Every finding on record at Just Like Family Home Healthcare LLC

This visit was for an Initial State Licensure and Initial Federal Medicaid survey of a Home Health provider. Survey Date(s): 04/13/2026, 04/14/2026, 04/15/2026 12 Month Unduplicated Admissions: 17 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: POC- Plan of Care RN- Registered Nurse HHA - Home Health Aide

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide its 15-day discharge policy to patients for 3 of 3 record reviews with home visits. (Patients #3, #5, #15) Findings include: During a home visit on 04/14/2026 at 9:30 AM, the surveyor reviewed Patient #3’s admission packet and found it did not contain a discharge policy. During a home visit on 04/14/2026 at 11:30 AM, the surveyor reviewed Patient #5’s admission packet and found it also lacked a discharge policy. During a home visit on 04/14/2026 at 1:00 PM, the surveyor reviewed Patient #15’s admission packet and found it did not include a discharge policy. During an interview on 04/14/2026 at 10:00 AM, the Administrator, who is an RN and conducted the visit for Patient #3,, reviewed the admission packet and confirmed the agency does not provide patients with a written discharge policy. She stated the agency uses the Notice of Medicare Non‑Coverage (NOMNC) as the discharge information and does not supply patients with the policy itself. IAC 410 17-12-3(i)

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure a current home health aide plan of care was available in the patient’s home for 2 of 2 observed home visits with aide services (Patient #3, #15). Findings include: 1. During a home visit observation on 04/14/2026 at 9:40 AM with Patient #3, the surveyor reviewed the agency admission folder and found an aide plan of care dated 10/01/2025. During an interview on 04/14/2026 at 9:40 AM, the Administrator reviewed the admission packet and confirmed the aide plan of care was outdated and that Patient #3’s packet should contain a current aide plan of care. 2. During a home visit observation on 04/14/2026 at 12:05 PM with Patient #15, the surveyor reviewed the agency admission folder and found it lacked an aide plan of care. During a home visit observation on 04/14/2026 at 12:05 PM, the Administrator indicated an aide plan of care should be in the patient’s home.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview the agency failed to adhere to infection prevention standards during 3 of 3 home visits. (Administrator three times) Findings include: 1. During a home visit observation on 04/14/2026 at 9:40 AM with Patient #3, the Administrator touched the outside of the glove box, collected gloves, and donned the gloves without performing hand hygiene before gloving. The Administrator took Patient #3’s vitals, placed the dirty vital equipment on a clean drape, cleaned the equipment, then placed the clean equipment on the drape next to the nursing bag to dry. Once dry, the Administrator placed the equipment in the clean compartment of the nursing bag. The Administrator failed to keep clean equipment separate from contaminated surfaces. 2. During a home visit observation on 04/14/2026 at 10:50 AM with Patient #5, the Administrator removed gloves, touched the nursing bag, then donned new gloves; the Administrator failed to perform hand hygiene before donning new gloves. The Administrator took Patient #5’s vitals, placed the dirty vital equipment on a clean drape, cleaned the equipment, then placed the clean equipment on the drape next to the nursing bag to dry. Once dry, the Administrator placed the equipment in the clean compartment of the nursing bag. The Administrator failed to keep clean equipment separate from contaminated surfaces. The Administrator donned gloves and collected the nursing bag, dirty drape, and trash bag from the floor. The Administrator failed to perform hand hygiene before gloving. 3. During a home visit observation on 04/14/2026 at 12:05 PM with Patient #15, the Administrator took Patient #15’s vitals, placed the dirty vital equipment on a clean drape, cleaned the equipment, then placed the clean equipment on the drape next to the nursing bag to dry. Once dry, the Administrator placed the equipment in the clean compartment of the nursing bag. The Administrator failed to keep clean equipment separate from contaminated surfaces. After placing the equipment in the nursing bag, the Administrator donned gloves, picked up the floor scale, and assisted Patient #15 to the scale; the Administrator failed to perform hand hygiene before gloving. 4. During an interview on 04/15/2026 at 11:07 AM, the Administrator indicated she missed some hand hygiene during the three home visits. The Administrator indicated that for bag technique, she identifies the drape the nursing bag is placed on as the clean drape and the drape with nothing on it as the dirty drape. The Administrator indicated she places clean equipment on the same drape as the nursing bag. The drape with the nursing bag on it is the clean drape and the drape without the nursing bag is the dirty drape.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a valid competency skills check‑off was completed by the RN using a patient or pseudo‑patient as required by 42 CFR 484.80 for 1 of 1 home health aide (HHA) personnel records reviewed (HHA 1). Findings include: A review of HHA 1’s personnel file evidenced the Home Health Aide Skills Competency Checklist did not demonstrate HHA 1 performed required skills using a patient or pseudo‑patient as outlined in 42 CFR 484.80. Missing competency demonstration included: communication skills, reading and recording vital signs, bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer and ambulation, and range of motion and positioning. During an interview on 04/14/2026 at 3:00 PM, the Administrator stated she could not provide documentation showing that skills check‑offs were completed using a patient or pseudo‑patient. IAC 410 17-14-1(1)(A)