Every finding on record at Hometown Home Healthcare Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: August 15, 18, 19, 20, 21, 2025 Active Census: 29 At this Emergency Preparedness survey, Hometown Home Healthcare was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to develop and implement EP policies and procedures to address potential hazards identified in its risk assessment (see E0013), develop and implement EP policies and procedures which indicated the agency’s system of medical documentation during an emergency (see E0023), failed to develop and implement EP policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies (see E0024), develop and maintain an EP communication plan which included names and contact information of staff and patients’ physicians (see E0030), failed to develop and maintain an EP communication plan which included contact information for Federal, State, regional, and local EP staff (see E0031), failed to develop and maintain a communication plan which included a method for sharing information and medical documentation for patients under agency’s care with other health care providers (see E0033), and failed to conduct exercises to test its EP plan annually (see E0039). The cumulative effect of these systemic issues evidenced the agency failed to develop and maintain a comprehensive emergency preparedness program which included all required elements, which resulted in the agency being found out of compliance with Condition of Participation 42 CFR 484.102 Emergency preparedness.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to develop and implement EP policies and procedures to address potential hazards identified in its risk assessment, which had the potential to affect all active patients and employees. Findings include: 1. The agency’s EP plan, last revised 8/01/2025, indicated the agency had developed policies to manage potential hazards the agency identified in the Hazard Vulnerability Analysis (HVA), including but not limited to “External Disaster (Mass Casualty Incident) … Influenza/Pandemic … Severe Weather ….” 2. Review of the agency’s EP policies and procedures failed to evidence policies to address potential hazards the agency identified in its risk assessment, including policies the EP plan indicated the agency had developed. 3. During an interview on 8/21/2025 beginning at 1:26 PM, CM reported the agency did not develop policies and procedures to address potential hazards it identified in the HVA.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to develop and implement EP policies and procedures which indicated the agency’s system of medical documentation during an emergency, which had the potential to affect all active patients. Findings include: 1. The agency’s EP plan, last revised 8/01/2025, failed to evidence the system of medical documentation the agency planned to use during an emergency which would preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records. 2. During an interview on 8/21/2025 beginning at 1:26 PM, CM stated she was unsure if the EP plan specified the system of medical documentation the agency would use during an emergency.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to develop and implement EP policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies, which had the potential to affect all active patients. Findings include: 1. The agency’s EP plan, last revised 8/01/2025, failed to evidence the agency’s policies and procedures regarding the use of volunteers in an emergency and/or emergency staffing strategies. 2. During an interview on 8/21/2025 beginning at 1:26 PM, CM reported she was unsure of the agency’s process for using volunteers during an emergency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to develop and maintain an EP communication plan which included names and contact information of staff and patients’ physicians, which had the potential to affect all active patients and staff. Findings include: 1. An undated agency policy “Emergency Management Policy” indicated the agency would compile and keep a list of staff names and telephone numbers in the on-call book. 2. The agency’s EP plan, last revised 8/01/2025, failed to evidence the agency had developed and maintained a communication plan with names and contact information of staff and patients’ physicians. 3. During an interview on 8/21/2025 beginning at 1:26 PM, CM reported the agency did not have a communication plan which included names and contact information for staff and patients’ physicians.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to develop and maintain an EP communication plan which included contact information for Federal, State, regional, and local EP staff, which had the potential to affect all active patients and staff. Findings include: 1. The agency’s EP plan, last revised 8/01/2025, failed to evidence the agency had developed and maintained a communication plan with contact information for Federal, State, tribal, regional, and local EP staff. 2. During an interview on 8/21/2025 beginning at 1:26 PM, CM reported the agency did not have a communication plan which included contact information for Federal, State, tribal, regional, and local EP staff.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to develop and maintain a communication plan which included a method for sharing information and medical documentation for patients under agency’s care with other health care providers, which had the potential to affect all active patients. Findings include: 1. The agency’s EP plan, last revised 8/01/2025, failed to evidence the agency had developed and maintained a communication plan which included a method for sharing information and medical documentation for patients under the agency’s care with other health care providers to maintain continuity of care. 2. During an interview on 8/21/2025 beginning at 1:26 PM, CM reported she was unsure of the agency’s method for sharing information and medical documentation with other health care providers during an emergency.

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 EP plan review and interview, the home health agency failed to conduct exercises to test its EP plan annually, which had the potential to affect all agency patients and staff. Findings include: 1. An undated agency policy “Emergency Management Policy” indicated the agency would conduct an “annual desktop drill to determine the effectiveness and efficiency of the current plan ….” 2. The agency’s EP plan, last revised 8/01/2025, failed to evidence the agency had completed any exercises to test its EP plan in 2023, 2024, or 2025. 3. During an interview on 8/21/2025 beginning at 12:09 PM, CM stated it had been “a few years” since the agency had conducted an exercise to test its EP plan. She was unsure of when the agency last conducted an EP testing exercise. CM reported the agency had not activated the EP plan during that time.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: August 15, 18, 19, 20, and 21, 2025 12-Month Unduplicated Skilled Admissions: 1 Partially Extended on 08/19/2025 at 3:58 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: CM Clinical Manager HHA Home Health Aide SN Skilled Nurse RN Registered Nurse POC Plan of Care SOC Start of Care OASIS Outcome and Assessment Information Set ADLs Activities of Daily Living QR 9/2/25 A2

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to transmit all OASIS assessments within 30 days of the assessment for 1 of 1 transmission on 08/04/2025 (Patient #3). Findings include: 1. Review of the undated Encoding and Reporting OASIS Data policy included, but not limited to, “…The agency will electronically report all OASIS data collected in accordance with federal regulations… Agency will encode individual patient assessment data within thirty (30) days of completing the comprehensive assessment…” 2. Review of the agency’s OASIS Agency Final Validation report from 08/04/2025 included a transmission for Patient #3’s comprehensive assessment completed on 05/27/2025. The OASIS data was transmitted 69 days after the comprehensive assessment. The agency failed to transmit Patient #3’s OASIS data from the comprehensive assessment within 30 days. 3. During an interview on 08/19/2025 at 3:32 PM, the CM indicated she was responsible for transmitting patients’ OASIS data. The CM relayed she had forgotten about it until she went to complete a different transmission.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide a written notice of the patient’s rights and responsibilities for 1 of 2 home visit observations where the home folder was observed (Patient #4). Findings include: 1. Patient #4’s clinical record evidenced a SOC date of 5/06/2025. Patient signed an “Admission Consent” which indicated Patient received the agency’s home folder on 5/06/2025. 2. A home visit observation with Patient #4 was conducted on 8/18/2025 beginning at 12:58 PM. During the visit, Patient’s home folder was reviewed, and failed to evidence a complete written copy of the patient’s rights and responsibilities. 3. During an interview on 8/18/2025 beginning at 2:12 PM, CM reported Patient’s home folder was missing every other page. 410 IAC 17-12-3(a)(1)(A)

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 home health agency failed to ensure the Patient received all services ordered in the POC for 1 of 2 active patient records reviewed of patients who received both SN and HHA services (Patient #1). Findings include: 1. Review of the undated Patient rights and responsibilities policy included, but not limited to, “… The client has the right to receive all services outlined in the plan of care…” 2. Review of the undated Missed Visit policy included, but not limited to, “… Care provided to client by all disciplines will follow established plan of care… Missed Visit report will be filled out and faxed to doctor regarding missed visit if visit was not made up…” 3. Review of Patient #1’s clinical record included a POC for certification period 06/17/2025 to 08/15/2025. The POC included HHA services for one to three hours per day, five to seven days per week. The clinical record included missed visit notes for 07/02/2025, 07/13/2025, 07/21/2025, 07/23/2025, 07/25/2025, and 08/14/2025 due to the agency being unable to staff the visits. During an interview on 08/19/2025 at 3:42 PM, the CM indicated Patient #1’s missed visits were due to the previous caregiver decided not to go back, and the agency was having trouble staffing Patient #1’s shifts.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to advise the patient nor the patient’s ordering provider that a discharge for cause was being considered for 1 of 1 closed record reviewed of a patient discharged for cause (Patient #9). Findings include: 1. The undated agency policy “Client Discharge Process” indicated agency documentation regarding discharge would include “Evidence that the decision was not made unilaterally. The client, family and physician participated in the decision to discharge client from the agency … all communication with the client … with copies sent to the primary physician.” 2. Patient #9’s clinical record evidenced a SOC date of 8/30/2024. The agency provided home health aide services with visits two hours per day, five days per week. HHA 6 last provided services on 4/19/2025. The CM documented Patient was discharged on 4/24/2025 due to an “unsafe work environment.” The record failed to evidence the agency notified Patient nor Patient’s ordering provider that a discharge for cause was being considered. 3. The agency’s complaint log evidenced on 4/21/2025, Patient #9 reported to the agency that HHA 6 had been physically abusive, threatening, and refused to perform ordered care, including bathing. The documentation included a written statement, dated 4/21/2025 and signed by HHA 6, which evidenced the aide had informed Patient that she had been feeling “nervous and unsafe/uncomfortable” due to other residents’ behavior in Patient’s apartment complex. HHA 6 informed Patient that if the behavior continued, the aide would request to no longer work with Patient, and the aide was unsure if there was any other staff available to provide Patient’s services. The documentation evidenced the agency mailed a notice of discharge to Patient on 4/24/2025. 4. During an interview on 8/20/2025 beginning at 3:35 PM, CM reported Patient #9 was discharged from the agency due to HHA 6’s request to stop working with Patient after being threatened with a gun and “harassed” by other residents in Patient’s apartment complex. CM stated after HHA 6 requested to be removed from Patient’s case, Patient made an allegation of abuse against the aide. CM reported she had spoken with Patient regarding the safety concerns “multiple times” and Patient had requested to be transferred to a PSA agency. CM stated she did not document these conversations. CM also reported she spoke with Patient’s ordering provider regarding Patient’s discharge, but did not document this report. 5. During an interview on 8/21/2025 beginning at 10:19 AM, Patient #9 stated when he/she reported HHA 6’s abuse to CM, Patient was told there were no other aides available to provide care except HHA 6. Patient reported he/she then requested a transfer to a PSA. Patient reported he/she did not speak with anyone at the agency regarding staff concerns with safety at Patient’s apartment complex. 410 IAC 17-12-2(i)

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to make and document efforts to resolve the problem which could result in a discharge for cause for 1 of 1 closed record reviewed of a patient discharged for cause (Patient #9). Findings include: 1. Patient #9’s clinical record evidenced a SOC date of 8/30/2024. The agency provided HHA services with visits two hours per day, five days per week. HHA 6 last provided services on 4/19/2025. The CM documented Patient was discharged on 4/24/2025 due to an “unsafe work environment.” The record failed to evidence the agency made efforts to resolve the problem and/or cause of the unsafe work environment prior to Patient’s discharge. 2. The agency’s complaint log evidenced on 4/21/2025, Patient #9 reported to the agency that HHA 6 had been physically abusive, threatening, and refused to perform ordered care, including bathing. The log documentation included a “Report of Concern,” dated 3/31/2025, which evidenced HHA 6 documented Patient’s apartment complex had received an anonymous threat involving the aide. The caller allegedly threatened to “shoot” HHA 6, Patient, and the apartment complex office staff. CM documented HHA 6 was “willing to continue going to [Patient’s home] as along as things improve and there are no more issues.” The record and complaint documentation failed to evidence further safety incidents. The documentation included a written statement, dated 4/21/2025 and signed by HHA 6, which evidenced the aide had informed Patient that she had been feeling “nervous and unsafe/uncomfortable” due to other residents’ behavior in Patient’s apartment complex. HHA 6 informed Patient that if the behavior continued, the aide would request to no longer work with Patient, and the aide was unsure if there was any other staff available to provide Patient’s services. 3. During an interview on 8/20/2025 beginning at 3:35 PM, CM reported Patient #9 was discharged from the agency due to HHA 6’s request to stop working with Patient after being threatened with a gun and “harassed” by other residents in Patient’s apartment complex. CM reported she had spoken with Patient and staff at the apartment complex regarding the safety concern with other residents, however CM stated she did not document these conversations. 4. During an interview on 8/21/2025 beginning at 10:19 AM, Patient #9 reported he/she did not speak with anyone at the agency regarding staff concerns with safety at Patient’s apartment complex.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a comprehensive assessment was completed within five days after the SOC for 6 of 6 active patients admitted in 2024 or later (Patient #1, 2, 4, 5, 6, 7). Findings include: 6. Patient #6’s clinical record evidenced CM completed an initial assessment and comprehensive assessment on 5/09/2025. The record indicated the agency first provided hands-on, direct care on 5/21/2025. The record failed to evidence the agency completed a comprehensive assessment within 5 calendar days of agency staff first providing hands-on, direct care services. During an interview on 8/20/2025 beginning at 1:09 PM, CM reported she did not provide any hands-on, direct care during her assessment on 5/09/2025. CM stated the agency first provided hands-on, direct care services on 5/21/2025. CM reported the agency did not complete a comprehensive assessment within five days of 5/21/2025. 7. Patient #7’s clinical record evidenced CM completed an initial assessment and comprehensive assessment on 4/14/2025. The record indicated the agency first provided hands-on, direct care on 5/06/2025. The record failed to evidence the agency completed a comprehensive assessment within 5 calendar days of agency staff first providing hands-on, direct care services. During an interview on 8/20/2025 beginning at 1:22 PM, CM stated the agency first provided hands-on, direct care services on 5/21/2025. CM reported the agency did not complete a comprehensive assessment within five days of 5/21/2025. 1. Review of the undated Comprehensive Assessment policy included, but not limited to, “… A thorough, well-organized comprehensive and accurate assessment, consistent with the patients immediate needs will be completed for all patients in a timely manner, but no later than five (5) days after start of care…) 2. Review of Patient #1’s clinical record included an HHA visit note from 04/29/2024, the first visit note in which hands on patient care was documented. The clinical record failed to include a comprehensive assessment conducted within five days after the SOC. During an interview on 08/20/2025 at 2:12 PM, the CM indicated Patient #1 first received hands on care from the agency on 04/29/2024. The CM further indicated a comprehensive assessment had not been performed within five days after that date. 3. Review of Patient #2’s clinical record included an HHA visit note dated 02/10/2025. The clinical record failed to include a comprehensive assessment conducted within five days after the SOC. During an interview on 08/20/2025 at 2:16 PM, the CM indicated Patient #2 first received hands on care from the agency on 02/10/2025. The CM further indicated a comprehensive assessment had not been performed within five days after that date. 4. Review of Patient #4’s clinical record included an HHA visit note dated 05/06/2025, which was the first visit in which the Patient received care from the agency. The clinical record failed to include a comprehensive assessment conducted within five days after the SOC. During an interview on 08/20/2025 at 2:25 PM, the CM indicated Patient #4 first received hands on care from the agency on 05/06/2025. The CM further indicated a comprehensive assessment had not been performed within five days after that date. 5. Review of Patient #5’s clinical record included an HHA visit note dated 08/12/24, which was the first visit in which the Patient received hands on care from the agency. The clinical record failed to include a comprehensive assessment conducted within five days after the SOC. During an interview on 08/20/2025 at 2:33 PM, the CM indicated Patient #5 first received hands on care from the agency on 04/29/2024. The CM further indicated a comprehensive assessment had not been performed within five days after that date.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the comprehensive assessment included patient goals for 7 of 8 patient records reviewed where the comprehensive assessment was reviewed for patient goals (Patient #1, 2, 3, 4, 5, 6, 7, 8). Findings include: 8. Patient #6’s clinical record evidenced CM completed an initial comprehensive assessment on 5/09/2025 and a recertification comprehensive assessment on 7/07/2025. The record failed to evidence CM identified patient goals and measurable outcomes during the comprehensive assessments. During an interview on 8/20/2025 beginning at 1:09 PM, CM reported she did not document patient goals and/or measurable outcomes within the comprehensive assessments on 5/09/2025 and 7/07/2025. 9. Patient #7’s clinical record evidenced CM completed an initial comprehensive assessment on 4/14/2025, a recertification comprehensive assessment on 6/11/2025, and a recertification comprehensive assessment on 8/11/2025. The record failed to evidence CM identified patient goals and measurable outcomes during the comprehensive assessments. During an interview on 8/20/2025 beginning at 1:22 PM, CM reported she did not document patient goals and/or measurable outcomes within the comprehensive assessments. 10. Patient #8’s clinical record evidenced CM completed a recertification comprehensive assessment on 9/26/2023. The record failed to evidence CM identified patient goals and measurable outcomes during the comprehensive assessment. During an interview on 8/20/2025 beginning at 1:35 PM, CM reported she did not document patient goals and/or measurable outcomes within the comprehensive assessments on 9/26/2023. 1. Review of the undated Comprehensive Patient Assessment policy included, but not limited to, “… goals are identified… Patient needs are assessed and care guidelines established based on the assessment data…” 2. Review of the undated Patient Reassessment/Update of Comprehensive Assessment policy included, but not limited to, “… Special attention will be paid to patient-centered goal setting, clarifying the patient’s personal goals and his/her expectations of the home care services…” 3. Review of Patient #1’s clinical record included a recertification comprehensive assessment dated 08/12/2025. The comprehensive assessment failed to include patient goals. During an interview on 08/20/2025 at 2:12 PM, the CM indicated the comprehensive assessment did not include patient goals. 4. Review of Patient #2’s clinical record included a recertification comprehensive assessment dated 07/21/2025 The comprehensive assessment failed to include patient goals. During an interview on 08/20/2025 at 2:16 PM, the CM indicated the comprehensive assessment did not include patient goals. 5. Review of Patient #3’s clinical record included a recertification comprehensive assessment dated 07/25/2025. The comprehensive assessment failed to include patient goals. During an interview on 08/20/2025 at 2:33 PM, the CM indicated the comprehensive assessment did not include patient goals. 6. Review of Patient #4’s clinical record included a recertification comprehensive assessment dated 08/18/2025. The comprehensive assessment failed to include patient goals. During an interview on 08/20/2025 at 2:25 PM, the CM indicated the comprehensive assessment did not include patient goals. 7. Review of Patient #5’s clinical record included a recertification comprehensive assessment dated 07/17/2025. The comprehensive assessment failed to include patient goals. During an interview on 08/20/2025 at 2:33 PM, the CM indicated the comprehensive assessment did not include patient goals.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the discharge comprehensive assessment failed to include patient progress toward goals for 3 of 3 closed records reviewed (Patient #8, 9, 10). Findings include: 2. Patient #8’s clinical record evidenced a discharge date of 10/10/2023. CM completed a discharge comprehensive assessment on 10/10/2023. The assessment failed to evidence a summary of Patient’s progress in meeting his/her care plan goals. During an interview on 8/20/2025 beginning at 1:35 PM, CM reported she did not document Patient’s progress in meeting his/her care plan goals on the discharge comprehensive assessment. 3. Patient #9’s clinical record evidenced a discharge date of 4/24/2025. CM completed a discharge comprehensive assessment on 4/24/2025. The assessment failed to evidence a summary of Patient’s progress in meeting his/her care plan goals. During an interview on 8/20/2025 beginning at 3:35 PM, CM reported she did not document Patient’s progress in meeting his/her care plan goals on the discharge comprehensive assessment. 1. Review of the undated Patient Discharge Process policy included, but not limited to, “… The Registered Nurse/Therapist shall ensure that the treatment goals and patient outcomes have been met…” 4. Review of Patient #10’s clinical record included a discharge comprehensive assessment. The discharge comprehensive assessment filed to include patient progress toward goals. During an interview on 08/21/2025 at 12:42 PM, the CM indicated the discharge comprehensive assessment did not include patient progress toward goals.

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 home health agency failed to ensure the POC included ongoing interventions to mitigate the risk of emergency department visits and re-hospitalizations and failed to ensure the POC did not include contradicting service frequencies for 8 of 8 patients whose POCs were reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8). Findings include: 7. Patient #6’s clinical record included a POC for the recertification period of 7/08/2025 – 9/05/2025. The POC included multiple frequency and duration orders for HHA services, including an order for HHA visits two hours per day, three days per week, and an order for HHA visits “1-2” hours per day, “1-2” days per week for one week then “1-2” hours per day, “1-3” days per week for eight weeks. The POC failed to evidence one clear order for the frequency and duration of HHA services. CM completed a recertification comprehensive assessment on 7/07/2025. The comprehensive assessment failed to evidence CM documented Patient’s risk factors for re-hospitalization and emergency department visits, nor interventions identified to address these risk factors. The recertification POC failed to evidence risk factors and interventions which aligned with the comprehensive assessment. During an interview on 8/20/2025 beginning at 1:09 PM, CM reported the agency trained her to write two orders for visit frequency and duration. 8. Patient #7’s clinical record included a POC for the recertification period of 8/12/2025 – 10/10/2025. The POC included multiple frequency and duration orders for HHA services, including an order for HHA visits two hours per day, two days per week, and an order for HHA visits “1-2” hours per day, “1-2” days per week for nine weeks. The POC failed to evidence one clear order for the frequency and duration of HHA services. CM completed a recertification comprehensive assessment on 8/11/2025. CM documented she addressed Patient’s risk factors for re-hospitalization and emergency department visits during the visit through a “discussion” with Patient including encouraging Patient to check their blood sugar daily and ensuring pets are out of the way and pathways clear. The recertification POC failed to evidence interventions to address Patient’s risk factors for re-hospitalization and emergency department visits which aligned with the comprehensive assessment. During an interview on 8/20/2025 beginning at 1:22 PM, CM reported the agency trained her to write two orders for visit frequency and duration. CM stated the order for HHA visits two hours per day, two days per week was used to schedule Patient’s visits. CM stated she also would obtain an order for a range of HHA visit frequency and duration for each of the nine weeks in the certification period. 9. Patient #8’s clinical record included a POC for the recertification period of 9/30/2023 – 11/28/2023. The POC included multiple frequency and duration orders for HHA services, including an order for HHA visits four hours per day, seven days per week, and an order for HHA visits “2-4” hours per day, one day per week for one week, “2-4” hours per day, “5-7” days per week for eight weeks, then “2-4” hours per day, “1-3” days per week for one week. The POC failed to evidence one clear order for the frequency and duration of HHA services. CM completed a recertification comprehensive assessment on 9/26/2023. CM documented Patient’s risk factors for hospitalization included “History of falls … Multiple emergency department visits … Currently taking 5 or more medications ….” CM documented she followed up Patient’s re-hospitalization and ED visits risk factors by a “discussion.” The POC failed to evidence CM documented the risk factors for re-hospitalization and ED visits identified nor interventions the agency would conduct to address all risk factors. Patient was admitted to a local hospital on 10/11/2023 for increased weakness and falls. During an interview on 8/20/2025 beginning at 1:35 PM, CM reported the agency trained her to write two orders for visit frequency and duration. CM stated agency HHA visits “generally” lasted four hours per day, seven days per week. CM reported she did not document Patient’s risk factors for re-hospitalization and ED visits nor interventions to address the risk factors on the POC. 1. Review of the undated Plan of Care policy included, but not limited to, The Plan of Care shall be completed in full to include… Type, frequency, and duration of all visits/services…Other appropriate items…” 2. Review of Patient #1’s clinical record included a POC for certification period 06/17/2025 to 08/15/2025. The POC failed to include ongoing interventions to mitigate the risk of emergency department visits and re-hospitalizations. The POC included HHA service frequency of three hours per day, seven days per week and also included HHA service frequency for week one of one to three hours per day, three to five days per week; for weeks two through eight of one to three hours per day, five to seven days per week; and for week nine of one to three hours per day, four to six days per week. The agency failed to ensure the POC was clear about the frequency and duration of HHA services. During an interview on 08/20/2025 at 2:12 PM, the CM indicated the way the frequency was on the POC was how she was taught to do it. The CM further indicated the first frequency was what the patient got generally, and then it was broken down by certification period. The CM indicated she would remove the general frequency from the POC. 3. Review of Patient #2’s clinical record included a POC for certification period 07/26/2025 to 09/23/2025. The POC failed to include ongoing interventions to mitigate the risk of emergency department visits and re-hospitalizations. The POC included HHA service frequency of two hours per day, three days per week and also included HHA service frequency for week two through nine of one to two hours per day, one to three days per week and for week ten of one to two hours per day, one day per week. The agency failed to ensure the POC was clear about the frequency and duration of HHA services. During an interview on 08/20/2025 at 2:16, the CM indicated she would remove the general frequency from the POC. 4. Review of Patient #3’s clinical record included a POC for certification period 07/30/2025 to 09/27/2025. The POC failed to include ongoing interventions to mitigate the risk of emergency department visits and re-hospitalizations. The POC included SN service frequency of eight hours per day, five days per week and also included SN service frequency for week one of six to eight hours per day, one to three days per week and for weeks two through nine of six to eight hours, three to five days per week. The agency failed to ensure the POC was clear about the frequency and duration of SN services. During an interview on 08/20/2025 at 2:23 PM, the CM indicated the way the frequency was on the POC was how she was taught to do it. The CM further indicated the first frequency was what the patient got generally, and then it was broken down by certification period. The CM indicated she would remove the general frequency from the POC. 5. Review of Patient #4’s clinical record included a POC for certification period 06/24/2025 to 08/22/2025. The POC failed to include ongoing interventions to mitigate the risk of emergency department visits and re-hospitalizations. The POC included HHA service frequency of two hours per day, two days per week and also included HHA service frequency of one to two hours per day, one to two days per week. The agency failed to ensure the POC was clear about the frequency and duration of HHA services. During an interview on 08/20/2025 at 2;25 PM, the CM indicated the way the frequency was on the POC was how she was taught to do it. The CM further indicated the first frequency was what the patient got generally, and then it was broken down by certification period. The CM indicated she would remove the general frequency from the POC. 6. Review of Patient #5’s clinical record included a POC for certification period 07/19/2025 to 09?16/2025. The POC failed to include ongoing interventions to mitigate the risk of emergency department visits and re-hospitalizations. The POC included HHA service frequency of two hours per day, three days per week and also included HHA service frequency for weeks two through nine of one to two hours per day, one to three days per week and for week ten of one to two hours per day, one day per week. The agency failed to ensure the POC was clear about the frequency and duration of HHA services. During an interview on 08/20/2025 at 2:33 PM, the CM indicated the way the frequency was on the POC was how she was taught to do it. The CM further indicated the first frequency was what the patient got generally, and then it was broken down by certification period. The CM indicated she would remove the general frequency from the POC. 410 IAC 17-13-1(a)(1)(B)(2)(iii) 410 IAC 17-13-1(a)(1)(B)(8)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure provider orders were obtained prior to providing services to the patient for 3 of 8 patient records where orders for services were reviewed (Patient #2, 4, 8). Findings include: 4. Patient #8’s clinical record included a POC for the recertification period of 9/30/2023 – 10/10/2023, which evidenced the agency was to provide HHA services. Agency staff conducted HHA visits on 9/30/2023, 10/01/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, and 10/08/2023. The record failed to evidence the agency received an order to recertify and continue Patient’s HHA visits until 10/09/2025. During an interview on 8/20/2025 beginning at 1:35 PM, CM reported she had called Patients’ ordering physician to obtain a verbal order to recertify and continue Patient’s services, however she “probably” had to leave a voicemail. CM stated there was no documentation the agency received a verbal order to continue services. 1. Review of the undated Physician Orders policy included, but not limited to, “… All medications, treatments and services provided to patients must be ordered by a physician… The order must include the date, specific order, be signed with the full name and title of the person receiving the order and be sent to the physician for signature…” 2. Review of Patient #2’s clinical record included an order dated 01/27/2025, signed by the provider on 01/30/2025, and received by fax on 02/03/2025 for Patient #2’s services to be on hold pending receipt of prior authorization from the insurance. The record failed to include an order for Patient #2 to be taken off hold after the prior authorization was received. Patient #2 received HHA services beginning on 02/10/2025. The agency failed to ensure provider orders were received prior to providing care for Patient #2. During an interview on 08/20/2025 at 2:16 PM, the CM indicated there was no order to take Patient #2 off of the service hold when the prior authorization was received. The CM further indicated Patient #2 first received hands on care from the agency on 02/10/2025. 3. Review of Patient #4’s clinical record included an order dated 04/28/2025, signed by the provider on 04/29/2025, and returned to the agency on 04/30/2025 for Patient #4’s services to be on hold pending receipt of prior authorization from the insurance. The record failed to include an order for Patient #4 to be taken off hold after the prior authorization was received. Patient #4 received HHA services beginning on 05/06/2025. The agency failed to ensure provider orders were received prior to providing care for Patient #4. During an interview on 08/21/2025 at 2:25 PM, the CM indicated she did not write an order to remove the services hold for Patient #4 after the prior authorization was received and further indicated Patient #4 first received hands on care from the agency on 05/06/2025. 410 IAC 17-13-1(a)

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure verbal order documentation included the date the order was received, time the order was received, and the person who provided the verbal order for 2 of 7 active records reviewed (Patient #6, #7). Findings include: 1. An undated agency policy “Physician Orders” indicated after an RN received a verbal order, the RN was to “write the order as given … The order must include the date ….” 2. Patient #6’s clinical record evidenced CM documented a verbal order to recertify and continue Patient’s home care services on 7/07/2025 at 3 PM. CM documented she left a voicemail with the ordering provider’s nurse. The record failed to evidence the date and time a verbal order was received. During an interview on 8/20/2025 beginning at 1:09 PM, CM reported she received a verbal order from a nurse at the ordering physician’s office later in the day on 7/07/2025. CM stated she failed to document the date and time she received the verbal order. 3. Patient #7’s clinical record evidenced CM documented a verbal order to recertify and continue Patient’s home care services on 8/11/2025 by CM. The record failed to evidence the date and time CM received the verbal order nor the person who provided the verbal order. During an interview on 8/20/2025 beginning at 1:22 PM, CM reported she received a verbal order from a nurse at the ordering physician’s office on 8/11/2025. CM stated she failed to document the date and time the verbal order was received nor the person who provided the verbal order. 410 IAC 17-14-1(a)(1)(H)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to alert the physician of the need to modify the POC for 3 of 7 active patient records reviewed (Patient #2, 4, 7). Findings include: 3. Patient #7’s clinical record evidenced the agency was to perform HHA visits for two hours per day, two days per week. The record indicated visits were not performed as scheduled on 6/28/2025, 7/05/2025, and 7/12/2025. The record failed to evidence the agency notified Patient’s physician of the missed visits. During an interview on 8/20/2025 beginning at 1:22 PM, CM reported the agency would notify Patient’s physician of missed visits via fax. CM stated the record failed to evidence the agency notified Patient’s physician of the missed visits. 1. Review of the undated Plan of Care policy included, but not limited to, “… Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care…” 2. Review of Patient #2’s clinical record included a POC for certification period 07/26/2025 to 09/23/2025 with orders for SN visits one time monthly for suprapubic catheter change. The clinical record included a SN note for 05/06/2025 but no other SN notes. The clinical record failed to evidence the provider was promptly notified of the need to alter the POC. During an interview on 08/20/2025 at 2:16 PM, the CM indicated she had only performed on SN visit since Patient #2’s SOC due to a supplier issue and indicated Patient #2 had been receiving catheter changes at the physician’s office because they could obtain the correct catheter type. The CM indicated there was an order for no catheter change in June and indicated there were no further orders to skip the catheter change nor further documentation the provider was notified of the need to modify the POC. 3. Review of Patient #4’s clinical record included a POC for certification period 06/24/2025 to 08/22/2025 with orders for HHA services two hours per day, two days per week for nine weeks to assist the Patient with ADLs and instrumental ADLs. HHA visit notes 06/17/2025 through 08/14/2025 indicated all tasks were performed. The record failed to include During an interview on 08/20/2025 at 9:37 AM, HHA 5 indicated she makes Patient #4’s bed and does his laundry and that they converse a lot. HHA 5 indicated she always asked Patient #4 if he wanted a shower, shampoo, and lotion, but he said it was done. HHA 5 further indicated she marked those tasks as complete because the Patient reported them as done. HHA 5 indicated the CM should be aware those tasks were already completed when she arrived at Patient #4’s home. During an interview on 08/20/2025 at 2:25 PM, the CM indicated HHA 5 had made her aware earlier that day of HHA 5 not assisting Patient #4 with showering and skin care during visits, so the physician had not been notified. During an interview on 08/21/2025 at 1:01 PM, the RN 1 indicated Patient #4 had expressed to her that they did not want shower or skin care assistance depending on their mood for the day. RN 1 further indicated she had made someone at the agency office aware but could not remember who she had told.

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 record review and interview, the home health agency failed to ensure the recertification POC included the patient’s progress toward their goals for 7 of 7 active patient records reviewed (Patient #1, 2, 3, 4, 5, 6, 7). Findings include: 7. Patient #6’s clinical record included a POC for the recertification period of 7/08/2025 – 9/05/2025. The POC failed to evidence Patient’s progress towards their measurable outcomes and goals. During an interview on 8/20/2025 beginning at 1:09 PM, CM reported she did not document Patient’s progress towards their measurable outcomes and goals on the POC. 8. Patient #7’s clinical record included a POC for the recertification period of 8/12/2025 – 10/10/2025. The POC failed to evidence Patient’s progress towards their measurable outcomes and goals. During an interview on 8/20/2025 beginning at 1:22 PM, CM reported she did not document Patient’s progress towards their measurable outcomes and goals on the POC. 1. Review of the undated Plan of Care policy included, but not limited to, “… The Plan of Care shall be completed in full to include… Treatment goals… Other appropriate items…” 2. Review of Patient #1’s clinical record included a POC for certification period 06/17/2025 to 08/15/2025. The POC failed to included Patient #1’s progress toward their goals. During an interview on 08/20/2025 at 2:12 PM, the CM indicated Patient #1’s POC did not include the Patient’s progress toward their goals. 3. Review of Patient #2’s clinical record included a POC for certification period 07/26/2025 to 09/23/2025. The POC failed to included Patient #2’s progress toward their goals. During an interview on 08/20/2025 at 2:16 PM, the CM indicated Patient #2’s POC did not include the Patient’s progress toward their goals. 4. Review of Patient #3’s clinical record included a POC for certification period 07/30/2025 to 09/27/2025. The POC failed to included Patient #3’s progress toward their goals. During an interview on 08/20/2025 at 2:23 PM, the CM indicated Patient #3’s POC did not include the Patient’s progress toward their goals. 5. Review of Patient #4’s clinical record included a POC for certification period 06/24/2025 to 08/22/2025. The POC failed to included Patient #4’s progress toward their goals. During an interview on 08/20/2025 at 2:25 PM, the CM indicated Patient #4’s POC did not include the Patient’s progress toward their goals. 6. Review of Patient #5’s clinical record included a POC for certification period 07/19/2025 to 09/16/2025. The POC failed to included Patient #5’s progress toward their goals. During an interview on 08/20/2025 at 2:33 PM, the CM indicated Patient #5’s POC did not include the Patient’s progress toward their goals.

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, policy review, and interview, the home health agency failed to ensure all staff followed agency policies and best practice specific to infection control for 2 of 4 home visit observations conducted (HHA 1, CM). Findings include: 1. An undated agency policy “Bag Technique management” indicated staff should perform hand hygiene prior to entering the nursing bag. 2. A document titled “Clinical Safety: Hand Hygiene for Healthcare Workers,” dated 2/27/2024 and obtained from www.cdc.gov, indicated staff should perform hand hygiene “immediately before touching a patient … after touching a patient or patient’s surroundings … immediately after glove removal.” 3. Manufacturer’s instructions for Lysol Disinfecting Wipes, obtained from www.lysol.com, indicated the dry time for the solution to effectively disinfect an item was four minutes. 4. During a home visit observation with Patient #4 on 8/18/2025 beginning at 12:58 PM, CM failed to perform hand hygiene prior to donning gloves on two occasions, failed to perform hand hygiene prior to removing gloves on two occasions, and failed to perform hand hygiene prior to entering the nursing bag on three occasions. CM also failed to allow the Lysol disinfectant to dry prior to returning her thermometer, oxygen saturation probe, blood pressure cuff, and stethoscope to the nursing bag. During an interview on 8/20/2025 beginning at 10:28 AM, CM reported during a home visit, staff should perform hand hygiene prior to patient care, before donning gloves, after removing gloves, and prior to entering the nursing bag. CM stated she performed hand hygiene prior to entering Patient’s home; however she did not have hand sanitizer available to perform hand hygiene during the visit. CM was unsure of the dry time for Chlorox Disinfecting Wipes. 2. During a home visit observation on 08/18/2025 beginning at 12:36 PM, observed HHA 1 provided care for Patient #2. HHA 1 performed hand hygiene and then assisted Patient #2 with unbuttoning their shirt. HHA 1 then donned gloves without first performing hand hygiene, During an interview on 08/18/2025 at 1:36 PM, HHA 1 indicated hand hygiene should be performed before and after patient care, if anything is visible on the hands, and before and after gloves.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all HHAs completed visit documentation according to agency policies and procedures for 1 of 3 active records reviewed of patients who received services from HHA 5 (Patient #6). Findings include: 1. The undated agency policy “Clinical Documentation” indicated staff should complete documentation of services on “the day the service is rendered.” 2. Patient #6’s clinical record included an order for Patient to receive HHA visits twice a week. HHA 5 completed Electronic Visit Verification (EVV, system which uses GPS to verify the date and time an employee arrives and leaves a patient’s home) on 8/04/2025, 8/07/2025, 8/13/2025, and 8/15/2025. The record failed to evidence HHA 5 documented the tasks performed or declined during Patient’s aide visit on these dates. 3. During an interview on 8/21/2025 beginning at 10:53 AM, HHA 5 reported she completed her visit documentation prior to leaving a patient’s home. The aide stated she performed visits with Patient on 8/04/2025, 8/07/2025, 8/13/2025, and 8/15/2025, however she was unable to document the tasks performed or declined on these dates.

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 supervise HHAs at least every 14 days for 2 of 2 active patients who received both SN and HHA services (Patient #1, 2). Findings include: 1. Review of the undated Home Health Aide Supervision policy included, but not limited to, “… Supervision of client services by a Registered Nurse or Therapist will be completed at least every two (2) weeks while the client is receiving skilled services… Supervisory visits are to be documented in the client’s chart on the Home Health Aide Supervision Form…” 2. Review of Patient #1’s clinical record included a POC for certification period 06/17/2025 to 08/15/2025. The POC included SN services to be provided once every 28 days for a medication injection and HHA services to be provided three hours per day, seven days per week. The record included an HHA supervisory visit form dated 06/30/2025 signed by RN 1 with the next HHA supervisory visit form signed by RN 1 and dated 07/15/2025, 15 days later. The record also included an HHA supervisory visit form signed by RN 1 dated 07/28/2025 with the next HHA supervisory visit form signed by RN 1 and dated 08/13/2025, 16 days later. The clinical record included HHA visit notes between 06/30/2025 and 07/15/2025 and between 07/28/2025 and 08/13/2025. The agency failed to ensure Patient #1 received HHA supervisory visits at least every 14 days. During an interview on 08/19/2025 at 3:29 PM, RN 1 indicated she conducted HHA supervisory visits twice per month for patients receiving skilled services. 3. Review of Patient #2’s clinical record included a POC for certification period 07/26/2025 to 09/23/2025. The POC included SN services to be provided once per month for suprapubic catheter change and HHA services to be provided two hours per day, three days per week. The record included an HHA supervisory form signed by RN 1 and dated 07/28/2025 with the next HHA supervisory form signed by RN 1 and dated 08/13/2025, 16 days later. The agency failed to ensure Patient #2 received HHA supervisory visits at least every 14 days. During an interview on 08/19/2025 at 3:31 PM, RN 1 indicated Patient #2 was skilled, so she performed HHA supervisory visits every other week. 4. During an interview on 08/19/2025 at 3:42 PM, the CM indicated HHA supervisory visits were to be done every 14 days for patients receiving skilled services and that she had told RN 1 this. The CM indicated RN 1 had not been doing the HHA supervisory visits correctly. 410 IAC 17-14-1(g)

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure aide supervisory visit notes included all required information for 6 of 7 patients whose aide supervisory visit notes were reviewed (Patient #1, 2, 4, 5, 6, 8). Findings include: 6. Patient #6’s clinical record included an order for the agency to provide HHA services. The record evidenced RN 1 documented an HHA supervisory visit note on 6/04/2025. The aide was not present during the visit. The record failed to evidence during the supervisory visit RN 1 ensured the HHA followed Patient’s POC, complied with infection prevention and control policies and procedures, and reported changes in Patient’s condition. During an interview on 8/20/2025 beginning at 12:04 PM, RN 1 reported when Patient’s aide was not present for an HHA supervisory visit, the nurse would not complete the section of the aide supervisory form which included evaluation of the tasks and responsibilities of “… Review the care plan prior to giving care … Adheres to standard/transmission precautions … provides care according to the care plan … Reports changes in clients [sic] condition/hazards in the home ….” 7. Patient #8’s clinical record included an order for the agency to provide HHA services. The record evidenced RN 1 documented HHA supervisory visit notes on 7/17/2023, 8/14/2023, and 9/11/2023. The aide was not present during the visits. The record failed to evidence during the supervisory visits RN 1 ensured the HHA followed Patient’s POC, complied with infection prevention and control policies and procedures, and reported changes in Patient’s condition. During an interview on 8/20/2025 beginning at 12:04 PM, RN 1 reported when Patient’s aide was not present for an HHA supervisory visit, the nurse would not complete the section of the aide supervisory form which included evaluation of the tasks and responsibilities of “… Review the care plan prior to giving care … Adheres to standard/transmission precautions … provides care according to the care plan … Reports changes in clients [sic] condition/hazards in the home ….” 1. Review of the undated Home Health Aide Supervision policy included, but not limited to, “… Supervisory visits are to be documented in the client’s chart on the Home Health Aide Supervision Form…” 2. Review of Patient #1’s clinical record included an order for the agency to provide HHA services. The record evidenced RN 1 documented an HHA supervisory visit note on 05/19/2025, 06/17/2025, 07/15/2025, and 08/13/2025. The aide was not present during the visit. The record failed to evidence during the supervisory visit RN 1 ensured the HHA followed Patient’s POC, complied with infection prevention and control policies and procedures, and reported changes in Patient’s condition. During an interview on 8/20/2025 beginning at 12:04 PM, RN 1 reported when Patient’s aide was not present for an HHA supervisory visit, the nurse would not complete the section of the aide supervisory form which included evaluation of the tasks and responsibilities of “… Review the care plan prior to giving care … Adheres to standard/transmission precautions … provides care according to the care plan … Reports changes in clients [sic] condition/hazards in the home ….” 3. Review of Patient #2’s clinical record included an order for the agency to provide HHA services. The record evidenced RN 1 documented an HHA supervisory visit note on 05/19/2025 and 08/13/2025. The aide was not present during the visit. The record failed to evidence during the supervisory visit RN 1 ensured the HHA followed Patient’s POC, complied with infection prevention and control policies and procedures, and reported changes in Patient’s condition. During an interview on 8/20/2025 beginning at 12:04 PM, RN 1 reported when Patient’s aide was not present for an HHA supervisory visit, the nurse would not complete the section of the aide supervisory form which included evaluation of the tasks and responsibilities of “… Review the care plan prior to giving care … Adheres to standard/transmission precautions … provides care according to the care plan … Reports changes in clients [sic] condition/hazards in the home ….” 4. Review of Patient #4’s clinical record included an order for the agency to provide HHA services. The record evidenced RN 1 documented an HHA supervisory visit note on 07/15/2025 and 08/14/2025. The aide was not present during the visit. The record failed to evidence during the supervisory visit RN 1 ensured the HHA followed Patient’s POC, complied with infection prevention and control policies and procedures, and reported changes in Patient’s condition. During an interview on 8/20/2025 beginning at 12:04 PM, RN 1 reported when Patient’s aide was not present for an HHA supervisory visit, the nurse would not complete the section of the aide supervisory form which included evaluation of the tasks and responsibilities of “… Review the care plan prior to giving care … Adheres to standard/transmission precautions … provides care according to the care plan … Reports changes in clients [sic] condition/hazards in the home ….” 5. Review of Patient #5’s clinical record included an order for the agency to provide HHA services. The record evidenced RN 1 documented an HHA supervisory visit note on 10/14/2024, 01/06/2025, 02/03/2025, 05/06/2025, 06/23/2025, and 07/21/2025. The aide was not present during the visit. The record failed to evidence during the supervisory visit RN 1 ensured the HHA followed Patient’s POC, complied with infection prevention and control policies and procedures, and reported changes in Patient’s condition. During an interview on 8/20/2025 beginning at 12:04 PM, RN 1 reported when Patient’s aide was not present for an HHA supervisory visit, the nurse would not complete the section of the aide supervisory form which included evaluation of the tasks and responsibilities of “… Review the care plan prior to giving care … Adheres to standard/transmission precautions … provides care according to the care plan … Reports changes in clients [sic] condition/hazards in the home ….” 6. During an interview on 08/20/2025 at 2:11 PM, the CM indicated HHA supervisory forms should include, aside from what was on the form, making sure the aide was following the care plan and reporting any patient changes. 410 IAC 17-15-1(a)(7)

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 home health agency failed to ensure the SOC date on the POC was accurate for 6 of 6 active patients admitted since the last recertification survey (Patient #1, 2, 4, 5, 6, 7). Findings include: 5. Patient #6’s clinical record evidenced CM completed an initial and comprehensive assessment on 5/09/2025. The assessment documentation failed to evidence CM provided hands-on, direct care during the visit. The record evidenced agency staff first provided hands-on, direct care on 5/21/2025. POCs for the initial certification period of 5/09/2025 – 7/07/2025 and recertification period of 7/08/2025 – 9/05/2025 evidenced a SOC date of 5/09/2025. The POCs failed to evidence the correct SOC date. During an interview on 8/20/2025 beginning at 1:09 PM, CM reported the agency first provided hands-on, direct care to Patient on 5/21/2025. CM reported she documented the SOC as the date she completed the initial and comprehensive assessment. 6. Patient #7’s clinical record evidenced CM completed an initial and comprehensive assessment on 4/14/2025. The assessment documentation failed to evidence CM provided hands-on, direct care during the visit. The record evidenced agency staff first provided hands-on, direct care on 5/06/2025. POCs for the initial certification period of 4/14/2025 – 6/12/2025, recertification period of 6/13/2025 – 8/11/2025, and recertification period of 8/12/2025 – 10/10/2025 evidenced a SOC date of 4/14/2025. The POCs failed to evidence the correct SOC date. During an interview on 8/20/2025 beginning at 1:22 PM, CM reported the agency first provided hands-on, direct care to Patient on 5/06/2025. CM reported she documented the SOC as the date she completed the initial and comprehensive assessment. 1. Review of the undated Comprehensive Patient Assessment policy included, but not limited to, “… A thorough, well-organized, comprehensive and accurate assessment, consistent with the patients immediate needs will be completed for all patients in a timely manner, but no later than five (5) calendar days after start of care…” 2. Review of Patient #1’s clinical record included an initial comprehensive assessment dated 04/23/2024, which did not include hands on care for Patient #1. The record also included a POC for certification period 06/17/2025 to 08/15/2025. The clinical record included an HHA visit note dated 04/29/2024, the first date which included evidence hands on care was provided to the patient. The POC included a SOC date of 04/23/2024. The POC failed to include the correct SOC date. During an interview on 08/20/2025 at 2:12 PM, the CM indicated the first date the agency provided hands on care for Patient #1 was 04/29/2024. The CM further indicated a comprehensive assessment was not performed within five days after that date. 3. Review of Patient #2’s clinical record included an initial comprehensive assessment dated 01/27/2025, which did not include hands on care for Patient #2. The record also included a POC for certification period 07/26/2025 to 09/23/2025. The clinical record included an HHA visit note dated 02/10/2025, the first date which included evidence hands on care was provided to the patient. The POC included a SOC date of 01/27/2025. The POC failed to include the correct SOC date. During an interview on 08/20/2025 at 2:16 PM, the CM indicated the first date the agency provided hands on care for Patient #2 was 02/10/2025. The CM further indicated a comprehensive assessment was not performed within five days after that date. 4. Review of Patient #4’s clinical record included an initial comprehensive assessment dated 04/25/2025. The record also included a POC for certification period 06/24/2025 to 08/22/2025. The clinical record included an HHA visit note dated 05/06/2025, the first date which included evidence hands on care was provided to the patient. The POC included a SOC date of 04/25/2025. The POC failed to include the correct SOC date. During an interview on 08/20/2025 at 2:25 PM, the CM indicated the first date the agency provided hands on care for Patient #4 was 05/06/2025. The CM further indicated a comprehensive assessment was not performed within five days after that date. 5. Review of Patient #5’s clinical record included an initial comprehensive assessment dated 07/24/2024, which did not include hands on care for Patient #5. The record also included a POC for certification period 07/19/2025 to 09/16/2025. The clinical record included an HHA visit note dated 08/12/2024, the first date on which hands on care was provided to the patient. The POC included a SOC date of 07/24/2024. The POC failed to include the correct SOC date. During an interview on 08/20/2025 at 2:33 PM, the CM indicated the first date the agency provided hands on care for Patient #5 was 08/12/2024. The CM further indicated a comprehensive assessment was not performed within five days after that date.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the discharge summary was sent to the responsible provider for 3 of 3 closed patient records reviewed (Patient #8, 9, 10). Findings include: 3. Patient #8’s clinical record evidenced a discharge date of 10/10/2023. Patient had an unplanned transfer to a local hospital, and his/her services did not resume after hospital discharge. The record failed to evidence the agency sent a transfer summary to the admitting hospital nor a discharge summary to Patient’s physician. During an interview on 8/20/2025 beginning at 1:35 PM, CM reported she was unsure if the agency sent a transfer summary to Patient’s admitting hospital nor a discharge summary to Patient’s physician. 4. Patient #9’s clinical record evidenced a discharge date of 4/24/2025. Patient was discharged for cause due to an “unsafe work environment.” Patient was to begin receiving services from a PSA on 5/01/2025. The record failed to evidence the agency sent a discharge summary to Patient’s ordering provider nor to the receiving PSA. During an interview on 8/20/2025 beginning at 3:35 PM, CM reported the agency did not send a discharge summary to Patient’s ordering provider. During a follow-up interview on 8/21/2025 beginning at 11:10 AM, CM reported there was no documentation which evidenced a discharge summary was sent to Patient's new PSA. 1. Review of the undated Discharge Summary policy included but not limited to “… When a patient is discharged from the agency, the supervising professional shall complete a Discharge Summary form within the time frame defined by the agency. A copy will be mailed to the physician upon request…The Discharge Summary will incorporate findings from the discharge OASIS assessment… If the patient is being referred to another agency or facility, a Transfer Summary form shall also be completed… The original Discharge Summary shall be filed in the clinical record…” 4. Review of Patient #10’s clinical record failed to include documentation a discharge summary was sent to the patient’s responsible provider. During an interview on 08/21/2025 at 12:42 PM, the CM indicated a discharge summary was not sent to the provider for Patient #10.

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 home health agency failed to ensure the HHA was accurately documenting which tasks were performed and which were refused by the patient for 1 of 4 active patients who had home visit observations (Patient #4). Findings include: During an interview on 8/18/2025 beginning at 2:24 PM, Patient #4 reported HHA 5 assisted with cleaning and housekeeping tasks only. Patient stated HHA 5 had not assisted with bathing, dressing, ambulation, or skin care nor had the aide asked Patient if he/she needed assistance with these personal care tasks. 1. Review of the undated Clinical Records/ Medical Record Retention policy included but not limited to “… Clinical records are legal documents containing comprehensive, accurate, and organized information…” 2. Review of the undated Home Health Aide job description included but not limited to “… Completes the appropriate records to document care given and pertinent observations…” 3. Review of Patient #4’s clinical record included aide visit notes from 06/17/2025 to 08/14/2025. All of these aide visit notes reviewed indicated all tasks in the aide care plan had been completed. The aide failed to accurately document tasks refused during HHA visits. 4. During an interview on 08/20/2025 at 9:37 AM, HHA 5 indicated she makes Patient #4’s bed, does their laundry, and converses a lot with the Patient during the visits. HHA 5 indicated she always asked Patient #4 if they wanted a shower, shampoo, and lotion, but he said it was done. HHA 5 further indicated she marked those tasks as complete because the Patient reported them as done. 5. During an interview on 08/20/2025 at 2:25 PM, the CM indicated the aide should not have marked a task as completed because Patient #4 completed it before the HHA had arrived. The CM indicated an HHA should document a task that was completed before the aide entered the home as refused and then put in a note saying it had already been done. 410 IAC 17-15-1(a)(7)

This visit was for a Federal/State complaint survey of a Home Health Provider. Survey Dates: February 3, 4, 5 and 6, 2025 Complaint: IN112454 with related deficiencies cited. 12 Month Unduplicated Skilled Admissions: 13 Abbreviations CM-Clinical Manager, HHA-Home Health Aide, RN-Registered Nurse, POC-Plan of Care, ROC-Resumption of Care, SOC-Start of Care QR A2 2/17/25

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 home health agency failed to ensure the patient received all HHA services as ordered in the plan of care for 4 of 5 records reviewed (Patient #2, 3, 4 and 5). Findings include: 1. The undated agency policy “Home Care Bill of Rights” indicated the patient has the right to receive all services outlined in the plan of care. 2. The undated agency policy “Plan of Care” indicated the client and other agency personnel shall participate in developing the Plan of Care and the client shall be informed of any changes in the Plan of Care. 3. Patient #2’s clinical record evidenced a POC for the certification period 12/27/24 to 2/24/25. The POC included orders for HHA visits two hours a day, five days a week. The record failed to evidence HHA visits were completed five days a week for the weeks of 12/22/24 and 12/29/24. During an interview on 2/5/25 at 1:05 PM, Patient #2 relayed the home health agency doesn’t notify him when they are not making a visit and he is unable to bathe that day by himself. During an interview on 2/6/25 at 9:55 AM, the CM confirmed that Patient #2 did not receive HHA visits as ordered in the POC. 4. Patient #3’s clinical record evidenced a POC for the certification period 1/04/25 to 3/04/25. The POC included orders for HHA visits two hours a day, three days a week. The record failed to evidence HHA visits were completed three days a week for the weeks of 12/15/24, 12/22/24, 12/29/24, 1/05/25, 1/12/25, 1/19/25 and 1/26/25. During an interview on 2/05/25 at 12:44 PM, Patient #3 relayed she requested HHA visits on Mondays, Wednesday and Friday since SOC and she never knew when the HHA’s were scheduled. She had several days when no one showed up and the agency didn’t call to give her notice that the HHA would not be making a visit. She also relayed the agency sent several different HHA’s and she requested one set HHA. During an interview on 2/06/25 at 10:05 AM, the CM confirmed that Patient #3 notified the agency when she went out of town and the clinical record failed to evidence documentation of this. She also relayed the home health agency failed to notify the physician regarding the change in HHA visit frequencies and she confirmed that Patient #3 did not receive HHA visits as ordered in the POC. 5. Patient #4’s clinical record evidenced a POC for the certification period 1/07/25 to 3/07/25. The POC included orders for HHA visits two hours a day, three days a week. The record failed to evidence HHA visits were completed three days a week for the weeks of 12/08/24, 12/15/24, 12/22/24, 12/29/24, 1/12/25 and 1/19/25 and failed to evidence documentation of attempting to reschedule the missed visits. During an interview on 2/06/25 at 10:13 AM, the CM confirmed Patient #4 did not receive HHA visits as ordered in the POC and she confirmed the clinical record did not include documentation of attempts to reschedule any HHA visits. 6. Patient #5’s clinical record evidenced a POC for the certification period 1/16/25 to 3/16/25. The POC included orders for HHA visits two hours a day, five days a week. The record failed to evidence HHA visits were completed five days a week for the weeks of 12/22/24 and 1/05/25 and failed to evidence documentation of attempting to reschedule the missed visits. During an interview on 2/06/25 at 10:20 AM, the CM confirmed Patient #5 did not receive HHA visits as ordered in the POC and she confirmed the clinical record did not include documentation of attempts to reschedule any HHA visits. 410 IAC 17-13-1(a)

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 the POC included accurate medications the patient is taking for 3 of 4 active records reviewed with SOC in the past 6 months (Patient #1, 2 and 3). Findings include: 1. The undated agency policy “Comprehensive Client Assessment” indicated the comprehensive assessment will include a review of all medications the client is using (prescription and nonprescription). 2. The undated agency policy “Plan of Care” indicated the Plan of Care shall be completed in full to include all medications, treatments and procedures. 3. Patient #1’s clinical record evidenced a SOC on 7/24/24 and included a POC and medication profile for the certification period 1/20/25 to 3/20/25. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #1’s medications. During a home visit observation conducted with Patient #1 and HHA 1 on 2/03/25 at 3:00 PM, Surveyor comparison of the home health agency’s POC medication list against the medications in the home evidenced the following discrepancies: -Baclofen (used to treat back pain) 10 milligram (mg), 1 tablet every 8 hours as needed was listed on the POC. This medication was not found in the home. -Loratadine (used to treat allergies) 10 mg, 1 tablet daily was listed on the POC. This medication was not found in the home. During an interview on 2/03/25 at 3:40 PM, Patient #1 relayed she did not have the Baclofen or Loratadine medications in the home and she had not been taking the medications for several months. 4. Patient #2’s clinical record evidenced a SOC on 8/29/24, a ROC on 12/30/24 and included a POC and medication profile for the certification period 12/27/24 to 2/24/25. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #2’s medications during the ROC visit on 12/30/24. During a home visit observation conducted with Patient #2 and HHA 2 on 2/04/25 at 1:05 PM, Surveyor comparison of the home health agency’s POC medication list against the medications in the home evidenced the following discrepancies: -Torsemide (used to treat heart failure) 10 mg, 2 tablets on Monday, Wednesday and Friday was found in the home. This medication was listed on the POC as 1 tablet twice a day on M-W-F. -Lantus Solustar Pen 100 units/ml (used to treat diabetes) was found in the home. This medication was listed on the POC as 15 units daily. Patient #2 stated he is taking 15 units twice a day. -Breo-Ellipta (used to treat asthma) 100/25 microgram (mcg) Inhaler was found in the home. The POC failed to evidence this medication listed. Patient #2 stated he is taking this inhaled once a day. -Albuterol Sulfate (used to treat asthma) 90 mcg inhaler was found in the home. The POC failed to evidence this medication listed. Patient #2 stated he used this inhaler as needed. During an interview on 2/04/25 at 1:15 PM, Patient #2 relayed the Lantus was prescribed on 12/27/24 and he has been using the Breo-Ellipta and Albuterol Sulfate inhalers for a year. 5. Patient #3’s clinical record evidenced a SOC on 9/27/24 and included a POC and medication profile for the certification period 1/04/25 to 3/04/25. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #3’s medications during the comprehensive assessment visit on 1/03/25. Review of the medication list on the POC for Patient #3 failed to evidence a muscle relaxer listed. During an interview on 2/05/25 at 3:56 PM, Patient #3 relayed she was prescribed Cyclobenzaprine (a muscle relaxer) from the pain clinic and she had been taking this medication for a long time for chronic back and neck pain. During an interview on 2/06/25 at 10:25 AM, the CM confirmed the POC for Patient #3 did not include a muscle relaxer. 410 IAC 17-13-1(a)(1)(C)(ix)

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 home health agency failed to document ROC orders were received from the attending practitioner for 1 of 1 active record reviewed with a ROC (Patient #2). Findings include: 1. The undated agency policy “Physician Orders” indicated all medications and treatments, that are part of the client’s plan of care, must be ordered by a physician, all verbal orders must be “read back” to the physician to verify the accuracy of the orders and to decrease errors to inaccurate documentation of verbal orders and the order must include the date, specific order, be signed with full name and title of person receiving the order and be sent to the physician for signature. 2. The undated agency policy “Comprehensive Client Assessment” indicated the resumption of care assessment identifies changes in diagnosis and/or service needs and a verbal order to resume care and for any changes in the plan of care will be sent to the physician. 3. The undated agency policy “Patient Reassessment/Update of Comprehensive Assessment” indicated physician orders will be completed for all reassessment visits and/or verbal orders for changes to the (485) plan of care. 4. Patient #3’s clinical record evidenced a hospital hold from 12/26/24 to 12/29/24, a ROC assessment completed on 12/30/24 and included a POC for the certification period 12/27/24 to 2/24/25. The record failed to evidence documentation of collaboration with the attending practitioner for the ROC. 5. During an interview on 2/06/25 at 9:55 AM, the CM relayed she did not collaborate with the attending practitioner for ROC orders.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 3 of 4 patient records reviewed who were admitted within the past 6 months (Patient #2, 3 and 4). Findings include: 1. The undated agency policy “Physician Orders” indicated all medications and treatments, that are part of the client’s plan of care, must be ordered by a physician, all verbal orders must be “read back” to the physician to verify the accuracy of the orders and to decrease errors to inaccurate documentation of verbal orders and the order must include the date, specific order, be signed with full name and title of person receiving the order and be sent to the physician for signature. 2. Patient #2’s clinical record included a POC for the certification period 12/27/24 to 2/24/25 with orders for HHA visit frequencies of two hours a day, five days a week. The record evidenced HHA visits were performed on 12/30/24, 1/01/25, 1/02/25, 1/03/25, 1/06/25, 1/07/25, 1/08/25, 1/09/25, 1/10/25, 1/13/25 and 1/14/25. The clinical record for Patient #2 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 2/06/25 at 9:55 AM, the CM relayed she did not obtain a verbal order from the attending practitioner for the recertification POC. 3. Patient #3’s clinical record included a POC for the certification period 1/04/25 to 3/04/25 with orders for HHA visit frequencies of two hours a day, three days a week. The record evidenced HHA visits were performed on 1/08/25, 1/10/25, 1/14/25, 1/16/25, 1/23/25, 1/28/25, 1/30/25 and 2/04/25. The clinical record for Patient #3 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 2/06/25 at 10:05 AM, the CM relayed she did not obtain a verbal order from the attending practitioner for the recertification POC. 4. Patient #4’s clinical record included a POC for the certification period 1/07/25 to 3/07/25 with orders for HHA visit frequencies of two hours a day, three days a week. The record evidenced HHA visits were performed on 1/08/25 and 1/10/25. The clinical record for Patient #3 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 2/06/25 at 10:13 AM, the CM relayed she did not obtain a verbal order from the attending practitioner for the recertification POC. 410 IAC 17-13-1(a)

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to review the POC with the attending practitioner during the ROC for 1 of 1 active record reviewed with a ROC (Patient #2). Findings include: 1. The undated agency policy “Physician Orders” indicated all medications and treatments, that are part of the client’s plan of care, must be ordered by a physician, all verbal orders must be “read back” to the physician to verify the accuracy of the orders and to decrease errors to inaccurate documentation of verbal orders and the order must include the date, specific order, be signed with full name and title of person receiving the order and be sent to the physician for signature. 2. The undated agency policy “Comprehensive Client Assessment” indicated the resumption of care assessment identifies changes in diagnosis and/or service needs and a verbal order to resume care and for any changes in the plan of care will be sent to the physician. 3. The undated agency policy “Patient Reassessment/Update of Comprehensive Assessment” indicated physician orders will be completed for all reassessment visits and/or verbal orders for changes to the (485) plan of care. 4. Patient #3’s clinical record included a SOC on 8/29/24 and evidenced a hospital hold from 12/26/24 to 12/29/24. A ROC assessment was completed on 12/30/24. The record failed to evidence documentation of collaboration with the attending practitioner for the ROC POC. 5. During an interview on 2/06/25 at 9:55 AM, the CM relayed she did not collaborate with the attending practitioner regarding the ROC POC. 410 IAC 17-13-1(a)(2)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the physician or allowed practitioner was promptly notified of the need to alter the POC related to missed visits for 4 of 5 patient records reviewed (Patient #2, 3, 4 and 5). Findings include: 1. The undated agency policy “Home Care Bill of Rights” indicated the patient has the right to receive all services outlined in the plan of care. 2. The undated agency policy “Plan of Care” indicated professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care. 3. Patient #2’s clinical record evidenced a POC for the certification period 12/27/24 to 2/24/25. The POC included orders for HHA visits two hours a day, five days a week. The record failed to evidence HHA visits were completed five days a week for the weeks of 12/22/24 and 12/29/24 and failed to include documentation of collaboration with the attending practitioner regarding the need to alter the POC frequencies. During an interview on 2/6/25 at 9:55 AM, the CM confirmed that Patient #2 did not receive HHA visits as ordered in the POC and she confirmed the clinical record failed to evidence documentation of collaboration with the attending practitioner regarding the need to alter the POC frequencies. 4. Patient #3’s clinical record evidenced a POC for the certification period 1/04/25 to 3/04/25. The POC included orders for HHA visits two hours a day, three days a week. The record failed to evidence HHA visits were completed three days a week for the weeks of 12/15/24, 12/22/24, 12/29/24, 1/05/25, 1/12/25, 1/19/25 and 1/26/25 and failed to include documentation of collaboration with the attending physician regarding the need to alter the POC frequencies. During an interview on 2/06/25 at 10:05 AM, the CM confirmed that Patient #3 did not receive HHA visits as ordered in the POC and the clinical record failed to evidence documentation of collaboration with the attending physician regarding the need to alter the POC frequencies. 5. Patient #4’s clinical record evidenced a POC for the certification period 1/07/25 to 3/07/25. The POC included orders for HHA visits two hours a day, three days a week. The record failed to evidence HHA visits were completed three days a week for the weeks of 12/08/24, 12/15/24, 12/22/24, 12/29/24, 1/12/25 and 1/19/25 and failed to include documentation of collaboration with the attending physician regarding the need to alter the POC frequencies. During an interview on 2/06/25 at 10:13 AM, the CM confirmed Patient #4 did not receive HHA visits as ordered in the POC and she confirmed the clinical record did not include documentation of collaboration with the attending physician regarding the need to alter the POC frequencies. 6. Patient #5’s clinical record evidenced a POC for the certification period 1/16/25 to 3/16/25. The POC included orders for HHA visits two hours a day, five days a week. The record failed to evidence HHA visits were completed five days a week for the weeks of 12/22/24 and 1/05/25 and failed to include documentation of collaboration with the attending physician regarding the need to alter the POC frequencies. During an interview on 2/06/25 at 10:20 AM, the CM confirmed Patient #5 did not receive HHA visits as ordered in the POC and the clinical record did not include documentation of collaboration with the attending physician regarding the need to alter the POC frequencies. 410 IAC 17-13-1(a)(2)

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 home health agency failed to ensure staff followed agency infection control policies and procedures related to hand hygiene for 1 of 1 home visit observation performed (HHA #1). Findings include: 1. The undated agency policy “Handwashing/Hand Hygiene” indicated hand washing and hand antisepsis indications are to be done after removing gloves, before eating, drinking, handling food or serving food. 2. During a home visit observation conducted with Patient #1 and HHA 1 on 2/03/25 at 3:00 PM, HHA 1 was observed assisting Patient #1 with a shower. After washing Patient #1’s back, HHA 1 removed her gloves. HHA 1 failed to perform hand hygiene and failed to apply new gloves for the duration of the shower. Later during the visit, HHA 1 was observed preparing a meal for Patient #1. HHA 1 removed 2 frozen chicken fingers from a bag and placed them in the air fryer to cook. HHA 1 failed to wear gloves while touching the food. 3. During an interview on 2/04/25 at 3:03 PM, HHA 1 stated she was nervous during the home visit observation and she confirmed gloves should have been worn for the entire shower and when handling food. 4. During an interview on 2/04/25 at 3:10 PM, the CM relayed hand hygiene should have been performed when removing gloves and gloves should have been worn during the shower and when preparing food. 410 IAC 17-12-1(m)

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 home health agency failed to ensure all entries in the clinical record were appropriately authenticated, dated and timed for 4 of 5 patient records reviewed (Patient #2, 3, 4 and 5). Findings include: 1. The undated agency policy “Clinical Documentation” indicated a separate note shall be completed for each visit and signed and dated by the appropriate professional and the actual time of the patient visit will be included in each note 2. Patient #2's clinical record evidenced a ROC comprehensive assessment performed on 12/30/24 by the CM. The comprehensive assessment visit note failed to evidence a time in and time out and failed to evidence the date and time the patient and the nurse signed the comprehensive assessment. During an interview on 2/06/25 at 9:55 AM, the CM relayed the comprehensive assessment was completed on 12/30/24 and confirmed the comprehensive assessment visit note failed to include visit times and failed to include signatures of the patient and nurse on the visit note. 3. Patient #3's clinical record evidenced a comprehensive assessment performed on 1/03/25 by the CM. The comprehensive assessment visit note failed to evidence a time in and time out; failed to evidence the date and time the patient signed the visit note and failed to evidence the time the CM signed the visit note. During an interview on 2/06/25 at 10:05 AM, the CM relayed the comprehensive assessment was completed on 1/03/25 and confirmed the comprehensive assessment visit note failed to include a time in and out and failed to include a time when the patient and nurse signed the visit note. 4. Patient #4's clinical record evidenced a comprehensive assessment performed on 1/06/25 by the CM. The comprehensive assessment visit note failed to evidence time in and time out; failed to evidence the date and time the patient signed and failed to evidence the time the CM signed the visit note. During an interview on 2/06/25 at 10:13 AM, the CM relayed the comprehensive assessment was completed on 1/06/25 and confirmed the comprehensive assessment visit note failed to include a time in and out; failed to include a date and time the patient signed and failed to include the time the nurse signed the visit note. 5. Patient #5's clinical record evidenced a comprehensive assessment performed on 1/13/25 by the CM. The comprehensive assessment visit note failed to evidence a time in and time out; failed to evidence the date and time the patient signed and failed to evidence the time the CM signed the comprehensive assessment. During an interview on 2/06/25 at 10:20 AM, the CM relayed the comprehensive assessment was completed on 1/13/25 for Patient #5 and confirmed the comprehensive assessment visit note failed to include a time in and out; failed to include a date and time the patient signed and failed to include the time the nurse signed the visit note. 410 IAC 17-15-1(a)(7)

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to follow their own policy and failed to ensure the Plan of Care was followed for 2 of 2 active clinical records reviewed receiving skilled nursing services (Patient #1 and 9). Findings include: 1. Review of Policy #2.06 “Care Planning/ 485” indicated all staff should follow the doctor ordered POC and indicated all services were to be performed only as ordered by the physician. 2. Review of Patient #1’s clinical record evidenced a POC (plan of care) for certification period 02/11/2023 – 04/11/2023 included orders for SN (skilled nursing) services for 6 - 8 hours per day, 3 - 5 days per week and indicated to flush feed tube with 60 ml (milliliters) of water before and after each feed. During a home visit observation on 04/10/23 beginning at 2:01 PM, observed LPN #1 flushed the feed tube with 30 ml of water prior to the feed. When asked about the flush, LPN #1 confirmed they flushed the feed tube with 30 ml of water before the feed. The agency failed to ensure the POC was followed as ordered by the physician. 3. Review of Patient #9’s clinical record evidenced a POC for certification period 04/01/2023 – 05/30/2023 which included orders for SN services for 10 - 12 hours per day, 1 - 3 days per week. The clinical record evidenced skilled nursing visits were conducted on 03/06/2023, 03/13/2023, 04/03/2023, and 04/10/2023, each with a duration of 8.0 hours. During an interview on 04/11/2023 at 01:04 PM, the Clinical Manager indicated they were not aware the patient had been receiving SN visits for a shorter time than ordered. The agency secretary indicated the patient had a different nurse on Mondays who was available for fewer hours, and scheduled a nurse for less than the ordered number of hours. The agency failed to ensure the POC was followed as ordered by the physician.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all clinical records were safeguarded against loss or unauthorized use for 1 of 2 home visit observations (Patient #5) and 1 of 1 clinical manager office observation (Patients #5, #12, #13, and #15). Findings include: Review of agency job description #HC-103 for the position of “Director of Nursing” (Clinical Manager), revised 07/2017, indicated the clinical manager’s “Essential Functions/Areas of Accountability” included but were not limited to “… 15. Assures clinical records are maintained in compliance with state and federal laws ….” Review of agency job description #HC-107 for the position of “Home Health Aide,” revised 07/2017, indicated the aide’s “Essential Functions/Areas of Accountability” included but were not limited to “… 5. Documents care provided and completes the forms required for the client’s records … 9. Maintains confidentiality in all aspects of the job ….” During a home visit observation conducted with Patient #13 (start of care 11/07/2022) and Home Health Aide #8 on 02/17/2023 starting at 9:00 AM, the aide reported they documented their visit notes on paper and the notes were kept in a folder, which was observed in Patient #13’s home. Review of HHA #8’s folder evidenced both blank and completed visit notes for Patient #5 (start of care 09/26/2022). During an interview with the Clinical Manager conducted on 02/17/2023 starting at 2:13 PM, the Clinical Manager stated staff should have a separate folder for each patient’s information and records. The Clinical Manager confirmed staff should not bring clinical records for patients into homes of other patients. During an observation of the Clinical Manager’s office conducted on 02/21/2023 starting at 4:28 PM, clinical records containing completed HHA visit notes for Patients #5, #12 (start of care 10/24/2022), #13, and #15 (start of care 10/21/2022) were observed on an open bookshelf in the office. The agency failed to evidence the records were secured to prevent access from restricted personnel or office visitors. The Clinical Manager was present for the observation and confirmed the clinical records were not kept in a secured location. 410 IAC 17-15-1(c)

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’s Governing Body failed to approve the frequency and detail of data collection for the agency’s quality analysis and performance improvement (QAPI) program, which had the potential to affect all agency staff and patients. Findings include: An agency policy #1.14 titled “QAPI Program & PIP,” revised 07/15/2021, indicated but was not limited to “… Procedure: … 8. The frequency and detail of the data collection must be approved by the governing body ….” The minutes from the agency’s joint QAPI and governing body meeting, dated 12/04/2022, indicated but was not limited to “… Governing Body. All findings have been reported. Recommendations: Will present to … QAPI … Actions: Governing body will report to QAPI. Responsible Party: Governing Body ….” The minutes failed to evidence the Governing Body approved the frequency and detail of data collection for the agency’s quality indicators within its QAPI program. During an interview conducted on 12/14/2022 at 4:26 PM with the Administrator and Clinical Manager, the Administrator confirmed the 12/04/2022 meeting was the only meeting held by the Governing Body since the 10/21/2022 Federal survey. The Administrator also confirmed they and Clinical Manager had decided on the quality indicators the QAPI program would track.

This visit was for a Federal Recertification and State Re-licensure survey of a home health agency Provider. Survey Dates: October 17, 18, 19, 20, and 21, 2022 Current Census: 20 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. During this Federal Recertification Survey, Hometown Home Healthcare was found to be out of compliance with Conditions of Participation 484.65 Quality assessment and performance improvement (QAPI) and 484.70 Infection prevention and control. Based on the Condition-level deficiencies during the October 21, 2022, survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on October 18, 2022. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from providing its own home health aide training and competency evaluation programs for a period of two years beginning October 21, 2022 and continuing through October 20, 2024. QR: Area 2 11/02/22

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 observation, record review, and interview, the home health agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health and psychosocial status for 2 of 5 active records reviewed (Patients #2 and 5). Findings include: The clinical record of Patient #2 was reviewed on 10/18/2022 and included plans of care for the certification periods of 07/31/2022 – 09/28/2022 and 09/29/2022 – 11/27/2022. The plans of care indicated the patient’s initial start of care was 06/11/2020, however due to the agency’s change of electronic medical record (EMR) system, Patient #2 was discharged then readmitted on 09/29/2022 with a new start of care date of 09/29/2022. The patient’s diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), Borderline Personality Disorder, and anxiety. The record included a comprehensive assessment completed on 09/29/2022 by the Clinical Manager. The comprehensive assessment failed to evidence a complete and thorough assessment of Patient #2’s COPD, Borderline Personality Disorder, and anxiety disorder, including the presence or absence of symptoms of these diseases/disorders. A home visit observation was conducted on 10/18/2022 at 11:34 AM with Patient #2. During the visit, Patient #2 was observed to have a dry hacking cough which produced sputum (color and consistency not observed). When queried if the cough was new or chronic, the patient confirmed the cough was chronic. The comprehensive assessment failed to evidence the presence of a chronic cough. An interview was conducted on 10/19/2022 at 3:53 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager confirmed the comprehensive assessment should include an assessment of the patient’s current health and psychosocial status. Policy 2.05 titled “Comprehensive Assessment,” dated 12/10/2019, indicated but was not limited to “…the clients current health, psychosocial, functional and cognitive status…the assessment should paint a picture of the clients status to assist the HHA in developing the care plan… assessment of the clients current health status include… all active health and medical problems…”

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 home health agency failed to ensure the comprehensive assessment contained a medication list which included indication for administration for as-needed (PRN) medications for 1 of 5 active records reviewed (Patient #2). Findings include: An agency policy #2.05 titled “Comprehensive Assessment,” dated 12/10/2019, indicated but was not limited to “… Procedure … The clients clinical record should identify all medications client is taking (both prescription and OTC [over-the-counter]) ….” The clinical record of Patient #2 was reviewed on 10/18/22 and included a plan of care for the certification period of 09/29/2022 to 11/27/2022 with start of care on 09/29/22. The record included a medication list, reviewed and signed by the Clinical Manager, on 09/29/22, which indicated the patient was currently prescribed Albuterol (medication given to treat shortness of breath and/or wheezing) nebulizer every 4-6 hours as needed, Tylenol (OTC medication given to treat pain and/or fever) every 6 hours as needed, and Albuterol inhaler every 4 hours as needed. The medication list failed to evidence the indication for administration for the as needed medications. An interview was conducted on 10/18/22 at 3:38 PM with the Administrator and Clinical Manager. When queried if the medication list should include indications for administration of the as needed medications, the Clinical Manager stated “we could put that on there.”

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the comprehensive assessment completed at the time of discharge accurately reflected the patient’s current wound status for 1 of 1 discharge records reviewed of a patient with a wound (Patient #6). Findings included: An agency policy #2.05 titled “Comprehensive Assessment,” dated 12/10/2019, indicated, but not limited to, “Procedure: … The clients current health … status … update of the comprehensive assessment at discharge.” The clinical record of Patient #6 was reviewed on 10/20/22 and included a plan of care for the certification period 03/06/22 to 05/04/22 with a start of care 07/09/2021. The record indicated the patient was discharged on 04/13/22 per patient request. The plan of care included physician orders for skilled nursing visits 1-3 hours per visit, 1-3 visits per day, 5-7 days per week for 8 weeks then 2-4 days per week for 1 week and nursing interventions included, but not limited to, “complete wound care daily.” The record included skilled nursing visits completed by Former Registered Nurse (RN) #1 on 04/08/22 at 5 PM, 04/09/2022 at 5 PM, 04/10/22 at 5 PM, 04/11/22 at 9 AM, 04/12/22 at 2 PM, and 04/13/22 at 5 PM which indicated Patient #6’s pressure ulcer to the left ischium (lower back portion of the hip bone) was closed and healed and the pressure ulcer wound to the right buttock measured 5.5 centimeters (cm) in length by 3.5 cm in width by 1.0 cm in depth. The record included a discharge assessment, completed on 04/13/22 by Former Clinical Manager #1, which indicated the patient’s left ischium pressure ulcer measured 0.25 cm in length by 0.25 in width by 0.25 cm in depth and the right buttock pressure ulcer measured 5.5 cm in length by 4.5 cm in width by 1.0 cm in depth. The discharge comprehensive assessment failed to evidence an accurate status of Patient #6’s wounds. An interview was conducted on 10/21/22 at 3:32 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager confirmed the wound measurements documented on a discharge comprehensive assessment should align with the measurements documented on recent skilled nursing visits.

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 and follow their own policy and include within the Plan of Care all required elements for 7 of 7 patient records reviewed (Patient #1, 2, 3, 4, 5, 6, and 7). Findings include: Findings included: Policy 2.06 titled “Care Planning,” dated 12/11/2019, indicated but not limited to “… the individualized plan of care must include the following:... all medications and treatments… safety measures to protect against injury… description of the clients risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors… any additional items the HHA or doctor may choose to include…” The clinical record of Patient #1 indicated a start of care date of 09/15/2016. The Plan of Care (POC) for certification period 08/15/2022 – 10/14/2022 failed to include risk for hospitalization and emergency department visits. The clinical record of Patient #3 indicated a start of care date of 10/07/2022. The Plan of Care (POC) for certification period 10/07/2022 – 12/05/2022 failed to include risk for hospitalization and emergency department visits. The clinical record of Patient #4 indicated a start of care date of 03/20/2020. The Plan of Care (POC) for certification period 09/06/2022 – 11/04/2022 failed to include risk for hospitalization and emergency department visits. The clinical record of Patient #7 indicated a start of care date of 12/02/2020. The Plan of Care (POC) for certification period 03/27/2022 – 05/25/2022 failed to include risk for hospitalization and emergency department visits. During an interview on 10/18/2022 beginning at 3:38PM, the clinical manager (CM) confirmed the vital sign parameters on the POC should match the vital sign parameters in the comprehensive assessment and confirmed PRN medications on the POC should have indications. During an interview on 10/19/2022 beginning at 3:53PM, the CM confirmed the safety measures on the Plan of Care should include all safety measures identified in the comprehensive assessment and confirmed the POC should include risk for emergency department (ED) visits and hospitalization and should also include interventions for those assessed as high risk for ED visits and hospitilizations. During an interview on 10/20/2022 beginning at 4:08PM, the CM confirmed goals on the POC should be measurable. The clinical record of Patient #2 was reviewed on 10/18/2022 and included plans of care for the certification periods of 07/31/2022 – 09/28/2022 and 09/29/2022 – 11/27/2022. The plans of care indicated the patient’s initial start of care was 06/11/2020, however due to the agency’s change of electronic medical record (EMR) system, Patient #2 was discharged then readmitted on 09/29/2022 with a new start of care date of 09/29/2022. The record included a comprehensive assessment completed on 09/29/2022 by the Clinical Manager. The plan of care for the certification period 09/29/2022 – 11/27/2022 failed to evidence safety measures which followed the safety measures indicated on the comprehensive assessment and failed to evidence hospitalization risk factors which followed the hospitalization risk factors indicated on the comprehensive assessment. The plan of care also included two separate sets of vital sign call parameters, one of which did not follow the vital sign call parameters indicated on the comprehensive assessment. Patient #2’s clinical record included a document titled “Indiana Health Care Representative Appointment,” signed by the patient and Clinical Manager on 09/28/2022, which indicated the patient named a health care representative. The plan of care failed to evidence Patient’s #2 health care representative with its Advance Directives section. Patient #5 Patient #6

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to notify the patient’s physician of missed visits according to agency policy and failed to promptly obtain clarification orders for discrepancies regarding the patient’s medications for 2 of 5 active records reviewed (#2, 5). Findings include: 1. An agency policy #3.05 titled “Missed Visit Documentation,” dated 05/21/2020, indicated but was not limited to “… Procedure: … 5. The Clinical Manager will complete a notification to the MD, informing the MD of the missed visit.” 2. An agency policy #2.55 titled “Medication Set Up Policy,” last revised 06/29/2019, indicated but was not limited to “… Instructions … 3. The medication list is current and updated with physician orders as changes occur … 10. The nurse will document and report any issues noted in regard to noncompliance … involving medication/drugs.” 3. The clinical record of Patient #2 was reviewed on 10/18/2022 and included plans of care [POC] for the certification periods of 07/31/22 to 09/28/22 and 09/29/22 to 11/27/22. The POC's indicated the patient’s initial start of care [SOC] was 06/11/2020 and due to the agency’s change of electronic medical record (EMR) system, Patient #2 was discharged then readmitted on 09/29/22 with a new SOC date of 09/29/22. The POC for the certification period of 07/31/22 to 09/28/22 included orders for home health aide visits for 2 hours per visit, 3 visits per week, and included, but was not limited to, “Orders for Discipline and Treatments … Visits may be altered due to weather, MD appointments and per patient request. No need to notify the MD of these types of changes to the [plan of care] ….” The record indicated aide visits were missed on 08/31/22 (no reason noted), 09/23/22 (no reason noted), and 09/26/22 (no reason noted). The record failed to evidence the patient’s physician was notified of the missed visits according to agency policy. A. The record included a physician order, dated 10/02/22 and signed by the Clinical Manager, which included, but was not limited to, “During medication reconciliation, it was noted that the medication in the home that client is taking do not match MD’s medication list. Please see medication list sent with order for all current medications. Please clarify and verify medications. Please let us know if any changes? Yes or No ….” The record included medical records for Patient #2’s visit with their primary care provider (PCP) on 08/23/22. The visit note included a medication list which, when compared with the agency’s medication list completed and signed by the Clinical Manager on 09/29/22, differed in the following ways with the following medications: B. The agency’s medication list did not include medications which were included on the PCP’s medication list: Cyclobenzaprine (given to relax muscles and treat a variety of musculoskeletal conditions), EpiPen (given to treat emergency allergic reaction), Lipitor (given to treat high cholesterol), Magnesium Citrate (supplement given to treat a variety of conditions resulting from low magnesium blood levels), Multivitamin, Nicoderm C-Q Clear (given to treat cravings for tobacco while quitting smoking), Nitrostat (given to treat chest pain, typically as needed), Sertraline (given to treat depression, anxiety, and other psychological conditions), Ventolin HFA (inhaler given to treat shortness of breath and/or wheezing), and Vitamin B6 (OTC supplement). C. The agency’s medication list indicated the patient was taking an Albuterol inhaler, however this medication was not included on the PCP’s medication list. D. The dose of the medication on the agency’s list differed from the PCP’s medication list for the following medications: Mucinex Extended Release (OTC medication given to treat a cough) listed as 1200 milligrams (mg), 1 tablet daily on the agency list and 600 mg, 1 tablet twice a day on the PCP list. Omeprazole (given to treat acid reflux) was listed as 1 capsule once a day on the agency list and 1 capsule once a day as needed on the PCP list. Vitamin C (OTC supplement) listed as 500 mg, 2 tabs twice a day, on agency list and 250 mg, 1 tab once a day on the PCP list. Vitamin D3 (OTC supplement) listed as 10,000 international units once a day on agency list and 5,000 international units once a day on the PCP list. The record failed to evidence the agency had received the physician order back from the PCP clarifying the above discrepancies. An interview was conducted on 10/18/2022 at 3:38 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager was unsure of the specific medications which differed from the PCP’s medication list nor if the agency had received a clarification order back from the PCP. When queried how the patient was to know which medications or dosages to take, the Clinical Manager stated Patient #2 would take or not take whichever medications they wanted to, regardless of if and how they were ordered. 4. The clinical record of Patient #5 was reviewed on 10/19/22 and included plans of care for the certification periods of 08/02/22 to 09/30/20 and 09/26/22 to 11/24/22. The POC for the certification period 08/02/22 – 09/30/22 indicated the SOC was 12/16/2019 and due to the agency’s change of electronic medical record (EMR) system, Patient #5 was discharged then readmitted on 09/26/22 with a new SOC date of 09/26/22. The POC for the certification period 08/02/22 to 09/30/22 included orders for home health aide visits for 2 hours per visit, 3-5 visits per week, and included, but was not limited to, “Orders for Discipline and Treatments … Visits may be altered due to weather, MD appointments and per patient request. No need to notify the MD of these types of changes to the [plan of care].” The record indicated aide visits were missed on 08/12/22 (no reason for missed visit noted), 09/14/22 (per patient request), and 09/16/22 (no reason for missed visit noted) and visits were conducted for less than the ordered duration on 08/24/22 (1.75 hours), 09/03/22 (1.25 hours), 09/04/22 (1.5 hours), and 09/12/22 (1.75 hours). The record failed to evidence the physician was notified of the missed visits per agency policy. 5. An interview was conducted on 10/19/2022 at 3:53 PM with the Administrator and Clinical Manager. During the interview, the Administrator indicated the agency was advised by the previous clinical manager there was no requirement to notify the physician of a missed visit since the POC indicated physician notification was not required for missed visit which occurred due to weather changes, doctor appointments, or patient request, therefore the agency had not been sending missed visit notifications to the attending physician. 410 IAC 17-13-1(a)(2)

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure its quality assessment and performance improvement (QAPI) program measured, analyzed, and tracked quality indicators and failed to evidence measurable improvement in quality indicators which would improve patient health outcomes, safety, and quality of care (see G642), failed to ensure its QAPI program took actions aimed at performance improvement which focused on high risk, high volume, or problem-prone areas (see G656), failed to ensure its QAPI program conducted at least one performance improvement project (PIP) each calendar year depending on the scope, complexity, and past performance of the agency’s services and operations, which included documenting the PIP(s) undertaken, the reason for conducting the project, and the measurable progress achieved on the project (see G658). Based on record review and interview, the governing body failed to ensure an ongoing program for its quality improvement and patient safety was maintained, failed to ensure the agency-wide QAPI efforts addressed priorities for improved quality of care and patient safety, and failed to ensure the QAPI program evaluated improvement actions for effectiveness (see G660). The cumulative effects of these systemic problems resulted in the agency failing to maintain an effective, ongoing, agency-wide, data drive QAPI program, which resulted in the agency being found out of compliance with Condition of Participation 42 CFR 484.65 Quality assessment and performance improvement.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure its quality assessment and performance improvement (QAPI) program measured, analyzed, and tracked quality indicators and failed to evidence measurable improvement in quality indicators which would improve patient health outcomes, safety, and quality of care, which had the potential to affect all agency patients and employees. Findings included: 1. An agency policy #5.51 titled “QAPI Program & PIP [Performance Improvement Project],” last revised 07/15/2021, indicated but was not limited to “… Procedure: … 1. Be able to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, client safety, and quality of care. 2. Measure, analyze, and track quality indicators ….” 2. Agency documents titled “Agency Monthly Management Meeting Agenda,” confirmed by the Alternate Administrator as the agency’s monthly QAPI quality indicator tracking for the months of October 2021 through September 2022, were reviewed on 10/21/2022. The documents failed to evidence the agency tracked any quality indicators for the months of May 2022, June 2022, July 2022, and August 2022. The September 2022 documents failed to evidence the agency tracked all of the quality indicators for the month. 3. An interview was conducted on 10/21/2022 at 1:27 PM with the Alternate Administrator. During the interview, the Alternate Administrator confirmed they were responsible for obtaining and documenting the agency’s quality indicators as part of its QAPI program and reported they had been unable to obtain the quality indicators for the above months due to multiple changes in electronic medical record (EMR) systems and several different people in the role of the clinical manager. 4. The agency’s Governing Body minutes for meetings held 02/29/2021 – 08/31/2022, confirmed by the Administrator as both the agency’s Governing Body meeting minutes and QAPI meeting minutes, were reviewed on 10/21/2022. The minutes indicated meetings were held on 02/29/2021, 07/27/2021, 08/29/2021, 12/15/2021, 03/01/2022, 05/16/2022, 05/26/2022, 06/29/2022, and 08/31/2022. Each meeting minute documentation included, but was not limited to, “… QAPI Update: Board received update from [Alternate Administrator] on QAPI activities. We will continue the same as we have been with no changes ….” The meeting minutes failed to evidence the agency analyzed and/or investigated any trends in quality indicators and failed to evidence measurable improvement in indicators. 5. An interview was conducted on 10/21/2022 at 3:32 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager reported they are new to the role and had not been trained on QAPI yet. 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 home health agency failed to ensure its quality assessment and performance improvement (QAPI) program took actions aimed at performance improvement which focused on high risk, high volume, or problem-prone areas, which had the potential to affect all agency patients and employees. Findings included: 1. An agency policy #5.51 titled “QAPI Program & PIP [Performance Improvement Project],” last revised 07/15/2021, indicated but was not limited to “… Procedure: … 7. The data collected must … identify opportunities for improvement … 9. Performance improvement activities must have: a. Focus on high risk, high volume, or problem-prone areas. 2. The agency’s Governing Body minutes for meetings held 02/29/2021 – 08/31/2022, confirmed by the Administrator as both the agency’s Governing Body meeting minutes and QAPI meeting minutes, were reviewed on 10/21/2022. The minutes indicated meetings were held on 02/29/2021, 07/27/2021, 08/29/2021, 12/15/2021, 03/01/2022, 05/16/2022, 05/26/2022, 06/29/2022, and 08/31/2022. Each meeting minute documentation indicated but was not limited to “… QAPI Update: Board received update from [Alternate Administrator] on QAPI activities. We will continue the same as we have been with no changes ….” The meeting minutes failed to evidence the agency took actions aimed at performance improvement which focused on high risk, high volume, or problem-prone areas. 3. An interview was conducted on 10/21/2022 at 3:32 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager reported they are new to the role and had not been trained on QAPI 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 home health agency failed to ensure its quality assessment and performance improvement (QAPI) program conducted at least one performance improvement project (PIP) each calendar year depending on the scope, complexity, and past performance of the agency’s services and operations, which included documenting the PIP(s) undertaken, the reason for conducting the project, and the measurable progress achieved on the project, which had the potential to affect all agency patients and staff. Findings included: 1. An agency policy #5.51 titled “QAPI Program & PIP [Performance Improvement Project],” last revised 07/15/2021, indicated but was not limited to “… Performance Improvement Projects. 1. Hometown must take actions aimed at performance improvement and, after implementing those actions, must measure its success and track performance to ensure that improvements are sustained … 6. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the agency’s services and operations. a. Hometown must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. b. Have at least one performance project either in development, ongoing, or completed each calendar year ….” 2. An interview was conducted on 10/21/2022 at 1:27 PM with the Alternate Administrator. During the interview, the Alternate Administrator stated they had never heard of a PIP prior to the survey and confirmed the agency had no current performance improvement activities or projects. 3. The agency’s Governing Body minutes for meetings held 02/29/2021 – 08/31/2022, confirmed by the Administrator as both the agency’s Governing Body meeting minutes and QAPI meeting minutes, were reviewed on 10/21/2022. The meeting minutes failed to evidence performance improvement projects were conducted by the agency. 4. An interview was conducted on 10/21/2022 at 3:32 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager reported they are new to the role and had not been trained on QAPI yet.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency’s governing body failed to ensure an ongoing program for its quality improvement and patient safety was maintained, failed to ensure the agency-wide quality assessment and performance improvement (QAPI) efforts addressed priorities for improved quality of care and patient safety, and failed to ensure the QAPI program evaluated improvement actions for effectiveness, which had the potential to affect all patients and employees. Findings included: 1. An agency policy #5.51 titled “QAPI Program & PIP [Performance Improvement Project],” last revised 07/15/2021, indicated but was not limited to “… The Board of Directors [Governing Body] is responsible for ensuring the following. That an ongoing program for quality improvement and client safety is defined, implemented, and maintained. Agency wide quality assessment and performance improvement efforts address priorities for improved quality of care and client safety, and all improvements actions are evaluated for effectiveness.” 2. The agency’s Governing Body minutes for meetings held 02/29/2021 – 08/31/2022, confirmed by the Administrator as both the agency’s Governing Body meeting minutes and QAPI meeting minutes, were reviewed on 10/21/22. The minutes indicated meetings were held on 02/29/21, 07/27/21, 08/29/21, 12/15/21, 03/01/22, 05/16/22, 05/26/22, 06/29/22, and 08/31/22. Each meeting minute documentation indicated but was not limited to “… QAPI Update: Board received update from [Alternate Administrator] on QAPI activities. We will continue the same as we have been with no changes ….” The meeting minutes failed to evidence the governing body ensured its QAPI program was maintained and all federal regulations related to QAPI, including the QAPI efforts needing to address priorities for improved quality of care and patient safety and evaluating improvement actions for effectiveness, were being met. The governing body meeting minutes also failed to evidence the body was aware and attempting resolution to the inability to obtain complete quality indicator data for the months of May 2022, June 2022, July 2022, August 2022, and September 2022. 3. An interview was conducted on 10/21/2022 at 3:32 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager reported they are new to the role and had not been trained on QAPI yet. The Administrator reported the Alternate Administrator was responsible for obtaining quality indicator data and the previous clinical manager had not done any work toward the agency’s QAPI program.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all staff followed accepted standard precautions and agency policies and procedures to prevent the transmission of infectious and communicable diseases (see G682) and failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable disease infection tracking (see G684). The cumulative effect of these problems resulted in the agency failing to maintain and document an infection control program and being found out of compliance with Condition of Participation 42 CFR 484.70 Infection Prevention and Control.

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 home health agency failed to ensure all staff followed accepted standard precautions and agency policies and procedures to prevent the transmission of infectious and communicable diseases for 1 of 3 staff members observed during a home visit (Home Health Aide #2). Findings include: An agency policy #2.82 titled “Hand Washing / Hand hygiene,” last revised 02/08/2019, indicated but was not limited to “… Hand Hygiene Technique … 7. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by manufacturer to hands and rub hands together vigorously for at least twenty (20) seconds ….” A home visit observation was conducted on 10/18/2022 at 11:34 AM with Patient #2 (start of care 09/29/2022 due to change in agency’s electronic medical record (EMR) system, previous start of care 06/11/2022) and Home Health Aide (HHA) #2. During the home visit, HHA #2 was observed performing hand hygiene using soap and water twice, scrubbing their hands for 16 seconds and 18 seconds respectively. During the home visit at 11:42 AM, Patient #2 asked HHA #2 how long the aide was instructed to wash their hands and the aide responded, “20 seconds … or sing ‘Happy Birthday’ song two times.” 410 IAC 17-12-1(m)

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 record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases which is an integral part of the agency’s quality assessment and performance improvement (QAPI) program, which had the potential to affect all patients and employees. Findings include: 1. An agency policy #2.52 titled “Infection Control,” dated 12/13/2019, indicated but was not limited to “… Procedure … the infection program must include: a program for the surveillance, identification, prevention, control and investigation of infections and communicable disease specific to care and services provided in the home setting ….” 2. Agency documents titled “Agency Monthly Management Meeting Agenda,” confirmed by the Alternate Administrator as the agency’s monthly QAPI quality indicator tracking for the months of October 2021 through September 2022, were reviewed on 10/21/2022. The documents failed to evidence the agency tracked patient infections for the months of May 2022, June 2022, July 2022, August 2022, and September 2022 and failed to evidence the agency tracked employee infections for all months reviewed. An interview was conducted on 10/21/2022 at 1:27 PM with the Alternate Administrator. During the interview, the Alternate Administrator confirmed they were responsible for obtaining and documenting the agency’s quality indicators, which included patient infections, as part of its QAPI program. The Alternate Administrator reported the number of infections were to be recorded monthly on the “Agency Monthly Management Meeting Agenda,” however they had been unable to obtain the number of patient infections due to the multiple changes in electronic medical record (EMR) systems and several different people in the role of clinical manager. 3. The agency’s Governing Body minutes for meetings held 02/29/2021 – 08/31/2022, confirmed by the Administrator as both the agency’s Governing Body meeting minutes and QAPI meeting minutes, were reviewed on 10/21/2022. The meeting minutes failed to evidence the agency analyzed and/or investigated any trends in patient or employee infections. 4. An interview was conducted on 10/21/2022 at 3:32 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager reported the agency was able to track patient infections in the new EMR system however both employees confirmed there could be a potential delay in tracking, analyzing, and investigating patient or employee infections during the agency’s transition to the new EMR system and as the Clinical Manager finished orientation to their role.

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 prepare a detailed and patient-specific home health aide (HHA) care plan for 2 of 5 active records reviewed (Patient #2 and 5). Findings included: 1. An agency policy #2.49 titled “Aide Assignments,” revised 07/23/2021, indicated but was not limited to “… Purpose: Home Health Aides are assigned to a specific patient by a registered nurse … with written patient care instructions for a home health Aide prepared by that registered nurse … The duties of a home health Aide include … ‘Assistance in administering medications,’ as referenced in this requirement, means that the [aide] may take only a passive role in this activity. Assistance may include items such as: Bringing a medication to the client either in a pill organizer or a medication container as request[ed] by the client or caregiver … Reminding the client to take the medication.” 2. The clinical record of Patient #2 was reviewed on 10/18/22 and include a plan of care [POC] for the certification period 09/29/22 to 11/27/22 with a start of care [SOC] date of 09/29/22. The POC included orders for home health aide for 2 hours per visit, 3 visits per week. The record included a “Custom HH Aide Care Plan,” signed by the Clinical Manager on 09/29/22, which indicated aide tasks included, but were not limited to, “… Medication Reminders. Instructions: Per shift … Nail Care. Instructions: clean, file, and trim 1 [time a] week, as requested.” The aide care plan failed to evidence the specific assistance the aide was to provide to Patient #2 with medication reminders (specific medication(s) versus the patient’s routine scheduled medications, whether the aide was to bring the medication set or bottle to the client, etc) and failed to evidence a clear frequency the aide was to perform nail care. 3. The clinical record of Patient #5 was reviewed on 10/19/22 and included a POC for the certification period of 09/26/22 to 11/24/22 which indicated the SOC was 09/26/22. The POC included orders for home health aide visits for 2 hours per visit, 3-5 visits per week and indicated vital sign call parameters included but were not limited to “Systolic [blood pressure, BP, top number of BP reading] greater than 160 or less than 90. Diastolic BP [bottom number of BP reading] greater than 95 or less than 60].” The record included a “HHA Care Plan,” signed by the Clinical Manager on 09/26/22, which indicated vital sign call parameters included but were not limited to systolic blood pressure greater than 120 or less than 50 and diastolic blood pressure greater than 160 or less than 90. The aide care plan indicated HHA tasks included but were not limited to “Assist with Chair Bath. Instructions: … 2 [times] a week … Shower with Chair. Instructions: … 3 [times] a week … Medication Reminders. Instructions: Per shift.” The care plan failed to evidence how the aide was to determine whether to perform a chair bath versus a shower and failed to evidence the specific assistance the aide was to provide to Patient #2 with medication reminders. 4. An interview was conducted on 10/17/22 at 3:38 PM with the Administrator and Clinical Manager. During the interview, the Clinical Manager confirmed the aide care plan should be detailed and patient-specific. When asked how the aide was to perform the task “Medication Reminder,” the Clinical Manager reported this was dependent on the patient. 410 IAC 17-13-2(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 record review and interview, the agency failed to ensure home health aides provided services as ordered in the care plan for 3 of 5 active patient records reviewed (Patient #2, 3, 4). Findings include: The clinical record of Patient #2 was reviewed on 10/18/2022 and include a plan of care for the certification period 09/29/2022 – 11/27/2022 which indicated a start of care date of 09/29/2022. The plan of care included service orders for home health aide for 2 hours per visit, 3 visits per week. The record included a “Custom HHAide Care Plan,” signed by the Clinical Manager on 09/29/2022, which indicated aide tasks included but were not limited to “… Safety Measures. Instructions: Keep pathways clear and well lighted [sic]. Applies to all Shifts … Ask if Any Falls. Instructions: Call RN/ [Case Manager] if fallen to report. Applies to all Shifts … Offer fluids (unless restricted). Instructions: Keep fluids beside client and encourage to drink. Applies to all shifts … Antiplatelet Precautions. Instructions: Watch for bruising … Applies to all shifts … Incontinence Care. Instructions: Assist with washing perianal area change depend – per request … Assist with Ambulation. Instructions: Encourage to ambulate per shift … Clean Bathroom. Instructions: After bathing. 3 [times per] week ….” The record included aide visit notes for visits completed by HHA #2 on 10/03/2022, 10/05/2022, 10/07/2022, 10/10/2022, 10/12/2022, and 10/14/2022, which failed to evidence the aide completed or the patient declined the above tasks. Policy 2.49 titled “Aide Assignments,” revised 07/23/2021, indicated but not limited to “…a home health aide provides services that are… included in the plan of care. Clinical record review for Patient #3 indicated a POC for the certification period 10/07/2022 – 12/05/2022 with orders for HHA (home health aide) services 2 hours per day, 2 days per week for tasks including but not limited to ask if any falls, offer fluids, tub bath, nail care, assist with dressing, assist with transfers as needed, and meal set up. The aide care plan tasks included but not limited to ask if any falls, offer fluids, tub bath, nail care, assist with dressing, assist with transfers as needed, and meal set up. The aide failed to perform the above tasks from the aide care plan on dates including 10/07/2022, 10/11/2022, 10/14/2022, and 10/18/2022. Clinical record review for Patient #4 indicated a POC for the certification period 09/06/2022 – 11/04/2022 with orders for HHA services 6-8 hours per day, 5-7 days per week for tasks including but not limited to personal care such as assist with bathing and meal prep. The aide care plan tasks for the AM shift included a complete bed bath daily. The aide care plan tasks for the afternoon and PM shifts included meal prep daily. The aide failed to perform a complete bed bath during the AM shift on dates including 09/07/2022, 09/08/2022, 10/17/2022, and 10/19/2022. The aide failed to perform meal prep during the afternoon shift on dates including 10/14/2022 and 10/17/2022. The aide failed to perform meal prep during the PM shift on dates including 09/06/2022, 09/07/2022, 09/08/2022, 10/14/2022, 10/15/2022, 10/16/2022, 10/17/2022, 10/18/2022, and 10/19/2022. During an interview on 10/18/2022 at 2:28PM during a home visit with Patient #3, HHA #1 indicated she knows which tasks to do by the app on her phone. When asked if she offers fluids, a task from the aide care plan, HHA #1 indicated she offers fluids and it can be documented in the notes section. HHA #1 also indicated the notes section is where she would document patient refusal of a task. When asked about tub bath from the aide care plan, HHA #1 indicated that task was taken off the app because the patient’s family preferred to give the bath at night. During an interview on 10/18/2022 beginning at 3:38PM, the clinical manager confirmed the aide should complete all tasks listed on the aide care plan or document patient refusal of a task, if applicable.