Every finding on record at Innovative Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 494.62. Survey Dates: 06/09/2025, 06/11/2025, and 06/12/2025 Active Census: 7 At this Emergency Preparedness survey, Abby Care Indiana was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 494.62. QR completed by Area 3 on 6/16/2025.

This visit was for an Initial Federal Medicaid Certification and State Licensure survey for a Home Health provider. Survey Dates: 06/09/2025, 06/11/2025, and 06/12/2025 12 Month Unduplicated Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA Home Health Aide OASIS Outcome and Assessment Information Set CNA Certified Nursing Assistant HHA Home Health Aide RN Registered Nurse DME Durable Medical Equipment DON Director of Nursing SN Skilled Nursing POC Plan of Care SOC Start of care ROC Resumption of Care QR by Area 3 on 6/16/2025.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the patient's psychosocial status for 7 of 7 active clinical records reviewed (Patients #1, 2, 3, 4, 5, 6, 7). Findings Include: 1. Review of an undated agency policy titled "Initial Assessments/Comprehensive Assessments" indicated but was not limited to, " … The Initial Comprehensive assessment also includes: Psychosocial status … Assessment of a patient's psychosocial status and his/her functional capacity within the community is intended to be a screening of the patient's relationships, living environment, impact on the delivery of services and ability to participate in his/her own care …" 2. Review of the clinical record for Patient #1 revealed a SOC certification assessment dated 04/29/2025. The assessment evidenced Patient #1 has but is not limited to, Unspecified Dementia (a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving), Schizophrenia (a chronic and serious mental disorder characterized by disruptions in thinking, perception, emotions, and social interaction), Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living) , and Osteoarthritis (degeneration of joint cartilage and the underlying bone resulting in pain and stiffness). The assessment failed to evidence the psychosocial status of Patient #1. During an interview on 06/12/2025 at 3:13 PM, RN 1 indicated the psychosocial status of Patient #1 to be: the patient lives with their family member full time, they have support from their church, Patient #1 has no issues communicating, but may ask questions several times due to forgetfulness, and the patient has a spiritual consideration - no blood products. 3. Review of the clinical record for Patient #2 revealed a SOC certification assessment dated 04/15/2025. The assessment Patient #2 has but is not limited to, Hemiplegia and hemiparesis following cerebral infarct affecting left dominant (hemiparesis refers to weakness on one side of the body, hemiplegia refers to a more severe or complete paralysis on one side of the body, resulting most commonly from a stroke, which is impaired blood flow to the brain resulting in brain damage), and Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria).The assessment failed to evidence the psychosocial status for Patient #2. During an interview on 06/12/2025 at 3:22 PM, RN 1 indicated Patient #2 has the church as a support system. RN 1 indicated Person 1, a friend of Patient #2, would be the power of attorney and care giver for Patient #2 if needed. When queried if there were any other resources needed or considerations, RN 1 indicated Patient #2 receives physical therapy from an outside agency, does not want to receive blood products, and no other community resources were required at the time. 4. Review of the clinical record for Patient #3 revealed a SOC certification assessment dated 04/23/2025. The POC evidenced Patient #3 has but is not limited to, Diffuse Traumatic Brain Injury (brain damage that occurs over a widespread area), Unspecified convulsions (sudden, involuntary muscle contractions or spasms that can affect any part of the body, the exact type of convulsion or its underlying causes is not clearly identified), Alcohol use (a chronic condition characterized by an impaired ability to control alcohol use, despite negative consequences), and Hypertension (condition where the force of blood pushing against the artery walls is consistently too high). The assessment failed to evidence the psychosocial status for Patient #3. During an interview on 06/12/2025 at 3:26 PM, RN 1 indicated psychosocially the patient requires more assistance, and the agency has been coordinating with Person 2, a case manager at Entity 2, a government depart for veterans. 5. Review of the clinical record for Patient #4 revealed a SOC certification assessment dated 02/25/2025. The assessment evidenced Patient #4 has but is not limited to, Intermittent Explosive Disorder (mental health condition characterized by recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), Autistic Disorder (a neuro(brain)developmental condition of variable severity with lifelong effects that can be recognized from early childhood, characterized by difficulties with social interaction and communication, and by restricted or repetitive patterns of thought and behavior), Generalized Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living), Major Depressive Disorder (mental health condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, the individual may also experience other symptoms such as disturbed sleep, feelings of guilt or inadequacy), and Disruptive Mood Dysregulation (a mental health condition in children and adolescents characterized by persistent irritability or angry mood, and frequent, intense temper outbursts that are disproportionate to the situation).The assessment failed to evidence the patient's psychosocial status. During an interview on 06/12/2025 at 3:32 PM, RN 1 indicated the patient lives with their parents and siblings, receives services from behavioral therapists weekly, attends a hybrid school program, and has no communication, spiritual or cultural concerns. RN 1 indicated Person 4, parent/caregiver of Patient #4, is great at finding and utilizing resources within the community and shares the information with RN 1 to pass along to other patients who could benefit. 6. Review of the clinical record for Patient #5 revealed a SOC certification assessment dated 03/04/2025. The assessment evidenced Patient #5 has but is not limited to, Hereditary and Idiopathic neuropathy (hereditary neuropathy refers to an inherited genetic disorder affecting the peripheral nervous system, and idiopathic neuropathy refers to nerve damage with an unknown cause), Hypertension (condition where the force of blood pushing against the artery walls is consistently too high), Acute on chronic congestive heart failure (long-term condition where the heart's pumping ability is weakened, leading to fluid buildup in the lungs and other parts of the body), and Chronic Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria). The assessment failed to evidence the patient's psychosocial status. During an interview on 06/12/2025 at 3:37 PM, RN 1 indicated the patient lives with family, is forgetful, has no communication issues, has no other service needs, and has no cultural or spiritual considerations. 7. Review of the clinical record for Patient #6 revealed a SOC certification assessment dated 03/06/2025. The assessment evidenced Patient #6 has but is not limited to, Obstructive Sleep Apnea (sleep disorder where breathing repeatedly stops and starts due to a physical obstruction in the upper airway during sleep), Hypertension, and Asthma (chronic lung disease characterized by recurrent episodes of inflammation and narrowing of the airways resulting in breathing difficulties). The assessment failed to evidence the psychosocial status for Patient #6. During an interview on 06/12/2025 at 3:41 PM, RN 1 indicated Patient #6 is the backbone of their family, and there are no other services in the community they would allow into their home. RN 1 indicated Patient #6 communicates well, and has no cultural or spiritual considerations. 8. Review of the clinical record for Patient #7 revealed a SOC certification assessment dated 03/13/2025. The assessment evidenced Patient #7 has but is not limited to, Polyarthritis (condition characterized by inflammation, stiffness, and pain in five or more joints at the same time), Lymphedema (localized swelling of the body caused by an abnormal accumulation of lymph (a colorless fluid containing white blood cells)), Hypertension, and Mixed Incontinence (form of urinary incontinence characterized by a combination of both stress incontinence and urge incontinence, resulting in involuntary leakage of urine). The assessment failed to evidence the patient's psychosocial status. During an interview on 06/12/2025 at 3:44 PM, RN 1 indicated Patient #7 has no communication issues or spiritual or cultural considerations. RN 1 indicated there are currently no other resources the patient could benefit from. 9. During an interview on 06/12/2025 at 1:40 PM, the Alternate Administrator indicated they thought the missing pieces were located on the POC. The Alternate Administrator failed to indicate the psychosocial status should be included on the comprehensive assessment. 10. During an interview on 06/12/2025 at 3:00 PM, RN 1 indicated they thought all of the admission packet paperwork was included in the comprehensive assessment. RN 1 indicated they did not realize they needed to include all of the pieces on the comprehensive assessment, since the missing items were documents elsewhere in the clinical record. 410 IAC 17-14-1(a)(1)(B)

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 agency failed to ensure the comprehensive assessment identified the patient's goals for 7 of 7 active clinical records reviewed (Patients #1, 2, 3, 4, 5, 6, 7). Findings Include: 1. Review of an undated agency policy titled "Initial Assessments/Comprehensive Assessments" indicated but was not limited to, " … The Initial Comprehensive Assessment also includes: … 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 measurable outcomes identified by the Agency …" 2. Review of the clinical record for Patient #1 revealed a SOC certification assessment dated 04/29/2025. The assessment evidenced Patient #1 had the following diagnoses including but not limited to, Unspecified Dementia (a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving), Schizophrenia (a chronic and serious mental disorder characterized by disruptions in thinking, perception, emotions, and social interaction), Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living), and Osteoarthritis (degeneration of joint cartilage and the underlying bone resulting in pain and stiffness). The assessment failed to evidence the patient's measurable goals. 3. Review of the clinical record for Patient #2 revealed a SOC certification assessment dated 04/15/2025. The assessment Patient #2 had the following diagnoses including but not limited to, Hemiplegia and hemiparesis following cerebral infarct affecting left dominant (hemiparesis refers to weakness on one side of the body, hemiplegia refers to a more severe or complete paralysis on one side of the body, resulting most commonly from a stroke, which is impaired blood flow to the brain resulting in brain damage), and Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria).The assessment failed to evidence the patient's measurable goals. 4. Review of the clinical record for Patient #3 revealed a SOC certification assessment dated 04/23/2025. The POC evidenced Patient #3 had the following diagnoses including but not limited to, Diffuse Traumatic Brain Injury (brain damage that occurs over a widespread area), Unspecified convulsions (sudden, involuntary muscle contractions or spasms that can affect any part of the body, the exact type of convulsion or its underlying causes is not clearly identified), Alcohol use (a chronic condition characterized by an impaired ability to control alcohol use, despite negative consequences), and Hypertension (condition where the force of blood pushing against the artery walls is consistently too high). The assessment failed to evidence patient's measurable goals. 5. Review of the clinical record for Patient #4 revealed a SOC certification assessment dated 02/25/2025. The assessment evidenced Patient #4 had the following diagnoses including but not limited to, Intermittent Explosive Disorder (mental health condition characterized by recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), Autistic Disorder (a neuro(brain)developmental condition of variable severity with lifelong effects that can be recognized from early childhood, characterized by difficulties with social interaction and communication, and by restricted or repetitive patterns of thought and behavior), Generalized Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living), Major Depressive Disorder (mental health condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, the individual may also experience other symptoms such as disturbed sleep, feelings of guilt or inadequacy), and Disruptive Mood Dysregulation (a mental health condition in children and adolescents characterized by persistent irritability or angry mood, and frequent, intense temper outbursts that are disproportionate to the situation).The assessment failed to evidence the patient's measurable goals. 6. Review of the clinical record for Patient #5 revealed a SOC certification assessment dated 03/04/2025. The assessment evidenced Patient #5 had the following diagnoses including but not limited to, Hereditary and Idiopathic neuropathy (hereditary neuropathy refers to an inherited genetic disorder affecting the peripheral nervous system, and idiopathic neuropathy refers to nerve damage with an unknown cause), Hypertension (condition where the force of blood pushing against the artery walls is consistently too high), Acute on chronic congestive heart failure (long-term condition where the heart's pumping ability is weakened, leading to fluid buildup in the lungs and other parts of the body), and Chronic Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria). The assessment failed to evidence the patient's individualized goals. 7. Review of the clinical record for Patient #6 revealed a SOC certification assessment dated 03/06/2025. The assessment evidenced Patient #6 had the following diagnoses including but not limited to, Obstructive Sleep Apnea (sleep disorder where breathing repeatedly stops and starts due to a physical obstruction in the upper airway during sleep), Hypertension, and Asthma (chronic lung disease characterized by recurrent episodes of inflammation and narrowing of the airways resulting in breathing difficulties). The assessment failed to evidence Patient #5's individualized goals. 8. Review of the clinical record for Patient #7 revealed a SOC certification assessment dated 03/13/2025. The assessment evidenced Patient #7 had the following diagnoses including but not limited to, Polyarthritis (condition characterized by inflammation, stiffness, and pain in five or more joints at the same time), Lymphedema (localized swelling of the body caused by an abnormal accumulation of lymph (a colorless fluid containing white blood cells)), Hypertension, and Mixed Incontinence (form of urinary incontinence characterized by a combination of both stress incontinence and urge incontinence, resulting in involuntary leakage of urine). The assessment failed to evidence the patient's individualized goals. 9. During an interview on 06/12/2025 at 3:15 PM, RN 1 indicated the goals listed on the POC should have been included on the SOC certification assessments. 10. During an interview on 06/12/2025 at 1:40 PM, the Alternate Administrator indicated they thought the missing pieces were located on the POC. The Alternate Administrator failed to indicate the goals should be included on the comprehensive assessment. 11. During an interview on 06/12/2025 at 3:00 PM, RN 1 indicated they thought all of the admission packet paperwork was included in the comprehensive assessment. RN 1 indicated they did not realize they needed to include all of the pieces on the comprehensive assessment, since the missing items are documents elsewhere in the clinical record.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included rehabilitative needs and discharge planning for 7 of 7 active clinical records (Patients #1, 2, 3, 4, 5, 6, 7). Findings Include: 1. Review of an undated agency policy titled "Initial Assessments/Comprehensive Assessments" indicated but was not limited to, " … The comprehensive assessment will identify the patient's need for home care and meet the patient's need for: … rehabilitative … discharge planning …" 2. Review of the clinical record for Patient #1 revealed a SOC certification assessment dated 04/29/2025. The assessment evidenced Patient #1 had but was not limited to, Unspecified Dementia (a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving), Schizophrenia (a chronic and serious mental disorder characterized by disruptions in thinking, perception, emotions, and social interaction), Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living) , and Osteoarthritis (degeneration of joint cartilage and the underlying bone resulting in pain and stiffness). The assessment failed to evidence any rehabilitative needs and discharge planning for Patient #1. During an interview on 06/12/2025 at 2:00 PM, RN 1 indicated Patient #1's rehabilitation potential as "fair to progress with the diagnosis of Dementia" When queried about discharge planning, RN 1 indicated they would plan to discharge to a nursing facility when Patient #2, the family member of Patient #1, was no longer able to provide care. During an interview on 06/12/2025 at 3:15 PM, RN 1 indicated Patient #1 uses a cane or walker to ambulate and struggles with long distances. 3. Review of the clinical record for Patient #2 revealed a SOC certification assessment dated 04/15/2025. The assessment Patient #2 had but was not limited to, Hemiplegia and hemiparesis following cerebral infarct affecting left dominant (hemiparesis refers to weakness on one side of the body, hemiplegia refers to a more severe or complete paralysis on one side of the body, resulting most commonly from a stroke, which is impaired blood flow to the brain resulting in brain damage), and Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria).The assessment failed to any rehabilitative needs and discharge planning for Patient #2. During an interview on 06/12/2025 at 2:09 PM, RN 1 indicated the rehabilitation potential for Patient #2 was good and discharge plan was to discharge the patient to the caregiver to assist with medication. 4. Review of the clinical record for Patient #3 revealed a SOC certification assessment dated 04/23/2025. The POC evidenced Patient #3 had but was not limited to, Diffuse Traumatic Brain Injury (brain damage that occurs over a widespread area), Unspecified convulsions (sudden, involuntary muscle contractions or spasms that can affect any part of the body, the exact type of convulsion or its underlying causes is not clearly identified), Alcohol use (a chronic condition characterized by an impaired ability to control alcohol use, despite negative consequences), and Hypertension (condition where the force of blood pushing against the artery walls is consistently too high). The assessment failed to evidence any rehabilitative needs and discharge planning for Patient #3. During an interview on 06/12/2025 at 2:17 PM, RN 1 indicated the rehabilitation potential for Patient #3 was fair and Patient #3 started physical therapy. When queried about the discharge plan, RN 1 indicated the agency would plan to discharge the patient to a skilled nursing facility or an assisted living facility. 5. Review of the clinical record for Patient #4 revealed a SOC certification assessment dated 02/25/2025. The assessment evidenced Patient #4 had but was not limited to, Intermittent Explosive Disorder (mental health condition characterized by recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), Autistic Disorder (a neuro(brain)developmental condition of variable severity with lifelong effects that can be recognized from early childhood, characterized by difficulties with social interaction and communication, and by restricted or repetitive patterns of thought and behavior), Generalized Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living), Major Depressive Disorder (mental health condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, the individual may also experience other symptoms such as disturbed sleep, feelings of guilt or inadequacy), and Disruptive Mood Dysregulation (a mental health condition in children and adolescents characterized by persistent irritability or angry mood, and frequent, intense temper outbursts that are disproportionate to the situation).The assessment failed to evidence any rehabilitative needs and discharge planning for Patient #4. During an interview on 06/12/2025 at 2:17 PM, RN 1 indicated Patient #4's rehabilitation potential was good. When queried about discharge planning, RN 1 indicated the discharge plan was to discharge to caregiver when able. During an interview on 06/12/2025 at 3:32 PM, RN 1 indicated Patient #4 was young and able to move around well, so there were no rehabilitative needs. 6. Review of the clinical record for Patient #5 revealed a SOC certification assessment dated 03/04/2025. The assessment evidenced Patient #5 had but was not limited to, Hereditary and Idiopathic neuropathy (hereditary neuropathy refers to an inherited genetic disorder affecting the peripheral nervous system, and idiopathic neuropathy refers to nerve damage with an unknown cause), Hypertension (condition where the force of blood pushing against the artery walls is consistently too high), Acute on chronic congestive heart failure (long-term condition where the heart's pumping ability is weakened, leading to fluid buildup in the lungs and other parts of the body), and Chronic Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria). The assessment failed to evidence the patient's rehabilitative needs and discharge planning. During an interview on 06/12/2025 at 2:17 PM, RN 1 indicated Patient #5's rehabilitation potential was fair. When queried about discharge planning, RN 1 indicated Patient #5 would be discharged to the caregiver when the caregiver was willing and able. 7. Review of the clinical record for Patient #6 revealed a SOC certification assessment dated 03/06/2025. The assessment evidenced Patient #6 had but was not limited to, Obstructive Sleep Apnea (sleep disorder where breathing repeatedly stops and starts due to a physical obstruction in the upper airway during sleep), Hypertension, and Asthma (chronic lung disease characterized by recurrent episodes of inflammation and narrowing of the airways resulting in breathing difficulties). The assessment failed to evidence the patient's rehabilitative needs and discharge planning. During an interview on 06/12/2025 at 2:25 PM, RN 1 indicated Patient #6's rehabilitation potential was fair to good. When queried about discharge planning, RN 1 indicated if Patient #6 can focus on themselves, the agency would discharge the patient to self if they met all of their goals. 8. Review of the clinical record for Patient #7 revealed a SOC certification assessment dated 03/13/2025. The assessment evidenced Patient #7 had but was not limited to, Polyarthritis (condition characterized by inflammation, stiffness, and pain in five or more joints at the same time), Lymphedema (localized swelling of the body caused by an abnormal accumulation of lymph (a colorless fluid containing white blood cells)), Hypertension, and Mixed Incontinence (form of urinary incontinence characterized by a combination of both stress incontinence and urge incontinence, resulting in involuntary leakage of urine). The assessment failed to evidence the patient's rehabilitative needs and discharge planning. During an interview on 06/12/2025 at 2:25 PM, RN 1 indicated Patient #7's rehabilitation potential was fair to progress towards goals. When queried about discharge planning, RN 1 indicated the agency would discharge the patient to the caregiver to ensure the patient continued taking their medications. 9. During an interview on 06/12/2025 at 1:40 PM, the Alternate Administrator indicated they thought the missing pieces were located on the POC. The Alternate Administrator failed to indicate the rehabilitative needs and discharge planning should be included on the comprehensive assessment. 10. During an interview on 06/12/2025 at 3:00 PM, RN 1 indicated they thought all of the admission packet paperwork was included in the comprehensive assessment. RN 1 indicated they did not realize they needed to include all of the pieces on the comprehensive assessment, since the missing items are documents elsewhere in the clinical record. 410 IAC 17-14-1(a)(1)(B)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC contained all of the necessary elements including rehab potential and discharge planning for 7 of 7 active clinical records reviewed (Patients #1, 2, 3, 4, 5, 6, 7). Findings Include: 1. Review of an undated agency policy titled " Plan of Care - CMS #485 and Physician/Practitioners Orders" indicated but was not limited to, " … The individualized plan of care must include the following: … rehabilitation potential … Discharge planning …" 2. Review of the clinical record for Patient #1 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/29/2025 for the certification period of 04/29/2025 through 06/27/2025 and signed by RN 1. The POC evidenced Patient #1 had but was not limited to, Unspecified Dementia (a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving), Schizophrenia (a chronic and serious mental disorder characterized by disruptions in thinking, perception, emotions, and social interaction), Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living) , and Osteoarthritis (degeneration of joint cartilage and the underlying bone resulting in pain and stiffness). The POC subsection titled "22. Goals/Rehabilitation Potential/Discharge Plans," evidenced but is not limited to, "1. Patient will have no falls throughout certification period … Patient/POA Goal: To help remove stress from husband and get the patient's medication's in order …" Review of the clinical record for Patient #1 revealed a SOC certification assessment dated 04/29/2025. The assessment failed to evidence the rehabilitation potential and discharge planning for Patient #1. The POC failed to evidence the rehabilitation potential and discharge planning. During an interview on 06/13/2025 at 2:00 PM, RN 1 indicated the POC does not specify a rehabilitation potential. When queried what they would designate Patient #1's rehabilitation potential as, RN 1 indicated "fair to progress with the diagnosis of Dementia" When queried about discharge planning, RN 1 indicated they would plan to discharge to a nursing facility when Patient #2, the family member of Patient #1, was no longer able to provide care. 3. Review of the clinical record for Patient #2 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/15/2025 for the certification period of 04/15/2025 through 06/13/2025 and signed by RN 1. The POC evidenced Patient #2 has but is not limited to, Hemiplegia and hemiparesis following cerebral infarct affecting left dominant (hemiparesis refers to weakness on one side of the body, hemiplegia refers to a more severe or complete paralysis on one side of the body, resulting most commonly from a stroke, which is impaired blood flow to the brain resulting in brain damage), and Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria). The POC subsection titled "22. Goals/Rehabilitation Potential/Discharge Plans," evidenced but is not limited to, "1. Patient will remain compliant with medication regimen throughout the certification period … Patient Goal: Patient would like to get back to [their] old self …" Review of the clinical record for Patient #2 revealed a SOC certification assessment dated 04/15/2025. The assessment failed to evidence the rehabilitation potential and discharge planning for Patient #2. The POC failed to evidence rehabilitation potential and discharge planning. During an interview on 06/12/2025 at 2:09 PM, RN 1 indicated the rehabilitation potential for Patient #2 is good and discharge plan is to discharge the patient to the caregiver to assist with medication. 4. Review of the clinical record for Patient #3 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/23/2025 for the certification period of 04/23/2025 through 06/21/2025 and signed by RN 1. The POC evidenced Patient #3 has but is not limited to, Diffuse Traumatic Brain Injury (brain damage that occurs over a widespread area), Unspecified convulsions (sudden, involuntary muscle contractions or spasms that can affect any part of the body, the exact type of convulsion or its underlying causes is not clearly identified), Alcohol use (a chronic condition characterized by an impaired ability to control alcohol use, despite negative consequences), and Hypertension (condition where the force of blood pushing against the artery walls is consistently too high). The POC subsection titled "22. Goals/Rehabilitation Potential/Discharge Plans," evidenced but is not limited to, "1. Patient will have no injuries r/t [related to] falls throughout the certification period … Patient Goal: To be able to manage [their] own health and finances …" Review of the clinical record for Patient #3 revealed a SOC certification assessment dated 04/23/2025. The assessment failed to evidence the rehabilitation potential and discharge planning for Patient #3. The POC failed to evidence rehabilitation potential and discharge planning. During an interview on 06/12/2025 at 2:17 PM, RN 1 indicated the rehabilitation potential for Patient #3 is fair. When queried about the discharge plan, RN 1 indicated the agency would plan to discharge the patient to a skilled nursing facility or an assisted living facility. 5. Review of the clinical record for Patient #4 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 02/25/2025 for the certification period of 04/25/2025 through 06/24/2025 and signed by RN 1. The POC evidenced Patient #4 has but is not limited to, Intermittent Explosive Disorder (mental health condition characterized by recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), Autistic Disorder (a neuro(brain)developmental condition of variable severity with lifelong effects that can be recognized from early childhood, characterized by difficulties with social interaction and communication, and by restricted or repetitive patterns of thought and behavior), Generalized Anxiety Disorder (a mental health condition characterized by persistent and excessive feelings of anxiety and fear that significantly impair daily living), Major Depressive Disorder (mental health condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, the individual may also experience other symptoms such as disturbed sleep, feelings of guilt or inadequacy), and Disruptive Mood Dysregulation (a mental health condition in children and adolescents characterized by persistent irritability or angry mood, and frequent, intense temper outbursts that are disproportionate to the situation). The POC subsection titled "22. Goals/Rehabilitation Potential/Discharge Plans," evidenced but is not limited to, "1. Patient will remain safe during impulsive behavior r/t [related to] intermittent explosive disorder diagnosis with the assistance of caregiver/parent throughout the certification period … Patient Goal: To have more social interactions with peers …" Review of the clinical record for Patient #4 revealed a SOC certification assessment dated 02/25/2025. The assessment failed to evidence the rehabilitation potential and discharge planning for Patient #4. The POC failed to evidence rehabilitation potential and discharge planning. During an interview on 06/12/2025 at 2:20 PM, RN 1 indicated Patient #4's rehabilitation potential is good. When queried about discharge planning, RN 1 indicated the discharge plan is to discharge to caregiver when able. 6. Review of the clinical record for Patient #5 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/04/2025 for the certification period of 05/03/2025 through 07/01/2025 and signed by RN 1. The POC evidenced Patient #5 has but is not limited to, Hereditary and Idiopathic neuropathy (hereditary neuropathy refers to an inherited genetic disorder affecting the peripheral nervous system, and idiopathic neuropathy refers to nerve damage with an unknown cause), Hypertension (condition where the force of blood pushing against the artery walls is consistently too high), Acute on chronic congestive heart failure (long-term condition where the heart's pumping ability is weakened, leading to fluid buildup in the lungs and other parts of the body), and Chronic Atrial Fibrillation (an irregular or rapid heart rhythm that originate in the upper chambers of the heart, also known as the atria). Review of the clinical record for Patient #5 revealed a SOC certification assessment dated 03/04/2025. The assessment failed to evidence the rehabilitation potential and discharge planning for Patient #5. The POC failed to evidence rehabilitation potential and discharge planning. During an interview on 06/12/2025 at 2:23 PM, RN 1 indicated Patient #5's rehabilitation potential is fair. When queried about discharge planning, RN 1 indicated Patient #5 would be discharged to the caregiver when the caregiver is willing and able. 7. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/06/2025 for the certification period of 05/05/2025 through 07/03/2025 and signed by RN 1. The POC evidenced Patient #6 has but is not limited to, Obstructive Sleep Apnea (sleep disorder where breathing repeatedly stops and starts due to a physical obstruction in the upper airway during sleep), Hypertension, and Asthma (chronic lung disease characterized by recurrent episodes of inflammation and narrowing of the airways resulting in breathing difficulties). Review of the clinical record for Patient #6 revealed a SOC certification assessment dated 03/06/2025. The assessment failed to evidence the rehabilitation potential and discharge planning for Patient #6. The POC failed to evidence rehabilitation potential and discharge planning. During an interview on 06/12/2025 at 2:25 PM, RN 1 indicated Patient #6's rehabilitation potential is fair to good. When queried about discharge planning, RN 1 indicated if Patient #6 can focus on themselves, the agency would discharge the patient to self if they met all of their goals. 8. Review of the clinical record for Patient #7 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/13/2025 for the certification period of 05/12/2025 through 07/10/2025 and signed by RN 1. The POC evidenced Patient #7 has but is not limited to, Polyarthritis (condition characterized by inflammation, stiffness, and pain in five or more joints at the same time), Lymphedema (localized swelling of the body caused by an abnormal accumulation of lymph (a colorless fluid containing white blood cells)), Hypertension, and Mixed Incontinence (form of urinary incontinence characterized by a combination of both stress incontinence and urge incontinence, resulting in involuntary leakage of urine). Review of the clinical record for Patient #7 revealed a SOC certification assessment dated 03/13/2025. The assessment failed to evidence the rehabilitation potential and discharge planning for Patient #7. The POC failed to evidence rehabilitation potential and discharge planning. During an interview on 06/12/2025 at 2:25 PM, RN 1 indicated Patient #7's rehabilitation potential is fair to progress towards goals. When queried about discharge planning, RN 1 indicated the agency would discharge the patient to the caregiver to ensure the patient continued taking their medications. 410 IAC 17-13-1(a)(1)(D)(iii, iv, v, xiii)