Every finding on record at Loving People Home Healthcare Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 12/22/2025, 12/23/2025, 12/24/2025 Active Census: 7 At this Emergency Preparedness survey, Loving People Home Healthcare Inc. was found to be in compliance with Emergency Preparedness Requirements for Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR by Area 3 on 12/31/2025.

This visit was for an Initial Federal Medicaid survey for a Home Health provider. Survey Dates: 12/22/2025, 12/23/2025, and 12/24/2025. 12 Month Unduplicated Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Loving People Home Healthcare Inc. is precluded from providing its own home health aide training and competency evaluation program for a period of 2 years beginning 12/24/2025 through 12/23/2027 for being found out of compliance with the Conditions of Participation 42 CFR 484.60 Care Planning, coordination, quality of care and 484.105 Organization and administration of services. Abbreviations: HHA Home Health Aide SN Skilled Nursing RN Registered Nurse CM Clinical Manager POC Plan of Care SOC Start of care ADLs Activities of Daily Living QR by Area 3 on 12/31/2025.

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 and interviews, the agency failed to ensure that 5 of 6 patients (Patients #1, 2, 3, 4, and 5) receiving HHA services were informed of and consented to the reduction in services to be provided by the agency. Findings include: 1. A review of a policy titled ‘Rights, Responsibilities and Ethics’ stated, “… The Agency must inform a patient orally and in writing of any changes … requirements … reduction in services … Participate in, be informed about, and consent … Establishing and revising the plan of care … any changes in the care to be furnished …” 2. A review of the clinical record of Patient #1 contained the initial POC signed and dated 07/31/2025 by Person 1, RN with a SOC 07/31/2025 for the initial certification period of 07/31/2025 through 09/28/2025 signed by the ordering provider on 08/06/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, and medication review and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained a POC signed and dated 09/25/2025 by RN 1 with a SOC 07/31/2025 for the 1st recertification period of 09/29/2025 through 11/27/2025 signed by the ordering provider on 09/29/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, and medication review and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained a POC signed and dated 11/24/2025 by RN 1 with a SOC 07/31/2025 for the 2nd recertification period of 11/28/2025 through 01/26/2026 signed 12/02/2025 by the ordering provider indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, medication review, medication set-up and HHA services 8 hours a day/5 days a week. A review of HHA visit notes indicated HHA services began on 07/07/2025, 07/08/2025, week of 07/11/2025 through 07/15/2025, 5 HHA visits occurred; week of 07/18/2025 through 07/22/2025, 5 HHA visits occurred; week of 07/25/2025 through 07/29/2025, 5 HHA visits occurred, 09/01/2025, 09/02/2025, 09/04/2025, 09/05/2025, week of 09/08/2025 through 09/12/2025, 5 HHA visits occurred; week of 09/15/2025 through 09/19/2025, 5 HHA visits occurred; week of 09/22/2025 through 09/26/2025, 5 HHA visits occurred; week of 09/29/2025 through 10/03/2025, 5 HHA visits occurred; week of 10/06/2025 through 10/10/2025, 5 HHA visits occurred; week of 10/13/2025 through 10/17/2025, 5 HHA visits occurred; then weekly visits occurred on 10/22/2025, 10/29/2025, 11/05/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The clinical record of Patient #1 failed to evidence documentation of the consent of Patient #1 to change the HHA service hours from 5 days a week to 1 day a week. 3. On 12/23/2025 at 10 AM, HHA 2, a family member and caregiver of Patient #1 indicated they were told to work one day a week and was not sure why. 4. A review of the clinical record of Patient #2 contained the initial POC signed and dated by Person 1, RN on 08/11/2025 and the ordering provider on 08/19/2025 for the initial certification period of 08/05/2025 through 10/03/2025 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week. A review of the clinical record of Patient #2 contained a POC signed and dated by Person 1, RN on 10/03/2025 and the ordering provider on 10/08/2025 for the 1st recertification period of 10/04/2025 through 12/02/2025 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week. A review of the clinical record of Patient #2 contained a POC signed and dated by RN 1 on 01/25/2025 and signed by the ordering provider on 12/01/2025 for the 2nd recertification period of 12/04/2025 through 02/01/2026 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week. A review of HHA visit notes week of 08/29/2025 through 08/31/2025, 5 HHA visits occurred; week of 09/03/2025 through 09/07/2025, 5 HHA visits occurred; week of 09/10/2025 through 09/14/2025, 5 HHA visits occurred; 09/17/2025, 09/21/2025, week of 09/24/2025 through 09/28/2025, 5 HHA visits occurred; weekly visits began on 10/01/2025, 10/08/2025, 10/15/2025, 10/22/2025, 10/29/2025, 11/06/2025, 11/13/2025, 11/18/2025, 11/27/2025, 12/04/2025, 12/11/2025, and 12/18/2025. The clinical record of Patient #2 failed to evidence documentation of informed consent of Patient #2 to change the HHA service hours from 5 days a week to 1 day a week. 5. On 12/23/2025 at 11 AM HHA 1, a family member and caregiver of Patient #2 indicated they were not sure about the Agency, their hours getting cut, did not understand how it happened, and was concerned. 6. A review of the clinical record of Patient #3 contained a POC signed by Person 1, RN, for the initial certification period for 09/04/2025 through 10/31/2025; signed 09/17/2025 by the ordering provider indicated SN orders were but not limited to medication review and HHA services were 8 hours a day/5 days a week. A review of the clinical record of Patient #3 contained a POC signed 10/27/2025 by the Administrator, for the recertification period 11/01/2025 through 12/30/2025, signed 10/30/2025 by the ordering provider indicated SN orders were but not limited to medication management and HHA services were 8 hours a day/5 days a week. A review of the clinical record of Patient #3 contained a SN visit note signed by Person 1, RN failed to evidence a medication set-up was conducted on 09/25/2025 and SN visit notes signed by the Administrator indicated medication set-up was conducted on 10/09/2025,10/22/2025, 11/05/2025, 11/19/2025,12/03/2025, and 12/17/2025. A review of HHA visit notes indicated services were initiated on 09/04/2025, 09/05/2025, week of 09/08/2025 through 09/12/2025, 5 HHA visits occurred; 09/15/2025, 09/18/2025, 09/19/2025, week of 09/22/2025 through 09/26/2025, 5 HHA visits occurred; week of 09/29/2025 through 10/03/2025, 5 HHA visits occurred; week of 10/06/2025 through 10/10/2025, 5 HHA visits occurred; week of 10/13/2025 through 10/17/2025, 5 HHA visits occurred; then weekly visits began on 10/22/2025, 10/29/2025, 11/05/2025, 11/12/2025, 11/26/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The clinical record of Patient #3 failed to evidence documentation of informed consent of Patient #3 to change the HHA service hours from 5 days a week to 1 day a week. 7. The clinical record review of Patient #4 contained a POC for the initial certification period of 5/28/2025 through 07/26/2025 with a SOC date of 05/28/2025 signed by Person 1, RN on 05/28/2025 signed by the ordering provider on 06/05/2025 indicated the following SN orders were observation and assessment of respiratory, gastrointestinal, cardiopulmonary, integumentary, endocrine, neurological, and renal/genitourinary, and pain status. The clinical record review of Patient #4 contained a POC for the 1st recertification period 07/27/2025 through 09/24/2025, signed by Person 1, RN and the ordering provider on 07/25/2025 indicated Patient #4 was to receive SN services to assess, evaluate medication and education 1 hour a week/2 hours a month and HHA services 8 hours 5 days a week for ADL’s. The Clinical record review of Patient #4 contained a POC for the 2nd recertification period 09/25/2025 through 11/23/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week signed by Person 1, RN and ordering provider on 09/22/2025. The clinical record review of Patient #4 contained a POC for the 3rd recertification for 11/24/2025 through 01/22/205 signed by the Administrator on 11/19/2025, signed by the ordering provider on 12/01/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week. A review of HHA visit notes beginning week of 06/18/2025 through 06/20/2025, 5 HHA visits occurred; week of 06/23/2025 through 06/27/2025, 5 HHA visits occurred; week of 06/20/2025 through 07/04/2025, 5 HHA visits occurred; 07/07/2025, 07/08/2025, 07/10/2025 07/11/2025, week of 07/14/2025 through 07/18/2025, 5 HHA visits occurred; week of 07/21/2025 through 07/25/2025, 5 HHA visits occurred; week of 07/28/2025 through 08/01/2025, 5 HHA visits occurred; week of 08/04/2025 through 08/08/2025, 5 HHA visits occurred; week of 08/11/2025 through 08/15/2025, 5 HHA visits occurred; 08/18/2025, 08/19/2025,08/20/2025, week of 08/25/2025 through 08/29/2025, 5 HHA visits occurred; 09/01/2025, 09/02/2025, 09/03/2025, 09/05/2025, week of 09/08/2025 through 09/12/2025, 5 HHA visits occurred; week of 09/15/2025 through 09/19/2025, 5 HHA visits occurred; week of 09/22/2025 through 09/25/2025, 4 HHA visits occurred; week of 09/29/2025 through 10/03/2025, 5 HHA visits occurred; week of 10/06/2025 through 10/10/2025, 5 HHA visits occurred; and week of 10/13/2025 through 10/17/2025, 5 HHA visits occurred. Beginning the week of 10/20/2025, the clinical record evidenced HHA visits were weekly, on 10/22/2025, 10/29/2025, 11/05/2025, 11/12/2025, 11/19/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The clinical record of Patient #4 failed to evidence documentation of informed consent of Patient #4 to change the HHA service hours from 5 days a week to 1 day a week. 8. The clinical record review of Patient #5 contained a POC for the initial certification period of 08/21/2025 through 10/19/2025 signed 08/22/2025 by Person 1, RN and signed 09/10/2025 by the ordering provider indicated SN services 1 hour every 2 weeks were but not limited to assess and evaluate disease process, education, and medication review. HHA services were to be provided 8 hours a day/5 days a week. The clinical record review of Patient #5 contained a POC for the 1st recertification period of 10/20/2025 through 12/18/2025 signed 10/17/2025 by the Administrator, signed by the ordering provider 10/31/2025 indicated SN services 2 times a month were but not limited to for medication set-up and HHA services were to be provided 8 hours a day/5 days a week. The clinical record review of Patient #5 contained a POC for the 2nd recertification period of 12/19/2025 through 02/16/2026 signed on 12/12/2025 by RN 1 indicated Patient #5 was to receive SN services 1 hour every 2 weeks for medication compliance and HHA services 8 hours a day/5 days a week during certification period. The record review of HHA visit notes evidenced visits were conducted week of 09/15/2025 through 09/20/2025, 5 HHA visits occurred; week of 09/22/2025 through 09/27/2025, 5 HHA visits occurred; week of 09/29/2025 through 10/04/2025, 5 HHA visits occurred; week of 10/06/2025 through 10/11/2025, 5 HHA visits occurred; week of 10/13/2025 through 10/18/2025, 5 HHA visits occurred. Weekly HHA visits began on 11/05/2025, 11/12/2025, 11/19/2025, 11/26/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The clinical record of Patient #5 failed to evidence documentation of informed consent of Patient #5 to change the HHA service hours from 5 days a week to 1 day a week. 9. On 12/23/2025 at 12 PM, when the above concerns were discussed with the Administrator and the Alternate Administrator, the Alternate Administrator indicated the Agency had mistakenly received their identification to start billing, then when the Agency was told to cease their billing, they were not sure how to handle the situation, they decided to decrease HHA visits to weekly. When this writer explained, the Agency accepted the patients and were responsible for the care of the patients, and if the Agency could no longer provide the care, it was the Agency’s responsibility to find another Agency for the patients, the Alternate Administrator indicated understanding. The Alternate Administrator indicated all the patients and families were aware of the situation. When queried if it was documented, the Alternate Administrator indicated it was not. 410 IAC 17-12-3(b)(2)(D)(ii)(AA) 410 IAC 17-12-3(b)(2)(D)(ii)(BB)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the ordering physician was notified of missed SN and HHA visits (see G0572), failed to ensure the POC included the duration of services (see G0574), and failed to obtain verbal orders prior to providing services (see G0580). 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 484.60, Care Planning, Coordination of Care, and Quality of Care, with the potential to affect all 7 current patients receiving Home Health services from this provider. Findings include: * 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the ordering provider was notified of missed SN and HHA visits with 5 of 7 patients who received SN services for medication set-up every 14 days and HHA services for ADL’s (Patients #1, 2, 4, 5 and 7) Findings include: 1. A policy titled, ‘Missed Visits’ stated, “… RN Case Manager responsibilities … update the physician … Documentation Requirements All missed visits must include: …Notifications made (scheduler, RNCM, physician) …” 2. A review of the clinical record of Patient #1 contained the initial POC signed and dated 07/31/2025 by Person 1, a RN with a SOC 07/31/2025 for the initial certification period of 07/31/2025 through 09/28/2025 signed by the ordering provider on 08/06/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, and medication review and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained a POC signed and dated 09/25/2025 by RN 1 with a SOC 07/31/2025 for the 1st recertification period of 09/29/2025 through 11/27/2025 signed by the ordering provider on 09/29/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, and medication review and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained a POC signed and dated 11/24/2025 by RN 1 with a SOC 07/31/2025 for the 2nd recertification period of 11/28/2025 through 01/26/2026 signed 12/02/2025 by the ordering provider indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, medication review, medication set-up and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained SN visit notes 08/15/2025, 08/29/2025, 09/12/2025,09/22/2025, 10/10/202, 10/22/2025, 11/05/2025,and 11/19/2025. A review of HHA visit notes indicated HHA services began 07/07/2025, 6 days after the SOC, 07/08/2025, week of 07/11/2025 through 07/15/2025, 5 HHA visits occurred; week of 07/18/2025 through 07/22/2025, 5 HHA visits occurred; week of 07/25/2025 through 07/29/2025, 5 HHA visits occurred; 09/01/2025, 09/02/2025, 09/04/2025, 09/05/2025, week of 09/08/2025 through 09/12/2025, 5 HHA visits occurred; week of 09/15/2025 through 09/19/2025, 5 HHA visits occurred; week of 09/22/2025 through 09/26/2025, 5 HHA visits occurred; week of 09/29/2025 through 10/03/2025, 5 HHA visits occurred; week of 10/06/2025 through 10/10/2025, 5 HHA visits occurred; week of 10/13/2025 through 10/17/2025, 5 HHA visits occurred; then weekly visits occurred on 10/22/2025, 10/29/2025, 11/05/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The record failed to evidence SN visits 10/06/2025, 12/03/2025, and 12/17/2025. The record failed to evidence HHA visits from the SOC 07/31/2025 through 07/06/25, 09/03/2025, 11/12/2025, 11/26/2025. The record failed to evidence the physician notification of the SN and HHA missed visits. 3. A review of the clinical record of Patient #2 contained the initial POC signed and dated by Person 1, a RN on 08/11/2025 and the ordering provider on 08/19/2025 for the initial certification period of 08/05/2025 through 10/03/2025 indicated but not limited to receive SN services 1 hour every 2 weeks/2 hours a month for medication management. A review of the clinical record of Patient #2 contained a POC signed and dated by Person 1, a RN on 10/03/2025 and the ordering provider on 10/08/2025 for the 1st recertification period of 10/04/2025 through 12/02/2025 indicated but not limited to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management. A review of the clinical record of Patient #2 contained a POC signed and dated by RN 1 on 01/25/2025 and signed by the ordering provider on 12/01/2025 for the 2nd recertification period of 12/04/2025 through 02/01/2026 indicated but not limited to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management. A review of the clinical record of Patient #2 contained SN visit notes signed by RN 1 on 11/20/205,12/04/2025, and 12/18/2025; and a SN note dated 09/11/2025 signed by Person 1, a RN . The record failed to evidence SN visits were conducted from the SOC 08/07/2025 until 09/11/2025 and failed to evidence SN visits from 09/11/2025 until 11/20/2025. The record failed to evidence the physician notification of the SN missed visits. 4. The clinical record review of Patient #4 contained a POC for the initial certification period of 5/28/2025 through 07/26/2025 with a SOC date of 05/28/2025 signed by Person 1, a RN on 05/28/2025, signed by the ordering provider on 06/05/2025 indicated the following SN orders were observation and assessment of respiratory, gastrointestinal, cardiopulmonary, integumentary, endocrine, neurological, and renal/genitourinary, and pain status. The clinical record review of Patient #4 contained a POC for the 1st recertification period 07/27/2025 through 09/24/2025, signed by Person 1, a RN and the ordering provider on 07/25/2025 indicated Patient #4 was to receive SN services to assess, evaluate medication and education 1 hour a week/2 hours a month and HHA services 8 hours 5 days a week for ADL’s. The Clinical record review of Patient #4 contained a POC for the 2nd recertification period 09/25/2025 through 11/23/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week signed by Person 1, a RN and ordering provider on 09/22/2025. The clinical record review of Patient #4 contained a POC for the 3rd recertification for 11/24/2025 through 01/22/205 signed by the Administrator on 11/19/2025, signed by the ordering provider on 12/01/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week. The record evidenced the 1st SN visit was conducted on 06/27/2025, 30 days after the SOC, a SN visit conducted on 07/15/2025 was 4 days late, a SN visit conducted on 08/08/2025 was 10 days late, a SN visit on 09/05/2025 was 14 days late, a SN visit conducted on 10/03/2025 was 1 day late. The record failed to evidence HHA visits on 07/09/2025, 08/21/2025, 08/22/2025, and 09/04/2025. The record failed to evidence the physician notification of the SN late visits and of the missed HHA visits. 5. The clinical record review of Patient #5 contained a POC for the initial certification period of 08/21/2025 through 10/19/2025 signed 08/22/2025 by Person 1, a RN and signed 09/10/2025 by the ordering provider indicated but not limited to SN services 1 hour every 2 weeks. The clinical record review of Patient #5 contained a POC for the 1st recertification period of 10/20/2025 through 12/18/2025 signed 10/17/2025 by the Administrator, signed by the ordering provider on 10/31/2025 indicated but not limited to SN services 2 times a month. The clinical record review of Patient #5 contained a POC for the 2nd recertification period of 12/19/2025 through 02/16/2026 signed on 12/12/2025 by RN 1indicated but not limited to SN services 1 hour every 2 weeks. The record review of the SN clinical notes of Patient #5 evidenced SN visits 09/18/2025, 28 days after the SOC, 09/29/2025, 10/13/2025, 11/04/2025, 8 days late, 11/18/2025, and 12/03/2025. The record failed to evidence the physician notification of the missed SN and late SN visits. 6. The clinical record review of Patient #7 contained a POC for the recertification period of 11/23/2025 through 01/21/2025 signed on 11/18/2025 by the Administrator and signed 09/27/2025 by the ordering provider indicated but not limited to SN services every 14 days to assess and evaluate disease process, education, fall prevention, medication review and set-up. The record review of Patient #7 evidenced SN visits with medication set-up occurred on 10/08/2025, 10/23/2025, 11/06/2025, 12/04/2025, and 12/18/2025. The record failed to evidence a SN visit for 11/20/2025. The record failed to evidence the physician notification of the SN missed visit. 7. On 12/22/2025 at 12:19 PM, the Administrator indicated there were no difficulties with staffing issues. On 12/23/2025 at 11:44 AM, when the above was discussed and the Administrator was queried on how missed visits should be handled, the Administrator indicated they should determine why the visit was missed, reschedule, and notify the physician. When queried if MD notification was created for the missed visits, they indicated no they had not done so. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the POC included the duration of services for 1 of 1 patient who received only SN services (Patient #6) and the duration of services for 6 of 7 patients who received SN and HHA services (Patients #1, 2, 3, 4, 5, and 7). Findings include: 1. A review of a policy titled ‘Care Planning’ stated, “… The plan of care … shall include … orders for all disciplines include amount, frequency, duration …” 2. A review of the clinical record of Patient #1 contained the initial POC signed and dated 07/31/2025 by Person 1, RN with a SOC 07/31/2025 for the initial certification period of 07/31/2025 through 09/28/2025 signed by the ordering provider on 08/06/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate disease process education, fall prevention and medication review and HHA services 8 hours a day/5 days a week for ADLs. A review of the clinical record of Patient #1 contained a POC signed and dated 09/25/2025 by RN 1 with a SOC 07/31/2025 for the 1st recertification period of 09/29/2025 through 11/27/2025 signed by the ordering provider on 09/29/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate disease process education, foll prevention, and medication review and HHA services 8 hours a day/5 days a week for ADLs. A review of the clinical record of Patient #1 contained a POC signed and dated 11/24/2025 by RN 1 with a SOC 07/31/2025 for the 2nd recertification period of 11/28/2025 through 01/26/2026 signed 12/02/2025 by the ordering provider indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month for medication review and set-up and HHA services 8 hours a day/5 days a week for ADLs. The POC’s failed to evidence the duration of the services. 3. A review of the clinical record of Patient #2 contained the initial POC signed and dated by Person 1, RN on 08/11/2025 and the ordering provider on 08/19/2025 for the initial certification period of 08/05/2025 through 10/03/2025 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week for ADLs. A review of the clinical record of Patient #2 contained a POC signed and dated by the Person 1, RN on 10/03/2025 and the ordering provider on 10/08/2025 for the 1st recertification period of 10/04/2025 through 12/02/2025 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week for ADLs. A review of the clinical record of Patient #2 contained a POC signed and dated by RN 1 on 01/25/2025 and signed by the ordering provider on 12/01/2025 for the 2nd recertification period of 12/04/2025 through 02/01/2026 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week for ADLs. The POC’s failed to evidence the duration of the services. 4. A review of the clinical record of Patient #3 contained a POC signed by Person 1, RN, for the initial certification period for 09/04/2025 through 10/31/2025; signed 09/17/2025 by the ordering provider indicated SN orders were but not limited to medication review and HHA services were 8 hours a day/5 days a week for ADLs. A review of the clinical record of Patient #3 contained a POC signed 10/27/2025 by the Administrator, for the recertification period 11/01/2025 through 12/30/2025, signed 10/30/2025 by the ordering provider indicated SN orders were but not limited to medication management and HHA services were 8 hours a day/5 days a week for ADLs. The POC’s failed to evidence the duration of the services. 5. The clinical record review of Patient #4 contained a POC for the initial certification period of 5/28/2025 through 07/26/2025 with a SOC date of 05/28/2025 signed by Person 1, RN 05/28/2025, signed by the ordering provider on 06/05/2025 indicated the following SN orders were observation and assessment of respiratory, gastrointestinal, cardiopulmonary, integumentary, endocrine, neurological, and renal/genitourinary, and pain status with HHA orders to provide/assist with personal care and assistance with ADL’s. The clinical record review of Patient #4 contained a POC for the 1st recertification period 07/27/2025 through 09/24/2025, signed by Person 1, RN and the ordering provider on 07/25/2025 indicated Patient #4 was to receive SN services to assess, evaluate medication and education 1 hour a week/2 hours a month and HHA services 8 hours 5 days a week for ADLs. The Clinical record review of Patient #4 contained a POC for the 2nd recertification period 09/25/2025 through 11/23/2025 signed by Person 1, RN and ordering provider on 09/22/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week for ADLs. The clinical record review of Patient #4 contained a POC for the 3rd recertification for 11/24/2025 through 01/22/205 signed by the Administrator on 11/19/2025, signed by the ordering provider on 12/01/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week for ADLs. The clinical record failed to evidence the duration of SN and HHA services and failed to identify medication-set up as a SN service. 6. The clinical record review of Patient #5 contained a POC for the initial certification period of 08/21/2025 through 10/19/2025 signed 08/22/2025 by Person 1, RN and signed 09/10/2025 by the ordering provider indicated SN services 1 hour every 2 weeks were but not limited to assess and evaluate disease process, education, and medication review. HHA services were to be provided 8 hours a day/5 days a week for ADLs. The clinical record review of Patient #5 contained a POC for the 2nd recertification period of 12/19/2025 through 02/16/2026 signed on 12/12/2025 by RN 1 indicated Patient #5 was to receive SN services 1 hour every 2 weeks for medication compliance and HHA services 8 hours a day/5 days a week during certification period for ADLs. The clinical record failed to evidence the duration of SN and HHA services during the initial certification period, failed to evidence the duration of SN services in the 2nd certification period and failed to identify medication set-up as a SN service. 7. The clinical record review of Patient #6 contained a POC for the initial certification period of 10/23/2025 through 12/21/2025 signed 10/23/2025 by RN 1 and signed 10/29/2025 by the ordering provider indicated SN services every other week for medication set-up. The clinical record review of Patient #6 contained a POC for the initial certification period of 12/22/2025 through 02/19/2026 signed 12/18/2025 by RN 1 and signed 12/19/2025 by the ordering provider indicated SN services every other week for medication set-up. The clinical record failed to evidence the duration of SN services. 8. The clinical record review of Patient #7 contained a POC for the initial certification period of 09/24/2025 through 11/23/2025 signed on 09/26/2025 by Person 1, RN and signed 09/27/2025 by the ordering provider indicated SN services every 14 days to “provide ongoing assessment, monitoring, and care coordination. HHA services were to be provided 3 times a week/40 hours a week for ADLs. The clinical record review of Patient #7 contained a POC for the recertification period of 11/23/2025 through 01/21/2025 signed on 11/18/2025 by the Administrator and signed 09/27/2025 by the ordering provider indicated SN services every 14 days to assess and evaluate disease process, education, fall prevention, medication review and set-up and HHA services were to be provided 3 times a week/40 hours a week for ADLs. The clinical record failed to evidence the duration of SN and HHA services. 9. On 12/23/2025 at 11:44 AM, when the above findings were discussed with the Administrator, they indicated with any order, frequency, duration, and type of service should be recorded. 410 IAC 17-13-1(a)(1)(D)(i-xiii)

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 follow the POC as ordered for 6 of 6 patients receiving SN and HHA services when the Agency reduced the frequency of HHA visits without a physician’s order (Patients #1, 2, 3, 4, 5, and 7) and failed to obtain physician’s order to conduct a medication set-up for 6 of 7 patients receiving medication set-up. (Patients #1, 2, 3, 4, 5, and 7) Findings include: 1. A review of a policy titled ‘Care Planning’ stated, “… O. Clinicians will inform the patient’s physician of any changes that suggest a need to alter the Plan of Care. Changes will be written, dated, and signed by the qualified clinician and physician making the changes …” 2. A review of the clinical record of Patient #1 contained the initial POC signed and dated 07/31/2025 by Person 1, RN with a SOC 07/31/2025 for the initial certification period of 07/31/2025 through 09/28/2025 signed by the ordering provider on 08/06/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, and medication review and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained a POC signed and dated 09/25/2025 by RN 1 with a SOC 07/31/2025 for the 1st recertification period of 09/29/2025 through 11/27/2025 signed by the ordering provider on 09/29/2025 indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, and medication review and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained a POC signed and dated 11/24/2025 by RN 1 with a SOC 07/31/2025 for the 2nd recertification period of 11/28/2025 through 01/26/2026 signed 12/02/2025 by the ordering provider indicated Patient #1 was to receive SN services 1 hour a week/2 hours per month to assess and evaluate, medication review, medication set-up and HHA services 8 hours a day/5 days a week. A review of the clinical record of Patient #1 contained SN visit notes 08/15/2025 a medication set-up was conducted, 08/29/2025 failed to evidence a medication set-up, 09/12/2025 failed to evidence a medication set-up, 09/22/2025 indicated education provided to client to fill pill box, 10/10/2025 medication set-up was conducted, 10/22/2025 medication set-up was conducted, 11/05/2025 medication set-up was conducted, and 11/19/2025 medication set-up was conducted. There were no SN visits to review from 11/20/2025 and including 12/23/2025. A review of HHA visit notes indicated HHA services began 07/07/2025, 6 days after the SOC, 07/08/2025, week of 07/11/2025 through 07/15/2025, 5 HHA visits occurred; week of 07/18/2025 through 07/22/2025, 5 HHA visits occurred; week of 07/25/2025 through 07/29/2025, 5 HHA visits occurred; 09/01/2025, 09/02/2025, 09/04/2025, 09/05/2025, week of 09/08/2025 through 09/12/2025, 5 HHA visits occurred; week of 09/15/2025 through 09/19/2025, 5 HHA visits occurred; week of 09/22/2025 through 09/26/2025, 5 HHA visits occurred; week of 09/29/2025 through 10/03/2025, 5 HHA visits occurred; week of 10/06/2025 through 10/10/2025, 5 HHA visits occurred; week of 10/13/2025 through 10/17/2025, 5 HHA visits occurred; then weekly visits occurred on 10/22/2025, 10/29/2025, 11/05/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The clinical record of Patient #1 failed to evidence physician orders for a medication set-up with the initial certification and 1st recertification, failed to evidence a physician’s order to change the frequency of SN visits from 11/20/2025 through 12/23/2025, and failed to evidence an order to change the frequency of HHA visits from 5 days a week to 1 day a week from 10/20/2025 through 12/23/2025. 3. A review of the clinical record of Patient #2 contained the initial POC signed and dated by Person 1, RN on 08/11/2025 and the ordering provider on 08/19/2025 for the initial certification period of 08/05/2025 through 10/03/2025 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week. A review of the clinical record of Patient #2 contained a POC signed and dated by Person 1, RN on 10/03/2025 and the ordering provider on 10/08/2025 for the 1st recertification period of 10/04/2025 through 12/02/2025 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week. A review of the clinical record of Patient #2 contained a POC signed and dated by RN 1 on 01/25/2025 and signed by the ordering provider on 12/01/2025 for the 2nd recertification period of 12/04/2025 through 02/01/2026 indicated Patient #2 was to receive SN services 1 hour every 2 weeks, 2 hours a month for medication management and HHA services 8 hours a day 5 days a week. A review of the clinical record of Patient #2 contained SN visit notes signed by RN 1 indicated medication set-up was conducted on 11/20/205,12/04/2025, 12/18/2025. A SN note dated 09/11/2025 signed by Person 1, RN failed to evidence a medication set-up was conducted. A review of HHA visit notes evidenced visits week of 08/29/2025, week of 08/31/202 through 09/06/2025, 5 HHA visits occurred; week of 09/07/2025 through 09/13/2025, 5 HHA visits occurred; 09/14/2025 through 9/20/2025, 5 HHA visits occurred; week of 09/21/2025 through 09/27/2025, 5 HHA visits occurred; then weekly visits began on 10/01/2025, 10/08/2025, 10/15/2025, 10/22/2025, 10/29/2025, 11/06/2025, 11/13/2025, 11/18/2025, 11/27/2025, 12/04/2025, 12/11/2025, and 12/18/2025. The clinical record of Patient #2 failed to evidence physician orders for a medication set-up and failed to evidence an order to change the frequency of HHA visits from 5 days a week to 1 day a week. 4. A review of the clinical record of Patient #3 contained a POC signed by Person 1, RN, for the initial certification period for 09/04/2025 through 10/31/2025; signed 09/17/2025 by the ordering provider indicated SN orders were but not limited to medication review and HHA services were 8 hours a day/5 days a week. A review of the clinical record of Patient #3 contained a POC signed 10/27/2025 by the Administrator, for the recertification period 11/01/2025 through 12/30/2025, signed 10/30/2025 by the ordering provider indicated SN orders were but not limited to medication management and HHA services were 8 hours a day/5 days a week. A review of the clinical record of Patient #3 contained a SN visit note signed by Person 1, RN failed to evidence a medication set-up was conducted on 09/25/2025 and SN visit notes on signed by the Administrator indicated medication set-up was conducted 10/09/2025,10/22/2025, 11/05/2025, 11/19/2025,12/03/2025, and 12/17/2025. HHA visit notes indicated services were initiated on 09/182025, 09/19/2025, 09/22/2025 and 09/23/2025, 10/29/2025, 11/12/2025. The clinical record of Patient #3 failed to evidence physician orders for a medication set-up for the initial certification period anf failed to evidence an physician's order to change the frequency of HHA visits from 5 days a week to 1 day a week. 5. The clinical record review of Patient #4 contained a POC for the initial certification period of 5/28/2025 through 07/26/2025 with a SOC date of 05/28/2025 signed by Person 1, RN on 05/28/2025 and signed by the ordering provider on 06/05/2025 indicated the following SN orders were observation and assessment of respiratory, gastrointestinal, cardiopulmonary, integumentary, endocrine, neurological, and renal/genitourinary, and pain status. The clinical record review of Patient #4 contained a POC for the 1st recertification period 07/27/2025 through 09/24/2025, signed by Person 1, RN and the ordering provider on 07/25/2025 indicated Patient #4 was to receive SN services to assess, evaluate medication and education 1 hour a week/2 hours a month and HHA services 8 hours 5 days a week for ADL’s. The Clinical record review of Patient #4 contained a POC for the 2nd recertification period 09/25/2025 through 11/23/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week signed by Person 1, RN and ordering provider on 09/22/2025. The clinical record review of Patient #4 contained a POC for the 3rd recertification for 11/24/2025 through 01/22/205 signed by the Administrator on 11/19/2025, signed by the ordering provider on 12/01/2025 indicated SN 1 hour a week/2 hours a month for but not limited to medication review and HHA services 8 hours a day/5 days a week. SN visit notes on 06/17/2025, 07/15/2025, 08/08/2025,09/05/2025, and 09/18/2025 failed to evidence a medication set-up was conducted. The clinical record evidenced HHA visit notes beginning on week of 06/15/2025 through 06/21/2025, 3 HHA visits occurred; week of 06/22/2025 through 06/28/2025, 5 HHA visits occurred; week of 06/29/2025 through 07/05/2025, 5 HHA visits occurred; 07/06/2025 through 07/12/2025, 4 HHA visits occurred; week of 07/13/2025 through 07/19/2025, 5 HHA visits occurred; week of 07/20/2025 through 07/26/2025, 5 HHA visits occurred; week of 07/27/2025 through 08/02/2025, 5 HHA visits occurred; week of 08/03/2025 through 08/09/2025, 5 HHA visits occurred; week of 08/10/2025 through 08/16/2025, 5 HHA visits occurred; week of 08/17/2025 through 08/23/2025, 3 HHA visits occurred; week of 08/24/2025 through 08/30/2025, 5 HHA visits occurred; week of 08/31/2025 through 09/06/2025, 4 HHA visits occurred; 09/07/2025 through 09/13/2025, 5 HHA visits occurred; week of 09/14/2025 through 09/20/2025, 5 HHA visits occurred; week of 09/21/2025 through 09/27/2025, 5 HHA visits occurred; week of 09/28/2025 through 10/04/2025,5 HHA visits occurred; week of 10/05/2025 through 10/11/2025, 5 HHA visits occurred; and week of 10/12/2025 through 10/18/2025, 5 HHA visits occurred. Beginning the week of 10/20/2025, the clinical record evidenced HHA visits were weekly, on 10/22/2025, 10/29/2025, 11/05/2025, 11/12/2025, 11/19/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The clinical record failed to evidence HHA visit notes from the SOC 05/28/2025 through 06/17/2025, missed visits on 07/09/2025, 08/21/2025. 08/22/2025 and 09/04/2025, and beginning the week of 10/20/2025, the clinical record evidenced HHA visits were weekly. The record failed to evidence physician orders for a medication set-up and failed to evidence a physician’s verbal order or communication notes to/from the ordering provider to change the HHA frequency. 6. The clinical record review of Patient #5 contained a POC for the initial certification period of 08/21/2025 through 10/19/2025 signed 08/22/2025 by Person 1, RN and signed 09/10/2025 by the ordering provider indicated SN services 1 hour every 2 weeks were but not limited to assess and evaluate disease process, education, and medication review. HHA services were to be provided 8 hours a day/5 days a week. The clinical record review of Patient #5 contained a POC for the 1st recertification period of 10/20/2025 through 12/18/2025 signed 10/17/2025 by the Administrator, signed by the ordering provider 10/31/2025 indicated SN services 2 times a month were but not limited to for medication set-up The clinical record review of Patient #5 contained a POC for the 2nd recertification period of 12/19/2025 through 02/16/2025 signed on 12/12/2025 by RN 1indicated Patient #5 was to receive SN services 1 hour every 2 weeks for medication compliance and HHA services 8 hours a day/5 days a week during certification period. The record review of the SN clinical notes of Patient #5 evidenced SN visits 09/18/2025, 09/29/2025, 10/13/2025, and 11/18/2025. The record review of HHA visit notes evidenced visits were conducted on the week of 09/14/2025 through 09/20/2025, 5 HHA visits occurred; week of 09/21/2025 through 09/27/2025, 5 HHA visits occurred; week of 09/28/2025 through 10/04/2025, 5 HHA visits occurred; week of 10/05/2025 through 10/11/2025, 5 HHA visits occurred; week of 10/12/2025 through 10/18/2025, 5 HHA visits occurred. Weekly visits begain on 11/05/2025, 11/12/2025, 11/19/2025, 11/26/2025, 12/03/2025, 12/10/2025, and 12/17/2025. The record review of Patient #5 failed to evidence SN visits were conducted 1 hour every 2 weeks as ordered, SN notes failed to evidence medication set-up was conducted on 09/29/2025 and 10/13/2025 and the record review failed to evidence HHA visits were conducted from 08/21/2025 through 09/14/2025 as ordered, failed to evidence HHA visits between 10/19/2025 through 11/04/2025. The clinical record evidenced HHA visits were weekly,beginning 11/05/2025, without a physician’s verbal order or communication notes to/from the ordering provider to change the HHA frequency. 7. The clinical record review of Patient #7 contained a POC for the initial certification period of 09/24/2025 through 11/23/2025 signed on 09/26/2025 by Person 1, RN and signed 09/27/2025 by the ordering provider indicated SN services every 14 days to “provide ongoing assessment, monitoring, and care coordination. HHA services were to be provided 3 times a week/40 hours a week. The clinical record review of Patient #7 contained a POC for the recertification period of 11/23/2025 through 01/21/2025 signed on 11/18/2025 by the Administrator and signed 09/27/2025 by the ordering provider indicated SN services every 14 days to assess and evaluate disease process, education, fall prevention, medication review and set-up and HHA services were to be provided 3 times a week/40 hours a week. The record review of Patient #7 evidenced SN visits with medication set-up occurred on 10/08/2025, 15 days later on 10/23/2025, 11/06/2025, 28 days later on 12/04/2025, and 12/18/2025. The record review of Patient #7 evidenced weekly HHA visits on 10/01/2025, 10/08/2025, 10/15/2025, 10/23/2025, 10/30/2025, 11/06/2025, 11/13/2025, 11/20/2025, 11/27/2025, 12/04/2025, 12/11/2025, and 12/18/2025. The record review of Patient #7 failed to evidence SN visits were conducted every 14 days weeks as ordered, failed to evidence physician orders for medication set-up on 10/08/2025 and 10/23/2025, and the clinical record evidenced HHA visits were weekly, without a physician’s verbal order or communication notes to/from the ordering provider to change the HHA frequency from 3 times a week to weekly. 8. On 12/22/2025 at 12:19 PM, the Administrator indicated the 7 active patients had received medication set-up for SN services to meet the Medicaid requirement. 9. On 12/23/2025 at 12 PM, when the above concerns were discussed with the Administrator and the Alternate Administrator, the Alternate Administrator indicated the Agency had mistakenly received their identification to start billing, then when the Agency was told to cease their billing, they were not sure how to handle the situation, they decided to decrease HHA visits to weekly. When this writer explained, the Agency accepted the patients and were responsible for the care of the patients, and if the Agency could no longer provide the care, it was the Agency’s responsibility to find another Agency for the patients, the Administrator indicated understanding. The Administrator indicated they knew there was a problem with not having correct orders for medication set-up and were trying to correct. 410 IAC 410 IAC 17-13-1(a)

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 1 of 1 SN followed accepted standards of practice for infection control. (RN 1) Findings include: 1. During a home observation visit on 12/22/2025 at 4 PM, RN 1 placed their nursing bag on the door handle, performed hand hygiene, retrieved equipment from their bag, without cleaning the bedside table, placed all equipment on the bedside table, proceeded with vital signs and assessment. When RN 1 completed the assessment, without cleaning the equipment, placed all into their nursing bag. 2. On 12/22/2025 at 5 PM during an interview, RN 1 explained how to set up a clean area for supplies and to clean equipment prior to placing in their nursing bag. RN 1 indicated they were nervous and is probably why they did not use the correct technique, and would clean the equipment and the bag when they returned home. 3. On 12/23/2025 at 3:45 PM, when the above home visit observation was discussed with the Administrator, they indicated RN 1 should had placed a barrier on the table for the equipment, should have cleaned the equipment and waited 1 minute for the dry time before placing the items back into their nursing bag. 410 IAC 17-12-1(m)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to provide establishment, oversight and active participation in the Agency’s Quality Assurance Performance Improvement (QAPI) program (see G0942) and failed to be responsible for the day-to-day operations (see G0948). The cumulative effect 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 at 42 CFR 484.105 Condition of Participation: Organization and Administration of Services, with the potential to affect all 7 current patients receiving Home Health services from this provider. *

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to provide establishment, oversight and active participation in the Agency’s Quality Assurance Performance Improvement (QAPI) program with 1 of 1 Agency. Findings include: 1. A review of a policy titled ‘Governing Body’ stated, “… Provide direction and leadership and be directly involved in the agency’s Quality Assessment and Performance Improvement Program …) 2. A review of the Governing Body minute meetings on 12/18/2024, 10/09/2025, and 12/05/2025 failed to evidence QAPI was discussed. 3. On 12/23/2025 at 11:44 AM, when queried of the Governing Body to determine which meeting the Governing Body established or participated with the QAPI program, the Administrator indicated there were no meetings to reflect the above. The Administrator indicated they do discuss QAPI but did not document the discussions. 410 IAC 17-12-1(b)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to be responsible for the day-to-day operations of 1 of 1 home health agency. Findings include: In regard to Patient Rights: 1. The Administrator failed to ensure the patient was informed of and consented to the change in service hours (see G0434) In regard to the individualized care planning, coordination of services, and quality of care: 1. The Administrator failed to ensure the ordering provider was notified of missed SN and HHA visits (see G572), failed to ensure the POC included the duration of services(see G574), and failed to follow the POC as ordered and failed to obtain physician’s order to conduct a medication set-up (see G580). In regard to patient safety: 1. The Administrator failed to ensure their clinicians adhered to standard precautions to prevent the transmission of infections and communicable diseases (see G682). 410 IAC 17-12-1(c)(1)