the screening. When asked why staff, within 6 feet of each other, were not wearing masks upon entrance to the agency office, the administrator indicated masks were not needed if more than 6 feet apart.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the establishment of skills competency for home health aides (HHA) included evaluation of the home health aide skills while performing required tasks with a patient or pseudo patient for 3 of 3 home health aides whose establishment of skills competency was reviewed. (HHA G, H, and I). 1. Review of an undated agency job description, titled “Position: Home Health Aide C-140: indicated “… qualifications … successful completion of a formal certification training program and/or a written skills test and competency evaluation ….” 2. Review of an agency document dated 6/2020, titled “Competency Skills Check-Off/Assessment, indicated “… skills … lab … home ….” that included the competency skills and location for completion of the check-off. 3. Review of HHA G personnel record on 9/23/2021, evidenced a date of hire of 1/22/2021, and evidenced documentation of the completion of agency’s training and competency program with office lab and patient home check-off of required skills on 1/25/2021, signed by HHA G and the clinical manager. During an interview with HHA G on 9/23/2021 at 3:05 PM, when asked the specifics of home health aide training received at agency, HHA G indicated the training lasted 3-4 days in office. HHA G indicated they went through the motions of giving a bed bath to a person in the office lab but did not use water and used disposable wipes on a person in the lab for the sponge bath. HHA G stated they placed the molded shampoo device under a person’s head but did not use water. Additionally, they did not remember performing a shower, but did watch a video on performing shampooing of hair. When asked when they began providing care to patients, HHA G indicated within a couple days after finished training. During an interview with clinical manager on 9/23/2021 at 3:30 PM, when asked if HHA G had been observed completing the tasks on the competency check-off list, she indicated the check off location is on the second floor of office and HHA completed demonstrations on a mannequin or on a person in the office. The clinical manager was asked about all skills check-off signed as completed on 1/25/21. The clinical manager indicated staff met at the home of a private account patient and went through tasks. If all tasks couldn’t be completed on patient, the HHA would give verbal instructions on what they would do for that situation. Lastly, any tasks not done on patients would be done in office and some tasks would be talked through with the nurse. 4. Review of HHA H personnel record on 9/24/2021, evidenced a date of hire of 5/20/2021, and evidenced documentation of the completion of agency’s training and competency program with office lab check-off of required skills on 5/20/2021, signed by HHA G and clinical manager. During an interview with HHA H on 9/24/2021 at 11:50 AM, when asked the specifics of home health aide training received at agency, HHA H indicated they watched videos. When asked if they could recall demonstrating the check-off tasks, HHA H indicated they did not have to demonstrate the tasks at agency because they brought his/her client to the agency. When asked about demonstration of specific check-off tasks, HHA H indicated no one observed him/her demonstrate a bath, sponge bath, shower, shampoo, nail or skin care, oral hygiene, or toileting. During an interview with administrator, clinical manager, and office manager on 9/24/2021 at 1:00 PM, when asked if HHA H had been observed completing the tasks on the competency check-off list, the clinical manager indicated HHA H was a home health aide when hired and had experience in caring for patient he/she had brought to the agency. When the clinical manager was asked about all skills check-off signed as completed on 5/20/21 in lab, the clinical manager indicated HHA H completed check-offs in office lab on pseudo-patient. 5. Review of HHA I personnel record on 9/24/2021, evidenced a date of hire of 5/5/2021, and evidenced documentation of the completion of agency’s training and competency program with office lab and patient home check-off of required skills on 5/5/2021, signed by HHA I, RN F, and clinical manager. During an interview with HHA I on 9/24/2021 at 11:30 AM, when asked the specifics of home health aide training received at agency, HHA I indicated the first day of hire his/her training was interrupted. While watching a training video and before it was finished, was asked to go provide care to a private account patient. Met patient at YMCA (Young Men’s Christian Association. It’s an organization that provides activities for communities), who had finished physical therapy, and drove patient home and provided care. When asked about demonstration of specific check-off tasks, HHA I indicated they watched a video for handwashing, bed bath, and sponge bath, and had no training for a tub bath, shower, shampoo, nail or skin care, oral hygiene, and toileting. HHA I indicated the agency asked him/her to sign off the training paperwork but had not received training, only watched videos in office. During an interview with administrator, clinical manager, and office manager on 9/24/2021 at 12:50 PM, when asked if HHA I had been observed completing the tasks on the competency check-off list, clinical manager indicated HHA I watched a training video for bed bath, sponge bath, tub bath, shampoo, nail and skin care, oral hygiene, toileting, transfers, and range of motion. Clinical manager indicated HHA I practiced taking temperature, pulse and respirations on pseudo-patient or staff in office and was observed doing handwashing in a return demonstration. Clinical manager indicated HHA I practiced on a mannequin in the office or with a patient in their home, a bed bath, sponge bath, tub bath, shampoo, nail and skin care, toileting, transfers, and range of motion. Furthermore, the clinical manager indicated HHA I practiced oral hygiene on self or with a patient in their home. 410 IAC 17-14-1(l)(A)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the home health aide (HHA) followed the plan of care for 1 of 1 home visits observed (#4). Review of an undated agency policy, titled “Home Health Aide Care Plan C-751” indicated “… a complete and appropriate Care Plan, identifying duties to be performed by the Home Health Aide … developed by a Registered Nurse … all home health aide staff will follow the identified plan ….” Review of an undated agency job description, titled “Position: Home Health Aide C-140” indicated “… provides personal care services under the direction of the Registered Nurse ….” Clinical record review was completed on 9/22/2021 for patient #4, start of care 7/7/2020, certification period 8/31/2021-10/29/2021, with a primary diagnosis of Parkinson’s disease (central nervous system disorder that affects movement). An agency document titled “Home Health Certification and Plan of Care” dated 8/30/2021, indicated “…orders … HHA … medication reminder ….” Clinical record review evidenced an agency document titled, “Care Plan for Patient #4” dated 8/27/2021, that indicated “… HHA is NOT to touch meds ….” A home observation visit was conducted with HHA G on 9/23/2021 at 9:05 AM, with patient #4. The patient complained of hand pain. HHA G was observed picking up tube of patient’s arthritis pain gel (diclofenac sodium topical gel 1%) and squeezing onto patient’s hand. HHA G indicated had driven patient to craft store in the past. HHA failed to follow the plan of care. During an interview on 9/23/2021 at 9:30 AM, when asked what tasks related to medication administration the HHA could perform, HHA G indicated the care plan stated not to touch the patient’s medications. During an interview on 9/23/2021 at 10:45 AM, when asked if a home health aide could assist the patient with medication administration, clinical manager indicated no. When asked if home health aides were allowed to drive patients on errands, the administrator and clinical manager indicated no.