Every finding on record at Lifestyles Homecare LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: June 3, 4, 5, 6 and 9, 2025 Active Census: 68 At this Emergency Preparedness survey, Lifestyles Homecare LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: June 3, 4, 5, 6 and 9, 2025 12 Month Unduplicated Skilled Admissions: 16 Survey was announced as partially extended on 6/05/25 at 12:09 PM Abbreviations ATTC-Attendant Care, CM-Clinical Manager, HHA-Home Health Aide, HMK-Homemaker, RN-Registered Nurse, POC-Plan of Care, SN-Skilled Nurse, SOC-Start of Care QR 6/16/25 A2

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient received services as ordered on the POC for 1 of 1 active record reviewed with a SOC in the past 60 days (Patient #7). Findings include: 1. The undated agency policy “Home Health Care Patient Rights” indicated Patients have the right to: the care to be furnished, based on the comprehensive assessment, the frequency of visits, any changes in the care to be furnished and has the right to receive all services outlined in the plan of care. 2. Patient #7’s clinical record evidenced a SOC on 4/8/25 and included a POC for the certification period 4/08/25 to 6/06/25. The POC indicated the patient was to receive HHA visits four to eight hours a day, one to two times a day, two to five days a week for 9 weeks; ATTC visits two to five hours a day, one to two times a day, two to five days a week for 9 weeks; and HMK visits two to four hours, one to two days a week for 9 weeks effective 4/08/25. The clinical record failed to evidence Patient #7 received HHA, ATTC and HMK visits as ordered during the week of 4/08/25 and failed to evidence documentation that Patient #7 and the physician were notified of not receiving POC visit frequencies as ordered. 3. During an interview on 6/09/25 at 12:18 PM, RN 4 confirmed Patient #7 did not receive any HHA visits the week of 4/08/25 and relayed the HHA visits began the following week on 4/14/25 after insurance approval was received. At 12:25 PM, she also confirmed the clinical record did not evidence any documentation of the delay reason and did not include documentation the patient or physician was notified in the delay of services.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the POC included the indication for all as needed medications for 1 of 1 patient record reviewed with a home visit observation with HHA services (Patient #4) and failed to ensure the frequency and duration of visits to be made for 3 of 3 patient records reviewed with respite services (Patient #2, 5 and 8). Findings include: 1. The undated agency policy “Medication Profile” indicated the medication profile shall be reviewed by a Registered Nurse every sixty (60) days and updated whenever there is a change or discontinuation in medication. 2. The undated agency policy “Plan of Care” indicated the Plan of Care shall be completed in full to include type, frequency and duration of all visits/services. 3. Patient #4’s clinical record evidenced a SOC on 9/26/22 and included a POC for the certification period 5/12/25 to 7/10/25. The POC evidenced the following medication: a) Tramadol 50 milligrams (mg), 1 tab by mouth every 8 hours as needed. The medication profile failed to include an indication for use. During an interview on 6/05/25 at 11:32 AM, RN 3 confirmed the Tramadol did not have an indication listed on the POC for as needed use and relayed it should be listed to take as needed for pain. 4. Patient #2’s clinical record included a POC for the certification period 5/20/25 to 7/18/25 with orders for SN visit frequencies of six to ten hours a day, four to five days a week for 9 weeks and respite SN visit frequencies Per Mother’s Request. The POC failed to include the frequency and duration of respite SN visits. During an interview on 6/09/25 at 12:11 PM, RN 4 verified the POC for Patient #2 did not include any frequency orders for respite SN visits. 5. Patient #5’s clinical record included a POC for the certification period 5/19/25 to 7/17/25 with orders for SN visit frequencies of one to three hours a day, four to seven days a week; HHA visit frequencies of one to eight hours a day, one to three times a day, four to seven days a week; ATTC visit frequencies of two to six hours, one to two times a day, four to seven days a week and respite HHA visit frequencies Per Patient/Family Request. The POC failed to include the frequency and duration of respite HHA visits. During an interview on 6/09/25 at 11:10 AM, RN 4 verified the POC for Patient #5 did not include any frequency orders for respite HHA visits. 6. Patient #8’s clinical record included a POC for the certification period 1/19/25 to 3/19/25 with orders for respite SN visit frequencies Per Mother’s Request. The POC failed to include the frequency and duration of respite SN visits. During an interview on 6/09/25 at 11:18 AM, RN 4 verified the POC for Patient #8 did not include any frequency orders for respite SN visits and she relayed the frequency orders should have been listed on the POC and approved by the physician. 410 IAC 17-13-1(a)(1)(C)(iii)(ix)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 7 of 7 active patient records reviewed (Patient #1, 2, 3, 4, 5, 6 and 7). Findings include: 1. The undated agency policy “Plan of Care” indicated home care services are furnished under the supervision and direction of the client’s physician. 2. Patient #1’s clinical record included a POC for certification period 5/28/25 to 7/26/25 with orders for SN visit frequencies of four to eight hours a day, five to seven days a week. The record evidenced SN visits were performed on 5/28/25, 5/29/25, 5/30/25, 6/02/25, 6/03/25 and 6/04/25. The clinical record for Patient #1 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 6/05/25 at 11:38 AM, RN 3 relayed Patient #1 did not have any changes and confirmed she did not collaborate with the physician. The recertification POC was created and faxed to the physician for signature. 3. Patient #2’s clinical record included a POC for the certification period 5/20/25 to 7/18/25 with orders for SN visit frequencies of six to ten hours a day, four to five days a week for 9 weeks and respite SN visit frequencies Per Mother’s Request. The record evidenced SN visits were performed on 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/26/25, 5/27/25 and 5/28/25. The clinical record for Patient #2 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 6/05/25 at 11:40 AM, RN 3 relayed Patient #2 did not have any changes and confirmed she did not collaborate with the physician. The recertification POC was created and faxed to the physician for signature. 4. Patient #3’s clinical record included a POC for the certification period 5/30/25 to 7/28/25 with orders for SN visit frequencies of two to eight hours a day, one to two times a day, five to seven days a week. The record evidenced SN visits were performed on 5/30/25, 6/02/25, 6/03/25, 6/04/25, 6/05/25 and 6/06/25. The clinical record for Patient #3 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 6/05/25 at 11:43 AM, RN 3 relayed Patient #3 she did not collaborate with the physician and the recertification POC was created and faxed to the physician for signature. 5. Patient #4’s clinical record included a POC for the certification period 5/12/25 to 7/10/25 with orders for SN visit frequencies of zero to one hour a day, zero to one day a week for 9 weeks; HHA frequencies of three to nine hours a day, one to two times a day, three to seven days a week; ATTC visit frequencies of one to five hours a day, one to two times a day, four to seven days a week; and HMK visit frequencies of two to four hours, zero to two days a week for 9 weeks. The record evidenced SN visits were performed on 5/12/25 and 5/19/25; HHA visits were performed on 5/12/25, 5/13/25, 5/14/25, 5/15/25, 5/16/25, 5/19/25, 5/20/25, 5/21/25 and 5/22/25; ATTC visits were performed on 5/13/25, 5/17/25, 5/20/25 and 5/21/25 and a HMK visit was performed on 5/14/25. The Clinical record for Patient #4 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 6/05/25 at 11:45 AM, RN 3 relayed Patient #4 did not have any changes and confirmed she did not collaborate with the physician. The recertification POC was created and faxed to the physician for signature. 6. Patient #5’s clinical record included a POC for the certification period 5/19/25 to 7/17/25 with orders for SN visit frequencies of one to three hours a day, four to seven days a week; HHA visit frequencies of one to eight hours a day, one to three times a day, four to seven days a week; ATTC visit frequencies of two to six hours, one to two times a day, four to seven days a week and respite HHA visit frequencies Per Patient/Family Request. The record evidenced SN visits were performed on 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 6/02/25, 6/03/25, 6/04/25, 6/06/25 and 6/07/25; HHA visits were performed on 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/25, 6/01/25, 6/02/25, 6/03/25, 6/04/25, 6/06/25, 6/07/25 and 6/08/25; and ATTC visits were performed on 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/25, 6/01/25, 6/02/25, 6/03/25, 6/04/25, 6/06/25, 6/07/25 and 6/08/25. The Clinical record for Patient #5 failed to include a verbal or signed written order for the SN, HHA and ATTC frequencies was obtained prior to the above visits performed. During an interview on 6/05/25 at 11:53 AM, RN 4 relayed Patient #5 did not have any changes. She created the recertification POC and faxed it to the physician for signature. 7. Patient #6’s clinical record included a POC for the certification period 5/29/25 to 7/27/25 with orders for SN visit frequencies of four to eight hours a day, six to seven days a week. The record evidenced SN visits were performed on 5/29/25, 5/30/25, 5/21/25, 6/01/25, 6/02/25, 6/03/25, 6/04/25, 6/05/25, 6/06/25, 6/07/25 and 6/08/25. The Clinical record for Patient #6 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 6/05/25 at 11:58 AM, RN 4 relayed she did not collaborate with the physician for the recertification POC. She created the recertification POC and faxed it to the physician for signature. 8. Patient #7’s clinical record evidenced a SOC on 4/08/25 and included a POC for the certification period 4/08/25 to 6/06/25 with orders for HHA visit frequencies of four to eight hours a day, one to two times a day, two to five days a week for 9 weeks. The record evidenced HHA visits were performed on 4/14/25 and 4/15/25. The Clinical record for Patient #7 failed to include a verbal or signed written order for the HHA frequencies was obtained prior to the above visits performed. During an interview on 6/05/25 at 12:04 PM, RN 4 relayed she did not collaborate with the physician for the POC frequency orders. She created the POC and faxed it to the physician for signature. 9. During an interview on 6/05/25 at 11:49 AM, the Administrator verified the home health agency did not collaborate with the physicians for POC frequency orders. The POC’s were created by the Alternate Administrator and sent to the physicians for review. 410 IAC 17-13-1(a)

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the POC was reviewed with the physician or attending practitioner no less frequently than once every 60 days for 4 of 6 active records reviewed with a recertification (Patient #2, 4, 5, and 6). Findings include: 1. The undated agency policy “Plan of Care” indicated home care services are furnished under the supervision and direction of the client’s physician and the total Plan of Care shall be reviewed by the attending physician and agency personnel as often as the severity of the client’s condition requires, but at least one time every sixty (60) days. 2. Patient #2’s clinical record evidenced a SOC on 6/15/20. The record included a POC for the certification period 5/20/25 to 7/18/25 and documents titled “60 Day Summary” sent 3/27/25 and 5/28/25. The recertification POC was sent to the physician on 5/28/25, 62 days after the last update was sent to the physician. The record failed to include collaboration with the physician for the recertification POC and failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 6/05/25 at 11:40 AM, RN 3 relayed Patient #2 did not have any changes and confirmed she did not collaborate with the physician. During an interview on 6/09/25 at 12:11 PM, the Alternate Administrator/RN 4 confirmed the POC and 60 Day Summary were not sent to the physician until 5/28/25. 3. Patient #4’s clinical record evidenced a SOC on 9/25/22. The record included a POC for the certification period 5/12/25 to 7/10/25 and documents titled “60 Day Summary” sent 3/17/25 and 5/22/25. The recertification POC was sent to the physician on 5/22/25, 66 days after the last update was sent to the physician. The record failed to include collaboration with the physician for the recertification POC and failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 6/05/25 at 11:45 AM, RN 3 relayed Patient #4 did not have any changes and confirmed she did not collaborate with the physician. During an interview on 6/09/25 at 12:04 PM, the Alternate Administrator/RN 4 confirmed the POC and 60 Day Summary were not sent to the physician until 5/22/25. 4. Patient #5’s clinical record evidenced a SOC on 2/01/13. The record included a POC for the certification period 5/19/25 to 7/17/25 and documents titled “60 Day Summary” sent 3/20/25 and 6/04/25. The recertification POC was sent to the physician on 6/04/25, 76 days after the last update was sent to the physician. The record failed to include collaboration with the physician for the recertification POC and failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 6/05/25 at 11:53 AM, RN 4 relayed Patient #5 did not have any changes. She created the recertification POC and faxed it to the physician for signature. During an interview on 6/09/25 at 11:57 AM, the Alternate Administrator/RN 4 confirmed the POC and 60 Day Summary were not sent to the physician until 6/04/25. 5. Patient #6’s clinical record evidenced a SOC on 2/19/21. The record included a POC for the certification period 5/29/25 to 7/27/25 and documents titled “60 Day Summary” sent 4/02/25 and 6/05/25. The recertification POC was sent to the physician on 6/05/25, 64 days after the last update was sent to the physician. The record failed to include collaboration with the physician for the recertification POC and failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 6/05/25 at 11:58 AM, RN 4 relayed she did not collaborate with the physician for the recertification POC. She created the recertification POC and faxed it to the physician for signature. During an interview on 6/09/25 at 12:08 PM, the Alternate Administrator/RN 4 confirmed the POC and 60 Day Summary were not sent to the physician until 6/05/25. 6. During an interview on 6/05/25 at 11:49 AM, the Administrator verified the home health agency did not collaborate with physicians for POC frequency orders. The POC’s were created by the Alternate Administrator and sent to the physician for review. 7. During an interview on 6/09/25 at 11:55 AM, the Alternate Administrator/RN 4 relayed the physician should be updated every 60 days. 410 IAC 17-13-1(a)(2)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure employees followed standards of practice for hand hygiene to reduce the spread of infections for 1 of 2 home visit observations with an RN (Patient #2). Findings include: 1. Review of “Lippincott’s best practice guidelines” indicated one should perform hand hygiene and put on clean gloves before removing the plug or cap of the gastrostomy tube. 2. During a home visit observation conducted with Patient #2 and RN 1 on 6/04/25 beginning at 11:50 AM, RN 1 connected the extension tubing to Patient #2’s gastrostomy tube (G tube) and checked for residual (the amount of fluid aspirated from the stomach before a feeding). RN 1 then donned gloves and connected the feed tubing to Patient #2’s extension tubing. RN 1 failed to wear gloves while connecting the extension tubing and failed to perform hand hygiene prior to putting on gloves. 3. During an interview on 6/04/25 at 2:04 PM, Surveyor asked if gloves should be worn when accessing the G-tube site, the Administrator stated “not technically since the gut is dirty.” Surveyor then asked if the nurse should have performed hand hygiene before putting on gloves and the Administrator relayed “it is all the same dirty gut area so I don’t think so.” 410 IAC 17-12-1(m)

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Care Agency. Survey Dates: 7/11, 7/12, 7/13 and 7/14/22 Partially Extended Survey Announced 7/11/2022 at 12:20PM. Extended survey was announced on 7/12/2022 at 3:33PM. Facility Number: IN012685 Census: 55 These deficiencies reflect State findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure all patients were informed of the following Patient Bill of Rights: the disciplines that will furnish care, factors that could impact treatment effectiveness, and any changes in the care to be furnished for 3 of 3 active patients with home visits [Patient # 5, 6, and 7] and the potential to affect all 55 current patients. Findings include: Review of an undated agency document titled “Client Handbook” included an undated section titled “Home Health Care Patient Bill of Rights” that was missing the following information that was to be provided to the patient: the disciplines that will furnish care, factors that could impact treatment effectiveness, and any changes in the care to be furnished. A home observation visit for Patient #5 was conducted on 07/12/2022 at 10:00AM. Observed agency folder in home with the undated Home Health Care Patient Bill of Rights missing the following information that was to be provided to the patient: the disciplines that will furnish care, factors that could impact treatment effectiveness, and any changes in the care to be furnished During an interview on 07/11/2022 at 11:35AM, when asked where in the Patient Bill of Rights this patient information is found, the Administrator reviewed the Patient Bill of Rights and indicated could not find. IAC 410 17-12-3(b)(2)(D)(i)(AA) IAC 410 17-12-3(b)(2)(D)(ii)(BB) A home observation visit for Patient #6 was conducted on 07/12/2022 at 12:58PM. Observed agency folder in home with the undated Home Health Care Patient Bill of Rights missing the following information that was to be provided to the patient: the disciplines that will furnish care, factors that could impact treatment effectiveness, and any changes in the care to be furnished. A home observation visit for Patient #7 was conducted on 07/13/2022 at 10:04AM. Observed agency folder in home with the undated Home Health Care Patient Bill of Rights missing the following information that was to be provided to the patient: the disciplines that will furnish care, factors that could impact treatment effectiveness, and any changes in the care to be furnished.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation reflected efforts made to resolve problem before discharging patient in 1 of 2 discharged record reviews (Patient #4). Findings include: Review of an undated agency document titled “Client Handbook” included an undated section titled “Home Health Care Patient Bill of Rights” that indicated “… patients have the right to … receive reasonable continuity of care services outlined in the plan of care ….” Review of an undated agency document titled “Client Handbook” included an undated section titled “Discharge and Transfer Policy” that indicated “… the goal of planning for discharge … … in advance is to ensure continuity of care … includes … client, family … in the discharge planning process … clients are informed of the reason for discharge ….” Record review for Patient #4, start of care date 08/09/2021 and discharge date of 03/07/2022, contained a plan of care for certification period 02/05/2022-04/05/2022 with SN (skilled nurse) orders for 1-4 hours, 0-2 days/week for 10 weeks … D/C (discharge) plans … when services are no longer needed, a higher level of care is required … per request ….” Review of an agency document dated 02/28/2022, titled “Nursing Visit Note” indicated “… SN told patient that he/she needs to be here on Mondays at 1:00PM for … visit to set up meds … can change the date or time if that doesn’t work … assures nurse he/she will be here next week … this is the 2nd time he/she hasn’t been present ….” Review of an agency document dated 03/07/2021 [sic], titled “Daily Care Logs” indicated “… received call from patients case manager … unable to see patient again this week … was not home when nurse arrived ….” Review of an agency document dated 03/10/2022, titled “Daily Care Logs” indicated “… sister … called … back … nurse … had standing appt (appointment) with patient every Monday for assessment, med set up, injection and that patient has not been home for 2 weeks, nor has … returned … phone call … are DC’ing (discharging) at the time ….” The documentation failed to evidence communication with patient regarding potential discharge, efforts to improve the problem, and the reason for discharge. Review of an agency document dated 03/14/2022, titled “Discharge Assessment Including Oasis Elements” indicated “… Oasis completed based on visit date: 02/24/2022 … reason for discharge … patient refuses services, or elects to be transferred or discharged … patient has not been home for 2 weekly scheduled SN visits and has not returned phone calls … was the discharge planned … no ....” During an interview on 07/13/2022 at 3:15PM, The administrator indicated that there was no documentation of the agency efforts to resolve the problem, indicated the patient would not be home, no documentation was provided by survey exit.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current respiratory status and mental status in the development and implementation of the plan of care for 2 of 7 patients (Patient #2 and #4). Findings include: 1. Review of an undated agency policy C-145, copyright Briggs Healthcare, Operational Guidelines titled “Comprehensive Client Assessment”, indicated “… the comprehensive assessment must accurately reflect the client’s (patient) status ….” 2. Record review for Patient #2, included an agency document, dated 06/08/2022, titled “Comprehensive Assessment” that documented “… breath sounds … clear … wheeze (high pitched whistling sound) all lobes (sections of lung) / dim (diminished) lower post (back of lung) lobes ….” 3. Record review for Patient #4, discharge date of 03/07/2022, contained an agency document dated 02/01/2022, titled “Comprehensive Assessment” indicated “… mental status … compliant with meds and regime, and daily problems … summary of setbacks/improvements since prior assessment … still poor at follow thru with medications ….” 4. During an interview on 07/11/2022 at 4:25PM, the administrator indicated the documentation form may be the problem, to explain why Patient # 2's comprehensive assessment included contradictory information of breath sounds documented as clear and wheezing within the same assessment. The agency did not provide further documentation, or information regarding the inconsistent documentation within the comprehensive assessment, by survey exit. 5. During an interview on 07/13/2022 at 3:30PM, the administrator indicated Patient #4 managed their own medications and no further documentation, or information regarding the documentation within the comprehensive assessment, was received, by survey exit.

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 patients’ plan of care included all required elements, and included the Patient's advance directive choice and the functional limitations for 1 of 5 active patient record reviews (Patient #2). Findings include: Review of an undated agency policy C-660, Home Care Operational Policy titled “Care Plans,” indicated “… following the initial assessment, a Care Plan shall be developed with the client … Care Plan shall be … evaluated, and revised … based upon … ongoing client assessments ….” Review of a document titled “Indiana Physician Orders for Scope of Treatment (POST),” dated 02/10/2022 by physician, and documented status pf Patient # 2 as “… Do Not Attempt Resuscitation ….” Review of an agency document dated 06/08/2022, titled “Comprehensive Assessment,” indicated “… gastrointestinal … no problem … genitourinary … no problem … DNR-Do Not Resuscitate (do not begin CPR) ….” Record review for Patient #2, contained a plan of care for certification period 06/11/2022-08/09/2022 that documented “… Risk Factors … incontinence … safety measures … full code ….” During an interview on 07/11/2022 at 4:26PM, the administrator had no response to explain why the plan of care for Patient #2 did not include the information obtained from the comprehensive assessment and POST order. The agency failed to provide further documentation or information by survey exit. IAC 410 17-13-1(a)(1)(D)(vi,xiii)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to notify the physician of missed visits for 1 of 3 active skilled nursing records reviewed (Patient #7.) 1. An agency policy C-680 titled “Clinical Documentation,” included, but not limited to, “…Services not provided and the reason for the missed visits will be documented and reported to the physician….” 2. The clinical record of Patient #7, with start of care (SOC) of 6/13/22, was reviewed on 7/12/22 and 7/13/22. The plan of care for the certification period 6/13/22 – 8/11/22 included orders for skilled nursing 6-14 hours per day, 3-6 days per week x 9 weeks to provide total care, administer medications and feedings via G-tube, assess, and teach family. The documentation included a Clinical Note, dated 06/30/22, which indicated a call was received from the patient’s primary caregiver who reported that they would be available from “July 1 to July 10” and would provide the patient's care and they did not need agency services during that time. The clinical record failed to evidence notification to the physician that the skilled nurse visits would not be provided to Patient #7, nor notification to the physician that the primary caregiver would provide the Patient's care, during the time period. 3. During an interview on 7/12/22 which began at 3:15PM, the Administrative Staff (AS) #1 indicated when a patient’s family member informs the agency they are canceling visits and they will provide the care, a nurse note should be made to document the request and the staff would be notified. AS #2 relayed there was no notification to the physician nor was an physician order received and within the clinical record; they didn’t write an order. IAC 410 17-13-1(a)(2)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure all staff followed standard precautions and infection control for 1 of 3 home visits observed (Patient #5). Findings include: 1. Review of an undated agency policy N-140, copyright Briggs Healthcare, Clinical Procedures titled “Infection Control” indicated “… gloves are disposable and are not meant to be reused ….” 2. Review of the Centers for Disease Control and Prevention (CDC) web reference, https://www.cdc.gov/handhygiene/providers/index.html, indicated “… Change gloves and perform hand hygiene during patient care … moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs ….” 3. During a home observation visit of home health aide (HHA) #1 while providing care to Patient #5, was conducted on 07/12/2022 at 10:00AM. Observed HHA #1, who wore the same pair of gloves throughout the care. Observed HHA #1 don gloves and assisted Patient with a sponge bath, began with Patients’ hands and ended with peri-area. Then, while wearing the same gloves, HHA #1 applied deodorant and lotion to Patients' arms and legs, applied incontinency brief and pajama bottoms. Then, observed HHA #1 wipe these same gloves with a disinfectant wipe and then assisted Patient with their walker. 4. During an interview on 07/12/22 at 3:15PM, the administrator indicated the employee should not have worn the same gloves throughout the care, should have completed hand hygiene, and was to follow standard infection control mitigation processes and the agency policies. 410 IAC 17-12-1(m)

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the orientation of the competency evaluation of home health aides (HHA) included the tasks of performing a tub bath and recognizing and reporting changes in skin condition that had the potential to affect all patients receiving home health aide services. Findings include: Review of an undated agency policy D-220, copyright Briggs Healthcare, Home Care Operational Guidelines titled “Competency Evaluation of Home Care Staff” indicated “… all new employees will be assessed for competency based on expected requirements for the position ….” Review of an undated agency document D-145, copyright Briggs Healthcare titled “Competency Evaluation-Home Health Aide” was missing the evaluation of the following skills: tub bath and recognizing and reporting changes in skin condition. During an interview on 07/13/2022 at 3:30PM, when asked when the D-145 Competency Evaluation is used, the administrator indicated is used on hire with home health aides during orientation. 410 IAC 17-14-1(l)(A)

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed ensure the home health aide (HHA) competency skills were evaluated with a patient or with a pseudo-patient (live person can be volunteer or staff) and follow their agency policy for 5 of 5 HHA employee records reviewed [Home Health aides #1, 2, 3, 4, and 5). Findings include: 1. Review of an undated agency document D-145, titled “Competency Evaluation-Home Health Aide” for HHA #2, HHA #3 and HHA #4 failed to evidence the location of the skill observations, which skills were evaluated on a patient and or a pseudo patient, and which skills required teaching during the competency. 2. Review of an undated agency document titled “Home Health Aide Competency Evaluation” for HHA 1 and HHA 5 failed to evidence the location of the competency observation and the type of patient used for the competency. 3. During an interview on 07/13/22 at 3:30PM, the administrator indicated the registered nurse and HHA are to go to a patient's home to observe the task provided by the HHA, to evaluate the skill and competency of the individual. No further information was provided by survey exit.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure the home health aide (HHA) followed the plan of care for 2 of 3 record reviews with home health aide only services (Patient #2 and 3). Findings include: 1. Review of an undated agency policy C-751, Home Care Operational Guidelines titled “Home Health Aide Care Plan” included, but not limited to, “… a complete and appropriate Care Plan, identifying duties to be performed by the Home Health Aide, shall be developed by a Registered Nurse … all home health aide staff will follow the identified plan.” 2. Record review for Patient #2 on 07/11/22, contained a plan of care for certification period 06/11/2022-08/09/2022, with physician orders “HHA … weeks 2-9 … 2-8 hour [sic], 4-7 days/week ….” A. Review of a document titled “Assessments & Care Plan,” dated 06/10/2022, indicated “… task: assist into and out of shower … Mon, Wed, Fri ….” B. Review of untitled agency documents used by HHA for documenting their aide care visit notes, indicated the task of assisting into and out of the shower was not completed for the visits made on 6/13/22, 6/15/22, 6/17/22, 6/20/22, 6/22/22, and 6/24/22. There were no visit notes dated after 6/26/22 within the clinical record. C. During an interview on 7/11/22 at 4:40PM, the administrator indicated the HHA monitored the patients’ bath, and indicated the patient may not require the assistance in and out of the shower. No further information was received by survey exit. 3. Record review for Patient #3, discharge date of 02/16/2022, contained a plan of care for certification period 01/26/2022-03/26/2022, that indicated “…HHA … week 1 … 10 hours, 1-2x (times)/day, 1-2 days/week … weeks 2-9 … 10 hours, 1-2x/day, 5-7 days/week ….” A. Review of a document titled “Assessments & Care Plan,” dated 01/26/2022, indicated “… task: assist into and out of shower … all shifts … all days … task: assist with shampoo … all shifts … all days ….” B. Review of untitled agency documents used by HHA for documenting visit notes, indicated the task of assisting into and out of the shower and the task of assisting with shampoo were not completed for visits made on 01/27/22, 02/01/22, 02/03/22, 02/05/22, 02/08/22, 02/10/22, 02/12/22 and 02/13/22. C. During an interview on 7/13/22 at 3:15PM, the administrator indicated the patients’ family member may be providing this care and therefore the aide did not assist during these visits. No further information was provided by the agency by survey exit.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to evidence the administrator reports to the governing body for 1 of 1 agency. 1. An agency policy C-105 titled “Position: Administrator,” indicated, but not limited to, “…Reports to: Governing Body…maintains ongoing liaison between the Governing Body and the Agency staff…” 2. The agency’s document “Organizational Chart” was reviewed on 7/11/22. The Organizational Chart failed to indicate the administrator reported to the Governing Body. 3. The agency’s document titled “Organizational Chart For Governing Body” was reviewed on 7/12/22 and failed to indicate the Governing Body oversees the administrator. 4. During and interview on 7/13/22 beginning at 3:15PM, Administrative Staff (AS) #1, indicated the organizational chart did not reflect the administrator reported to anyone or body, and indicated they had the governing body on a separate organizational chart. The Organizational Chart For Governing Body was reviewed and did not indicate their was a Governing Body was over the administrator. AS #1 indicated they were the owner, administrator, and the director of nursing and reported to self, indicating their was no governing body for the agency. IAC 410 17-12-1(a)(1)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to follow their own policies and ensure that documentation of home visits be incorporated into the clinical record within seven (7) days for 3 of 5 active records reviewed (Patient #1, 2, and 5). Findings include: An agency policy C-870 “Clinical Records/Medical Record Retention” indicated, but limited to, “…Documentation must be returned to agency within twenty-four (24) hours of the most recent home care visit pertinent to that discipline and filed in the clinical record within seven (7) days…” An agency policy C-680 “Clinical Documentation” indicated, but not limited to, “…Documentation the services ordered on the plan of care will be completed the day the service is rendered and incorporated into the clinical record within seven (7) days after the care has been provided…” The clinical record of Patient #1, with start of care (SOC) of 3/18/22, was reviewed on 7/11/22. The plan of care (POC) for the certification period 5/17/22 – 7/15/22 indicated, but not limited to, orders for skilled nursing 0-1 hours per day x 9 weeks to assess vital signs, evaluate pain, and monitor for signs and symptoms of infection and orders for home health aide (HHA) services 2-6 hours, 1-3 times per day, 4-7 days per week x 9 weeks to assist with ADLs, monitor for seizure and fall precautions, and notify nurse of concerns regarding urine output, constipation, and skin integrity. The clinical record failed to evidence HHA visits past 7/3/22. During an interview with Administrative Staff (AS) #1 on 7/11/22 at 4:43PM, AS #1 indicated HHA notes are typically in the chart quick, usually within the week after. The clinical record of Patient #2, with start of care (SOC) of 11/03/2017, was reviewed on 7/11/22. The plan of care (POC) for the certification period 06/11/2022 – 08/09/2022 indicated, but not limited to, orders for home health aide (HHA) services 2-8 hours, 4-7 days per week x 9 weeks to assist with ADLs, observe bowel and bladder patterns, observe behavior, and notify nurse of concerns regarding bowel, bladder, and behavior. The clinical record failed to evidence HHA visits past 06/27/22. The clinical record of Patient #5, with start of care of 03/11/2016, was reviewed on 07/12/2022. The plan of care for the certification period 06/10/2022 – 08/08/2022 indicated, but not limited to, orders for home health aide services 8-12 hours, 1-2 times per day, 3-5 days per week to assist with ADLs, patient reminders, and observe behavior and notify nurse of concerns The clinical record failed to evidence HHA visits past 07/02/22.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure patient's clinical records would be made available to the patient, free of charge with the potential to affect all 55 current patients, for 1 of 1 agency. Findings include: Review of an undated document titled “Notice of Privacy Practices for Protected Health Information” indicated “… if you request a copy of your health information, we will charge a reasonable fee for copying ….” A home observation visit for Patient #5 was conducted on 07/12/2022 at 10:00AM. Observed agency folder in home with undated Notice of Privacy Practice for Protected Health Information informing the patient of the charge when requesting a copy of medical record. During an interview on 07/11/2022 at 11:30AM, when asked for the process taken when a patient requests their medical record, the administrator read the Notice of Privacy Practices for Protected Health Information and indicated it reads a fee is charged. A home observation visit for Patient #6 was conducted on 07/12/2022 at 12:58PM. Observed agency folder in home with undated Notice of Privacy Practice for Protected Health Information informing the patient of a charge when requesting a copy of medical record. A home observation visit for Patient #5 was conducted on 07/13/2022 at 10:04AM. Observed agency folder in home with undated Notice of Privacy Practice for Protected Health Information informing the patient of a charge when requesting a copy of medical record.