Every finding on record at Inspiring Care at Home

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 06/08, 06/09, 06/10, and 06/11/2026 Active Census: 7 At this Emergency Preparedness survey, Inspiring Care at Home was found to be out of compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 6/17/2026.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to provide initial emergency preparedness training for existing staff for 4 of 4 personnel records reviewed (Administrator/DON, Alternate Administrator/Alternate DON, HHA 1, and HHA 2/Owner). Findings Include: 1. Review of an undated agency policy titled "Emergency Operations Plan" indicated but was not limited to, " … Goals: … Providing education to staff on the elements of the Emergency Operations Plan during orientation and annually thereafter … Staff will attend orientation upon hire and an annual update of their specific roles and responsibilities and the skill they require to perform their duties during an emergency. Inservice education will be given on the backup communication system and obtaining supplies/equipment in the event of an emergency …" 2. Review of the Administrator/DON's personnel file failed to evidence emergency preparedness training. 3. Review of the Alternate Administrator/Alternate DON's personnel file failed to evidence emergency preparedness training. 4. Review of the HHA 1's personnel file failed to evidence emergency preparedness training. 5. Review of the HHA 2/Owner's personnel file failed to evidence emergency preparedness training. During an interview on 06/11/2026 at 2:06 PM, the Administrator/DON stated, "feel like should be" when asked if EP training was completed at orientation.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to analyze and document the agency's response to the tabletop drill for 1 of 1 home health agency. Findings Include: 1. Review of an undated agency policy titled "All-Hazard Emergency Preparedness Policy" indicated but was not limited to, "Drills … Agency staff members will participate in an annual desktop drill …" 2. Review of an agency document dated 06/17/2025 titled "Emergency Preparedness Tabletop Exercise" indicated but was not limited to, " … V. After Action Review Following the discussion, document: What worked well? What gaps were identified? What improvements or training are needed? Timeline for implementing changes …" The document failed to evidence the analysis and documentation of the agency's response to the tabletop drill. During an interview on 06/11/2026 at 2:32 PM, the Administrator/DON indicated the after action plan should have been completed.

This visit was for a State Relicensure and Initial Medicaid survey for a Home Health provider. Survey Date(s): 06/08, 06/09, 06/10, and 06/11/2026 12 Month Unduplicated Admissions: 12 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA - Home Health Aide SN- Skilled Nurse RN- Registered Nurse POC- Plan of Care SOC- Start of Care DC - Discharge DON- Director of Nursing DME- Durable Medical Equipment ADL- Activities of Daily Living QAPI- Quality Assurance Performance Improvement OASIS- Outcome and Assessment Information Set QR completed by Area 3 on 6/18/2026.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient received an OASIS Privacy Notice for 1 of 1 agency admission packets reviewed. Findings Include: 1. Review of the agency's admission packet failed to evidence the OASIS Privacy Notice. 2. During a home visit on 06/09/2026 at 2:00 PM, at Patient # 3's residence, the admission packet provided to them on their SOC of 03/19/2026, failed to evidence the OASIS Privacy Notice. 43. During a home visit on 06/10/2026 at 1:00 PM, at Patient #4's residence, the admission packet provided to them on their SOC of 11/10/2025, failed to evidence the OASIS Privacy Notice. During an interview on 06/11/2026 at 2:16 PM, the Administrator/DON and HHA 2 (Owner) indicated they were familiar with the OASIS Privacy Notice.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the admission packet contained the state department of health complaint hotline number for 1 of 1 agency admission packet reviewed. Findings Include: 1. Review of an undated document titled "Your Rights and Responsibilities as a Client" indicated but was not limited to, " … As a client you have the right to: … Be informed of your state's hotline and the agencies contact information making suggestions or complaints …" 2. Review of the agency's admission packet failed to evidence the state department of health complaint hotline. 3. During a home visit on 06/09/2026 at 2:00 PM, at Patient # 3's residence, the admission packet provided to them on their SOC of 03/19/2026, failed to evidence the state department of health complaint hotline. 4. During a home visit on 06/10/2026 at 1:00 PM, at Patient #4's residence, the admission packet provided to them on their SOC of 11/10/2025, failed to evidence the state department of health complaint hotline. 5. On 06/11/2026 at 2:16 PM, the Administrator/DON was requested to locate the state department of health complaint hotline within the admission packet. During an interview on 06/11/2026 at 2:16 PM, the Administrator/DON indicated the complaint hotline was not located within the admission packet. 410 IAC 17-12-3(b)(2)(C)

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 agency failed to provide services as ordered by the physician for 2 of 4 clinical records reviewed with patients receiving SN and HHA services (Patient #5 and 8) and for 2 of 5 clinical records reviewed with patients receiving wound care (Patient #6 and 12). Findings Include: 1. Review of an undated agency policy titled "Wound Care Policy and Procedure" indicated but was not limited to, " … Procedure … Wound care performed per physician orders … Skilled nursing responsibilities: Perform ordered wound care … Physician notification: Notify physician of … need for treatment modification …" Review of an undated agency policy titled "Care Plan Policy" indicated but was not limited to, " … Review and Update of the Care Plan Care plans must be reviewed at least every 60 days (or more frequently if the patient's condition warrants) … All staff involved in patient care will follow the individualized plan of care … Staff are responsible for documenting interventions, patient responses, and progress toward goals at each visit …" 2. Review of Patient #5's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/26/2025 for the certification period of 03/26/2026 through 05/24/2026 and signed by the Administrator/DON. The POC indicated but was not limited, Patient #5 received SN services once a week for 60 days for medication set up, and HHA twice per week. Review of Patient #5's active clinical record revealed a signed physician order dated 03/25/2026. The order indicated Patient #5 received HHA services twice a week for 60 days. Review of Patient #5's active clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 11/26/2025 for the certification period of 03/26/2026 through 05/24/2026 and signed by the Administrator/DON. The document indicated Patient #5 received five visits per week for bathing and light housekeeping. Review of Patient #5's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/26/2025 for the certification period of 05/25/2026 through 07/23/2026 and signed by the Administrator/DON. The POC indicated Patient #5 received SN services once a week for 60 days to fill the medication planner to promote adherence to the medication regimen. Review of Patient #5's active clinical record revealed a signed physician order dated 05/24/2026. The order indicated the patient received SN services once a week for 60 days to fill the medication planner to promote adherence to the medication regimen. Review of Patient #5's active clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 11/26/2025 for the certification period of 05/25/2026 through 07/23/2026 and signed by the Administrator/DON. The document indicated Patient #5 received one visit per week for bathing and light housekeeping. Review of Patient #5's active clinical record revealed a document titled "Visit Record". The record for the week of 04/05/2026, signed by HHA 3, and dated 04/10/2026 indicated Patient #5 received HHA services 04/06/2026 through 04/10/2026. The record for the week of 04/12/2026, signed by HHA 3, and dated 04/17/2026 indicated Patient #5 received HHA services 04/13/2026 through 04/17/2026. The record for the week of 04/19/2026, signed by HHA 3, and dated 04/24/2026 indicated Patient #5 received HHA services 04/20/2026 through 04/24/2026. The record for the week of 04/26/2026, signed by HHA 3, and dated 05/01/2026 indicated Patient #5 received HHA services 04/27/2026 through 05/01/2026. The record for the week of 05/03/2026, signed by HHA 3, and dated 05/08/2026 indicated Patient #5 received HHA services 05/04/2026 through 05/08/2026. The record for the week of 05/10/2026, signed by HHA 3, and dated 05/15/2026 indicated Patient #5 received HHA services 05/11/2026 through 05/15/2026. The record for the week of 05/17/2026, signed by HHA 3, and dated 05/22/2026 indicated Patient #5 received HHA services 05/18/2026 through 05/22/2026. The record for the week of 05/10/2026, signed by HHA 3, and dated 05/15/2026 indicated Patient #5 received HHA services 05/11/2026 through 05/15/2026. The record for the week of 05/24/2026, signed by HHA 3 and dated 05/29/2026. The document indicated Patient #5 received HHA services 05/25/2026 through 05/29/2026. The active clinical record failed to evidence Patient #5 received HHA services as ordered within the POC. During an interview on 06/11/2026 at 1:09 PM, HHA 3 indicated they provided care for Patient #5. HHA 3 indicated they provided care for Patient #5 Monday through Friday. When asked when was the last time they visited the patient, HHA 3 indicated they were unsure. During an interview on 06/11/2026 at 4:00 PM, the Administrator/DON indicated there should not have been any HHA care provided. 3. Review of Patient #6's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/17/2026 for the certification period of 04/17/2026 through 06/15/2026 and signed by the Administrator/DON. The POC indicated Patient #6 received SN services once a week for 60 days for wound care. Review of Patient #6's active clinical record revealed a signed physician order dated 04/17/2026. The order indicated the patient received wound care for a left medial (situated in the middle or closer to the center) lower leg wound, a left lateral (situated on, directed toward, or coming from the side) lower leg wound, and a right lower leg wound. Review of Patient #6's active clinical record revealed a SOC OASIS dated 04/17/2026 and signed by the Administrator/DON. The OASIS indicated there were wounds on the anterior bilateral lower extremities (the front of the legs). The OASIS stated, " … unable to provide wound care. Patient has unna boots [specialized, semi-rigid compression bandage applied to the lower leg. It is primarily used to reduce swelling, promote venous circulation, and heal stubborn wounds] that are to remain in place until Monday …" Review of Patient #6's active clinical record revealed a document titled "Nursing Visit Note". The note dated 04/20/2026 and signed by the Administrator/DON indicated there were two wounds located on the left leg, and no wounds on the right leg. The note stated but was not limited to, " … Left medial with 80-90% slough [layer of dead, non-viable tissue located within the wound bed]. Left lateral with 50% slough. Patient tolerated dressing changes. Edema [swelling] notes to BLE [bilateral lower extremities] …" The note dated 04/27/2026 and signed by the Administrator/DON indicated there were two wounds located on the left leg, and no wounds on the right leg. The note stated but was not limited to, " … Patient tolerated dressing without complaint …" The note dated 05/04/2026 and signed by the Administrator/DON indicated there were two wounds located on the left leg, no wounds on the right leg, wound care was performed, and the patient failed to attend their wound clinic appointment the previous week. The note dated 05/11/2026 and signed by the Administrator/DON indicated there was one wound located on the left leg, and no wounds on the right leg. The note stated but was not limited to, " … Left lateral wound healed. Left medial wound mostly gran [granulated, the growth of new, temporary connective tissue and tiny blood vessels (capillaries) that fills an open wound bed from the base upward during the healing process]. Unna boots applied to LLE [left lower extremity] …" The note dated 05/18/2026 and signed by the Administrator/DON indicated there was one wound located on the left leg, no wounds on the right leg, wound care was performed, and the patient failed to attend their wound clinic appointment the previous week. The note dated 05/25/2026 and signed by the Administrator/DON indicated there was one wound located on the left leg, no wounds on the right leg, wound care was performed, and the patient failed to attend their wound clinic appointment the previous week. The note dated 06/04/2026 and signed by the Administrator/DON indicated there were no wounds. The noted stated but was not limited to, " … wound to leg has healed …" Review of Patient #6's active clinical record revealed communications notes. The communication notes dated 04/17/2026 through 06/11/2026 failed to evidence the physician was notified wound care was not completed on the right leg wound. The active clinical record failed to evidence wound care was performed on the right leg wound. During an interview on 06/11/2026 at 9:54 AM, the Administrator/DON indicated there was no update to the POC to change the wound care orders. 4. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 01/12/2026 through 03/12/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week for 60 days for wound care and assessments and HHA services five days a week for ADL assistance. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 01/12/2026 for the certification period of 01/12/2026 through 03/12/2026 and signed by the Administrator/DON. The document indicated Patient #8 received five visits per week for bathing, oral hygiene, dressing/undressing, assistance with toileting, perineal care, transfer assistance, meal preparation/feeding, and light housekeeping. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 03/13/2026 through 05/11/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week for 60 days for assessment related to debility and HHA services five days a week. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 01/12/2026 for the certification period of 03/13/2026 through 05/11/2026. The document indicated Patient #8 received five visits per week for bathing, oral hygiene, dressing/undressing, assistance with toileting, perineal care, transfer assistance, meal preparation/feeding, and light housekeeping. Review of Patient #8's inactive clinical record for the period of 01/12/2026 through 05/11/2026 failed to evidence HHA visit notes. Review of Patient #8's inactive clinical record revealed communication notes. The communication notes for the period of 01/12/2026 through 05/11/2026 failed to evidence communication regarding HHA services. The clinical record failed to evidence Patient #8 received HHA services as ordered by the physician. During an interview on 06/11/2026 at 12:09 PM, Patient #8 indicated the agency offered other HHA's but they never showed up. 5. Review of Patient #12's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/15/2025 for the certification period of 09/15/2025 through 11/13/2025 and signed by the Administrator/DON. The POC indicated Patient #12 received SN services three times a week for wound care. Review of Patient #12's inactive clinical record revealed a document titled "Nursing Visit Note". The notes indicated Patient #12 received services 09/15, 09/17, 09/19, 09/26, 10/03, 10/09, and 10/16/2025. The clinical record failed to evidence wound care was performed three times a week. Review of Patient #12's inactive clinical record revealed communications notes. The communication notes dated 09/15/2026 through 10/17/2025 failed to evidence the physician was notified wound care was not completed as ordered. On 06/11/2026 an order to change the frequency of SN visits was requested. During an interview on 06/11/2026 at 1:11 PM, the Administrator/DON indicated there was no order to change the frequency of SN visits. During an interview on 06/11/2026 at 3:11 PM, the Administrator/DON indicated they should have notified the physician of the missed visits and requested an order to change the frequency of SN visits. 410 IAC 17-13-1(a)

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 agency failed to ensure the physician was notified of the need to alter the POC for 3 of 5 clinical records with patients receiving wound care (Patient #6, 7, and 12) and for 1 of 1 inactive clinical records reviewed with a patient receiving SN and HHA services (Patient #8). Findings Include: 1. Review of an undated agency policy titled "Care Plan Policy" indicated but was not limited to, " … Review and Update of the Care Plan Care plans must be reviewed at least every 60 days (or more frequently if the patient's condition warrants) … The care plan must be updated when: The patient's condition changes significantly. There is a change in a caregiver or patient preference. New Interventions, goals, or services are initiated. All updates require a physician/practitioner order and documentation in the clinical record …" 2. Review of Patient #6's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/17/2026 for the certification period of 04/17/2026 through 06/15/2026 and signed by the Administrator/DON. The POC indicated Patient #6 received SN services once a week for 60 days for wound care. Review of Patient #6's active clinical record revealed a signed physician order dated 04/17/2026. The order indicated the patient received wound care for a left medial (situated in the middle or closer to the center) lower leg wound, a left lateral (situated on, directed toward, or coming from the side) lower leg wound, and a right lower leg wound. Review of Patient #6's active clinical record revealed a SOC OASIS dated 04/17/2026 and signed by the Administrator/DON. The OASIS indicated there were wounds on the anterior bilateral lower extremities (the front of the legs). The OASIS stated, " … unable to provide wound care. Patient has unna boots [specialized, semi-rigid compression bandage applied to the lower leg. It is primarily used to reduce swelling, promote venous circulation, and heal stubborn wounds] that are to remain in place until Monday …" Review of Patient #6's active clinical record revealed a document titled "Nursing Visit Note". The note dated 04/20/2026 and signed by the Administrator/DON indicated there were two wounds located on the left leg, and no wounds on the right leg. The note stated but was not limited to, " … Left medial with 80-90% slough [layer of dead, non-viable tissue located within the wound bed]. Left lateral with 50% slough. Patient tolerated dressing changes. Edema [swelling] notes to BLE [bilateral lower extremities] …" The note dated 04/27/2026 and signed by the Administrator/DON indicated there were two wounds located on the left leg, and no wounds on the right leg. The note stated but was not limited to, " … Patient tolerated dressing without complaint …" The note dated 05/04/2026 and signed by the Administrator/DON indicated there were two wounds located on the left leg, no wounds on the right leg, wound care was performed, and the patient failed to attend their wound clinic appointment the previous week. The note dated 05/11/2026 and signed by the Administrator/DON indicated there was one wound located on the left leg, and no wounds on the right leg. The note stated but was not limited to, " … Left lateral wound healed. Left medial wound mostly gran [granulated, the growth of new, temporary connective tissue and tiny blood vessels (capillaries) that fills an open wound bed from the base upward during the healing process]. Unna boots applied to LLE [left lower extremity] …" The note dated 05/18/2026 and signed by the Administrator/DON indicated there was one wound located on the left leg, no wounds on the right leg, wound care was performed, and the patient failed to attend their wound clinic appointment the previous week. The note dated 05/25/2026 and signed by the Administrator/DON indicated there was one wound located on the left leg, no wounds on the right leg, wound care was performed, and the patient failed to attend their wound clinic appointment the previous week. The note dated 06/04/2026 and signed by the Administrator/DON indicated there were no wounds. The noted stated but was not limited to, " … wound to leg has healed …" Review of Patient #6's active clinical record revealed communications notes. The communication notes dated 04/17/2026 through 06/11/2026 failed to evidence the physician was notified wound care was not completed on the right leg wound. The active clinical record failed to evidence the POC was updated to reflect updated wound care orders. During an interview on 06/11/2026 at 9:54 AM, the Administrator/DON indicated there was no update to the POC to change the wound care orders. 3. Review of Patient #7's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/31/2026 for the certification period of 05/31/2026 through 07/29/2026 and signed by the Administrator/DON. The POC indicated Patient #7 received SN services twice a week for 60 days for right lower extremity (RLE) wound care. Review of Patient #7's active clinical record revealed a document titled "Physician/NPP Verbal Orders". The unsigned order indicated the specific wound care order to be performed. Review of Patient #7's active clinical record failed to evidence SN visit notes from 05/31/2026 through 06/11/2026. Review of Patient #7's active clinical record failed to evidence communication notes from 05/31/2026 through 06/11/2026. The active clinical record failed to evidence the physician was notified of the need to update the POC. During an interview on 06/10/2026 at 11:09 AM, the Administrator/DON indicated no wound care was performed due to the agency waiting for orders. During an interview on 06/11/2026 at 9:54 AM, the Administrator/DON indicated they admitted the patient following a hospitalization. The Administrator/DON indicated the wound was reportedly open, but was now granulated. When asked how was the wound managed while waiting for the signed wound care order, the Administrator/DON indicated they imagined the wound care was not being performed. The Administrator/DON indicated they left wound care supplies with the patient just in case. When asked if they used verbal orders, the Administrator/DON indicated they would accept verbal orders if they were able to reach someone authorized to give verbal orders. 4. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 01/12/2026 through 03/12/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week for 60 days for wound care and assessments and HHA services five days a week for ADL assistance. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 01/12/2026 for the certification period of 01/12/2026 through 03/12/2026 and signed by the Administrator/DON. The document indicated Patient #8 received five visits per week for bathing, oral hygiene, dressing/undressing, assistance with toileting, perineal care, transfer assistance, meal preparation/feeding, and light housekeeping. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 03/13/2026 through 05/11/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week for 60 days for assessment related to debility and HHA services five days a week. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 01/12/2026 for the certification period of 03/13/2026 through 05/11/2026. The document indicated Patient #8 received five visits per week for bathing, oral hygiene, dressing/undressing, assistance with toileting, perineal care, transfer assistance, meal preparation/feeding, and light housekeeping. Review of Patient #8's inactive clinical record for the period of 01/12/2026 through 05/11/2026 failed to evidence HHA visit notes. Review of Patient #8's inactive clinical record revealed a document titled "Physician/NPP Verbal Orders". The orders for the period of 01/12/2026 through 05/11/2026 failed to evidence an alteration was made to the POC. Review of Patient #8's inactive clinical record revealed communication notes. The communication notes for the period of 01/12/2026 through 05/11/2026 failed to evidence notification to the physician regarding a need to alter the POC. The clinical record failed to evidence the RN notified the physician of the need to alter the POC. During an interview on 06/11/2026 at 2:40 PM, the Administrator/DON indicated the HHA should have been discharged. 5. Review of Patient #12's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/15/2025 for the certification period of 09/15/2025 through 11/13/2025 and signed by the Administrator/DON. The POC indicated Patient #12 received SN services three times a week for wound care. Review of Patient #12's inactive clinical record revealed a document titled "Nursing Visit Note". The notes indicated Patient #12 received services 09/15, 09/17, 09/19, 09/26, 10/03, 10/09, and 10/16/2025. The clinical record failed to evidence wound care was performed three times a week. Review of Patient #12's inactive clinical record revealed communications notes. The communication notes dated 09/15/2026 through 10/17/2025 failed to evidence the physician was notified of a need to alter the POC. On 06/11/2026 an order to change the frequency of SN visits was requested. During an interview on 06/11/2026 at 1:11 PM, the Administrator/DON indicated there was no order to change the frequency of SN visits. During an interview on 06/11/2026 at 3:11 PM, the Administrator/DON indicated they should have notified the physician of the missed visits and requested an order to change the frequency of SN visits. 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 Governing Body failed to develop, implement, evaluate, and maintain an ongoing, agency-wide QAPI program that measured, analyzed, and tracked measurable and data-driven quality indicators, including adverse events, for health, safety, agency operations, and quality of care (G642); failed to use quality indicator data to monitor the effectiveness and safety of care and services and identified opportunities for improvement (G644); failed to focus on high risk, high volume, or problem-prone areas, such as hospitalizations, infections, adverse events, and home health aide services (G646); initiated performance improvement plans which tracked and analyzed adverse events and implemented corrective or preventative actions (G654); measured and tracked the success of performance improvement in the identified areas to ensure that improvements were sustained (G656); conducted performance improvement projects (PIP) that reflected the scope and complexity of the needs of the agency’s patient needs and previously identified regulatory performance needs, and documented the PIPs undertaken and the measurable progress achieved (G658); failed to ensure the QAPI program established clear expectations for patient safety and assessed for and addressed any findings of fraud or waste (G660) for 1 of 1 Governing Body of a Home Health Agency. The cumulative effects of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.65, Quality Assessment and Performance Improvement. Findings Include: 1. Review of an undated agency policy titled "Quality Assessment and Performance Improvement (QAPI) Policy and Program " indicated but was not limited to, " … Purpose To establish and maintain an agency-wide Quality Assessment and Performance Improvement (QAPI) program that systematically monitors, evaluates, and improves the quality of patient care and administrative services … The Governing Body holds ultimate responsibility for QAPI. The Administrator and Clinical Manager oversee daily QAPI operations … Program Scope Covers all services (clinical and administrative), including patient outcomes, infection control, safety, timeliness, and satisfaction. Addresses adverse events, complaints, hospitalizations, and readmissions …" Review of an undated agency policy titled "Wound Care Policy and Procedure" indicated but was not limited to, " … Procedure … Quality Assurance: Monitor wound outcomes through QAPI activities to improve patient outcomes and quality of care …" Review of an undated agency policy titled "Care Plan Policy" indicated but was not limited, " … Compliance with this policy will be monitored through … the agency's Quality Assessment and Performance Improvement (QAPI) program …" Review of an undated agency policy titled "Change of Condition Policy" indicated but was not limited, " … A change of condition includes, but is not limited: … Hospitalization, emergency room visits, or physician visits related to health decline … Quality Assurance All change-of-condition incidents will be reviewed through the agency's Quality Assurance and Performance Improvement (QAPI) program to identify trends, improve patient outcomes, and ensure compliance with agency standards …" 2. Review of an agency binder labeled QAPI revealed an undated document titled "QAPI Performance Improvement Plan" evidenced a blank example of how a home health agency could review their QAPI program. The binder revealed an undated document titled "Quarterly Review Worksheet" evidenced a blank example of how a home health agency could perform quarterly reviews. The binder revealed an undated document titled "Quality Review Form" evidenced a blank example of how a home health agency could perform a chart audit. The binder revealed an undated document titled "Potentially Avoidable Event Audit" evidenced a blank example of how a home health agency could monitor potentially avoidable events. The binder revealed an undated document titled "Inspiring Care At Home Health Quality Assessment and Performance Meeting Data: …" evidenced a blank example of how the agency planned to record QAPI meetings. The binder revealed an undated document titled "Confidential Risk Identification Log" evidenced a blank example of how a home health agency could monitor incidents. The binder revealed an undated document titled "Infection Control Log" evidenced a blank example of how a home health agency could monitor infections. 3. Review of an agency binder revealed an undated documented titled "Performance Improvement Project (PIP)" indicated but was not limited to, " … Date Initiated: 8/27/2025 Target Completion Date: 11/19/2025 …" The document failed to evidence the baselines for the performance indicators, due dates for the interventions and action steps, and post-project comparison of accuracy rates. The QAPI program failed to evidence the agency identified and analyzed issues affecting the quality of care, patient safety, and the efforts to improve health outcomes. During an interview on 06/11/2026 at 2:28 PM, when queried about what information was being tracked such as infections, falls, or hospitalizations, HHA 2 (Owner) questioned if any of their patients had those problems. When queried how would the agency know there was an issue if they were not tracking, HHA 2 (Owner) indicated they understood and the Administrator/DON stated, "that's a good question," and indicated the agency had hospitalizations.

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 agency failed to ensure the HHAs were supervised and included all the necessary elements for 4 of 4 clinical records reviewed with patients receiving HHA services (Patients #1, 4, 5, and 8). Findings Include: 1. Review of Patient #1's active Clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 08/04/2025 for the certification period of 04/01/2026 through 05/30/2026 and signed by the Administrator/DON. The POC indicated but was not limited, Patient #1 received SN services once a week for 60 day for medication fill assistance to promote adherence to medication regimen, and HHA once per week. Review of Patient #1's active clinical record evidenced SN visit notes. The visit notes dated 04/08/2026, 04/15/2026, 04/29/2026, 05/20/2026 indicated a supervisory visit was performed. The supervisory visit notes failed to evidence if the HHA maintained open communication, demonstrated competency with assigned task, complied with infection prevention procedures, and/or honored patient rights. 2. Review of Patient #4's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/10/2025 for the certification period of 05/22/2026 through 07/20/2026 and signed by the Administrator/DON. The POC indicated but was not limited, Patient #4 received SN services twice a week for 60 days for skilled wound care, and HHA once per week to assist with bathing. Review of Patient #4's active clinical record evidenced SN visit notes. The visit notes dated 03/31/2026, 04/06/2026, 04/09/2026, 04/14/2026, 04/20/2026, 04/28/2026, 04/30/2026, 05/08/2026, 05/15/2026, 05/19/2026, and 05/26/2026 indicated a supervisory visit was performed. The supervisory visit notes failed to evidence if the HHA maintained open communication, demonstrated competency with assigned task, complied with infection prevention procedures, and/or honored patient rights. 3. Review of Patient #5's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/26/2025 for the certification period of 03/26/2026 through 05/24/2026 and signed by the Administrator/DON. The POC indicated but was not limited, Patient #5 received SN services once a week for 60 days for medication set up, and HHA twice per week. Review of Patient #5's active clinical record revealed a signed physician order dated 03/25/2026. The order indicated Patient #5 received HHA services twice a week for 60 days. Review of Patient #5's active clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 11/26/2025 for the certification period of 03/26/2026 through 05/24/2026 and signed by the Administrator/DON. The document indicated Patient #5 received five visits per week for bathing and light housekeeping. Review of Patient #5's active clinical record evidenced SN visit notes. The visit notes dated 04/17/2026, 05/01/2026, 05/15/2026, and 05/29/2026 indicated a supervisory visit was performed. The supervisory visit notes failed to evidence if the HHA maintained open communication, demonstrated competency with assigned task, complied with infection prevention procedures, and/or honored patient rights. 4. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 01/12/2026 through 03/12/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week for 60 days for wound care and assessments and HHA services five days a week for ADL assistance. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 01/12/2026 for the certification period of 01/12/2026 through 03/12/2026 and signed by the Administrator/DON. The document indicated Patient #8 received five visits per week for bathing, oral hygiene, dressing/undressing, assistance with toileting, perineal care, transfer assistance, meal preparation/feeding, and light housekeeping. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 03/13/2026 through 05/11/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week for 60 days for assessment related to debility and HHA services five days a week. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Aide Plan of Care" with a SOC date of 01/12/2026 for the certification period of 03/13/2026 through 05/11/2026. The document indicated Patient #8 received five visits per week for bathing, oral hygiene, dressing/undressing, assistance with toileting, perineal care, transfer assistance, meal preparation/feeding, and light housekeeping. Review of Patient #8's inactive clinical record evidenced SN visit notes. The visit notes dated 01/16/2026, 01/23/2026, 03/03/2026, 03/13/2026, 03/20/2026, 03/27/2026, 04/03/2026, and 04/15/2026 indicated a supervisory visit was performed. The supervisory visit notes failed to evidence if the HHA maintained open communication, demonstrated competency with assigned task, complied with infection prevention procedures, and/or honored patient rights. During an interview on 06/11/2026 at 3:18 PM, the Administrator/DON indicated when a supervisory visit was performed they verify the patient was happy and ensure the HHA was following the POC. The Administrator/DON failed to include if the HHA maintained open communication, demonstrated competency with assigned task, complied with infection prevention procedures, and/or honored patient rights. 410 IAC 17-14-1(n)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a transfer summary was completed for a patient transferred to another provider for 2 of 2 clinical records reviewed with patients hospitalized (Patient #4 and 8), and failed to ensure a discharge summary was completed and contained all the necessary elements for 5 of 5 inactive clinical records reviewed (Patient #8, 9, 10, 11, and 12). Findings Include: 1. Review of Patient #4's active clinical record revealed a document titled "Physician/NPP Verbal Orders". The order dated 11/10/2025 indicated the SN performed wound care to the left upper chest and right lower abdominal quadrant. The signed order dated 12/02/2025 indicated services on hold due to hospitalization. The signed order dated 12/04/2025 indicated resume services. The signed order dated 01/18/2026 indicated services on hold. The signed order dated 01/23/2026 indicated resume services. On 06/09/2026 at 11:22 AM the transfer summary was requested for both hospitalizations. During an interview on 06/09/2026 at XX:XX APM, the Administrator/DON indicated there was no transfer summary completed, only the communication notes. 3. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 01/12/2026 through 03/12/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week and HHA services five days a week. Review of Patient #8's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/12/2026 for the certification period of 03/13/2026 through 05/11/2026 and signed by the Administrator/DON. The POC indicated Patient #8 received SN services once a week and HHA services five days a week. Review of Patient #8's inactive clinical record revealed a document titled "Physician/NPP Verbal Orders". The signed physician order dated 01/24/2026 indicated services on hold due to the patient admitted to the hospital. The signed physician orders dated 02/24/2026 indicated SN and HHA services were resumed. The clinical record failed to evidence a discharge order. On 06/11/2026 at 11:23 AM, the transfer summary and discharge summary were requested. During an interview on 06/11/2026 at 1:11 PM, the Administrator/DON indicated there was no transfer or discharge summary. 4. Review of Patient #9's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 08/15/2025 for the certification period of 08/15/2025 through 10/13/2025 and signed by the Administrator/DON. The POC indicated Patient #9 received SN services weekly. Review of Patient #9's inactive clinical record revealed a document titled "Physician/NPP Verbal Orders". The signed physician order dated 09/05/2025 indicated the patient was discharged due to goals met. Review of Patient #9's inactive clinical record revealed a DC OASIS. On 06/11/2026 at 11:23 AM, the discharge summary was requested. During an interview on 06/11/2026 at 1:11 PM, the Administrator/DON indicated a discharge summary was not completed. 5. Review of Patient #10's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/25/2025 for the certification period of 03/24/2026 through 05/22/2026 and signed by the Administrator/DON. The POC indicated Patient #10 received SN services weekly. Review of Patient #10's inactive clinical record revealed a document titled "Physician/NPP Verbal Orders". The signed physician order dated 05/22/2026 indicated the patient was discharged due to goals met. Review of Patient #10's inactive clinical record revealed a discharge summary. The summary indicated Patient #10's date of birth, past medical history, an assessment of the patient, and status of goals. The discharge summary failed to evidence the admission and discharge dates, the physician responsible for home health POC, reason for admission to home health, type of services provided and frequency of services, laboratory data, and patient/family post-discharge instructions. 6. Review of Patient #11's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 08/08/2025 for the certification period of 10/07/2025 through 12/05/2025 and signed by the Administrator/DON. The POC indicated Patient #11 received SN services weekly. Review of Patient #11's inactive clinical record revealed a document titled "Physician/NPP Verbal Orders". The signed physician order dated 12/30/2025 indicated the patient was discharged. Review of Patient #11's inactive clinical record revealed a DC OASIS. On 06/11/2026 at 11:23 AM, the discharge summary was requested. During an interview on 06/11/2026 at 1:11 PM, the Administrator/DON indicated there was no discharge summary. 7. Review of Patient #12's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/15/2025 for the certification period of 09/15/2025 through 11/13/2025 and signed by the Administrator/DON. The POC indicated Patient #12 received SN services three times a week. Review of Patient #12's inactive clinical record revealed a document titled "Physician/NPP Verbal Orders". The signed physician order dated 10/17/2025 indicated the patient was discharged due to an upcoming surgery. Review of Patient #12's inactive clinical record revealed a discharge summary. The summary indicated Patient #12's date of birth, physician, allergies, admitting diagnosis, additional diagnosis, reason for admission to home health, an assessment of the patient, and status of goals. The discharge summary failed to evidence the admission and discharge dates, frequency of services provided, laboratory data, patient/family post-discharge instructions, and verification the discharge summary was sent to the physician within five days. During an interview on 06/11/2026 at 3:01 PM, the Administrator/DON indicated the discharge summary should contain past medical history, allergies, a synopsis of what occurred, what goals were met, an assessment, SOC date, DC date, medication list, and sent to the physician within 48 hours. 410 IAC 17-15-1(a)(7)