Every finding on record at Loving Touch Home Health Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 12/16, 12/17, and 12/18/2025 Active Census: 7 At this Emergency Preparedness survey, Loving Touch Home Health Services, LLC was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 12/23/2025.

This visit was for an initial Federal Medicaid survey of a Home Health provider. Survey Dates: 12/16, 12/17, and 12/18/2025 12-Month Unduplicated Skilled Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. During this Federal Certification Survey, Maximum Home Healthcare LLC was found to be out of compliance with Conditions of Participation 42 CFR §484.60 Care Planning, Coordination of Services, and Quality of Care. Based on the Condition-level deficiencies during the 12/18/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 12/18/2025. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning 12/18/2025 and continuing through 12/17/2027. Abbreviations: HHA- Home Health Aide POC-Plan of Care SOC- Start of Care RN-Registered Nurse SN- Skilled Nursing OASIS- Outcome and Assessment Information Set ADL- Activities of Daily Living DME- Durable Medical Equipment CM-Clinical Manager

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was seen within 48 hours of the agency receiving the referral for 7 of 7 active clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, and #7) Findings Include: 1. A review of the clinical record for Patient #1 contained a document titled “INTAKE REFFERAL FORM” dated 10/10/2025 and signed by the Administrator/Clinical Manager on 11/04/2025. During an interview on 12/17/2025 at 3:10 PM, the Administrator/Clinical Manager confirmed Patient #1’s initial assessment visit was completed on 11/04/2025 at 10:30 AM. She reported once they received Patient #1’s referral on 10/10/2025 they did not do the initial assessment because they did not have doctors order until 11/04/2025. The initial assessment visit failed to evidence it was completed withing 48 hours of receiving the referral. 2. A review of Patient #2's active clinical record evidenced a document titled "Intake Referral Form" and dated by the Administrator (the patient's CM) on 11/06/2025. An order to evaluate and admit Patient #2 was signed by the patient's physician, Person 6, on 11/17/2025. Patient #2's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/18/2025 by the Administrator/CM. The agency failed to ensure the patient was seen within 48 hours of a referral to be evaluated for Home Health care services. 3. A review of Patient #3's active clinical record evidenced a document titled "Intake Referral Form" and dated by the Administrator/CM on 10/16/2025. An order to evaluate and admit Patient #3 was signed by the patient's physician, Person 7, on 11/05/2025. Patient #3's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 10/29/2025 by the Administrator/CM. The agency failed to ensure the patient was seen within 48 hours of a referral to be evaluated for Home Health care services. 4. A review of Patient #4's active clinical record evidenced a document titled "Intake Referral Form" and dated 10/29/2025. An order to evaluate and admit Patient #4 was signed by the patient's physician, Person 10, on 10/31/2025. Patient #4's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/01/2025 by the Administrator/CM. The agency failed to ensure the patient was seen within 48 hours of a referral to be evaluated for Home Health care services. 5. A review of Patient #5's active clinical record evidenced a document titled "Intake Referral Form" dated 10/28/2025. An order to evaluate and admit Patient #5 was signed by the patient's physician, Person 7, on 10/31/2025. Patient #5's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/02/2025 by the Administrator/CM. The agency failed to ensure the patient was seen within 48 hours of a referral to be evaluated for Home Health care services. 6. A review of Patient #6's active clinical record evidenced a document titled "Intake Referral Form" and dated by the Administrator (the patient's CM) on 10/18/2025. An order to evaluate and admit Patient #6 was signed by the patient's physician, Person 9, on 10/22/2025. Patient #6's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 10/31/2025 by the Administrator/CM. The agency failed to ensure the patient was seen within 48 hours of a referral to be evaluated for Home Health care services. 7. A review of Patient #7's active clinical record evidenced a document titled "Intake Referral Form" and dated by the Administrator/CM on 10/22/2025. An order to evaluate and admit Patient #7 was signed by the patient's physician, Person 12, on 11/05/2025. Patient #7's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/08/2025 by the Administrator/CM. The agency failed to ensure the patient was seen within 48 hours of a referral to be evaluated for Home Health care services. 8. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, when queried regarding the process for a referral, the Administrator indicated the referral form was completed and an order to evaluate and admit the patient was faxed to the physician. The Administrator, the CM for all active patients, indicated the time between the referral and the SOC was them waiting for the physicians to sign and return the orders. Once they received the signed order, they had 48 hours to complete a SOC assessment. They had not called to get verbal orders from the physicians while they were waiting for them to sign the order form. They indicated they only called to ask the physician's office to send back the signed order. 410 IAC 17-14-1(a)(1)(A)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patients’ current health, psychosocial, and functional status in 5 of 7 active clinical records reviewed. (Patients #1, #2, #4, #5, and #6) Findings Include: 1. A review of Patient #1’s clinical record evidenced a start of care (SOC) comprehensive assessment dated 11/04/2025 by the Administrator/Clinical Manager failed to evidenced information under sections, “cognitive patterns”, “diabetic foot care,” and “patient knowledge level.” The sections were left blank. During an interview on 12/17/2025 at 3:10 PM the Administrator/Clinical Manager reported Patient #1 was receiving home health services for diabetic education and monitoring for hypoglycemic episodes (blood sugar dropping low and depriving the body of its main energy source with symptoms including shakiness and confusion). Administrator/RN confirmed on the comprehensive assessment the sections on knowledge level and cognitive patterns were not documented and the assessment of diabetic foot care was left blank. 2. Patient #2's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/18/2025 by the Administrator/CM. The subsection titled "Mouth Condition" was left blank. The section titled "Psychosocial Status" evidenced HHA 3 was the patient's caregiver, but failed to evidence their availability. The subsection "Communication" failed to evidence whether the patient was motivated to learn. The assessment had not included the patient identified learning preferences. The comprehensive assessment failed to ensure it included the patient's health and psychosocial status. 3. A review of Patient #4's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/01/2025 by the Administrator/CM. The subsection titled "Prognosis" was blank. The "Respiratory" section failed to evidence the breath sounds of the lungs and if the patient had a cough. It also revealed the patient was on 3-4 liters of Oxygen through a nasal cannula. Under the "Special Treatment, Procedures, and Programs" section the box next to Oxygen Therapy was blank along with if they used Oxygen continuously, intermittently, or on high-concentration. The comprehensive assessment failed to ensure it included the patient's current health status, prognosis, and their oxygen therapy. 4. A review of Patient #5's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/02/2025 by the Administrator/CM. The functional limitations and ability to handle personal finances section were left blank. The section titled "Fall Risk Assessment" had not indicated the patient took 5 or more medications. The "Allergies" subsection was blank. The "DME and Supplies" section was blank. During an interview with Patient #5 on 12/18/2025 at 12:45 PM, they explained they were able to manage most things on their own, but with their left arm injury, it has been increasingly difficult to perform basic tasks. They indicated they used a cane and rollator to move around and they fall often. The comprehensive assessment failed to ensure it included the patient's health status and reflected the patient's functional limitations, their ability to handle their own finances, include all the elements making the patient a fall risk, included whether the patient had allergies, and the patient's DME and supplies. 5. A review of Patient #6's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 10/31/2025 by the Administrator/CM. The "Respiratory" section failed to evidence the breath sounds of the lungs and if the patient had a cough. It also revealed the patient was on Oxygen through a nasal cannula. The patient's diet was listed as both regular and low fat. Under the "Special Treatment, Procedures, and Programs" section the CM marked the patient had none of the treatments and the box next to Oxygen Therapy was blank along with if they used Oxygen continuously, intermittently, or on high-concentration. The comprehensive assessment failed to ensure it included the patient's health status and reflected the patient's specific diet and the special treatments they received. During an interview with the Administrator/CM and the Alternate Administrator on 12/17/2025 at 1:40 PM, the Administrator/CM indicated their charting was not enough and they had missed information on the visit notes. 6. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, the CM explained the comprehensive assessments had not been completed for some of the patients because they forgot to complete all the questions or missed them. They explained Patient #7 was on a Diabetic (a disease where the body is unable to appropriately use insulin), low salt diet. The Administrator indicated Patient #6 was on a regular diet. The comprehensive assessment should reflect the POC and the patient's current health status for all active patients. 410 IAC 17-14-1(a)(1)(A)

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 POCs were individualized, included HHA service frequency, all medications, correct diet, advance directives, DME, rehabilitation potential, safety measures, emergency room risk, education, and measurable and patient-centered goals ( see G0574), provide services as ordered by physician ( see G0580), notify the physician of not meeting the POC ( see G0590), and document the coordination of care with other entities providing services for the patients ( see G0608). 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 484.60 Care Planning, coordination of services, and quality of care, with the potential to affect all 7 active patients receiving Home Health services from this provider. 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 observation, record review, and interview, the agency failed to ensure the POC was individualized and included all pertinent diagnoses, all medications, psychosocial status, frequency of HHA visits, rehabilitation potential, safety measures to protect from injury, the risk for emergency room and hospital re-admission, patient and caregiver education and interventions, patient-specific and measurable goals, advance directives, all pertinent diagnoses, DME and supplies, and nutritional requirements for 7 of 7 active clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, and #7) Findings Include: 1. A review of an undated policy titled "Plan of Care" indicated but was not limited to, " … The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary … 2. The Plan of Care shall be completed in full to include: a. All pertinent diagnosis(es) … c. … frequency … of all visits/services … e. Need for/presence of home medical equipment and assistive devices … i. Rehabilitation potential … l. Specific dietary or nutritional requirements or restrictions. m. Medications … n. Medical supplies and equipment required. o. Any safety measures to protect against injury. p. Instructions to client/caregiver … q. Treatment goals. r. Instructions for timely discharge or referral. s. Discharge Plans. t. Name and address of client's physician … u. Other appropriate items. v. All of the above items must always be addressed on the Plan of Care. …" 2. A review of the active clinical record for Patient #1 with a SOC of 11/04/2025 and an initial certification period of 11/04/2025 to 01/02/2026 evidenced a principal diagnosis of hypoglycemia unspecified (blood sugar dropping low and depriving the body of its main energy source with symptoms including shakiness and confusion). The POC goals section indicated the patient will verbalize understanding of the disease process within 4 weeks, the patient will verbalize understanding of diabetic care including foot care and skin monitoring, stable blood sugar readings and no hypoglycemic episodes. The POC failed to evidence measurable goals including what Patient #1 would be able to verbalize for the disease process, what signs or symptoms to look for foot care and skin monitoring and define what “stable” blood sugars Patient #1’s goal would be. During an interview on 12/17/2025 at 3:10 PM, the Administrator/Clinical Manager reported Patient #1’s goals should be individualized and specific to a diabetic diet is, and how Patient #1 charted their blood sugar levels. When queried what “stable” meant they reported the agency has set parameters for blood sugar levels. 3. A review of Patient #2's active clinical record evidenced a POC with a SOC date of 11/18/2025 and an initial certification period from 11/18/2025 to 01/16/2025. The POC included the following diagnoses: Symptomatic Epilepsy with Complex Seizures (a brain disorder causing sudden electrical activity in the brain causing disruptions in awareness, staring spells, and violent jerking), Presence of a Neurostimulator (a device used to monitor the electrical patterns in the brain to see when a seizure is starting and send pulses to the brain to stop the seizure), Altered Mental Status (a change in the person's brain function impacting their memory), and Hyperlipidemia (condition where there are high levels of fat in the blood). The POC revealed the patient received 20 hours a week for 8 weeks of HHA services and SN visits every 2 weeks for 8 weeks for vital sign assessment, patient education, and medication set-up. The section titled "Functional Limitation" evidenced the patient had ambulation and endurance limitations. The "Safety Measures" section included "seizure precautions. The area labeled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … seizure control, improved quality of life avoiding triggers, managing safety, medication compliance, Discharge from HHA when goals are met and epilepsy can be safely managed. …" Patient #2's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/18/2025 by the Administrator/CM. The section titled "Psychosocial Status" evidenced HHA 3 was the patient's caregiver, and evidenced the patient needed assistance with personal finances. Under the section "Risk for Hospitalization" the boxes for noncompliance with medical instructions, needs assistance with ADLs, assistance with taking medications, and seizure activity were checked by the CM. The subsection for Rehabilitation potential evidenced the CM listed the patient as "Fair". Patient #2's clinical record evidenced a document titled "Aide/Homemaker Care Plan" dated 11/18/2025 by the Administrator/CM. The document indicated the patient received 5 hours of care daily, 4 times a week. During a home visit at Patient #2's residence on 12/17/2025 at 11:00 AM, the patient's admission packet revealed the patient's seizure plan. In the event of a seizure, the patient was to be lowered to the floor and dangerous objects removed from around the patient. The POC failed to evidence Patient #2's psychosocial status, seizure precautions specific to the patient, patient-specific and measurable goals, the education provided to the patient, the rehabilitation potential, advance directive information, risk for hospitalization and emergency room visit, safety measures reflected all limitations, the specific HHA frequency to include how many hours a day and days a week the patient needs the services, and the physician's address. 4. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 10/29/2025 and an initial certification period from 10/29/2025 to 12/27/2025. The POC included the following diagnoses: Idiopathic Autonomic Neuropathy (condition where nerve damage affects heart rate, blood pressure, and other body functions), Abnormalities of gait and mobility, and Hypertension (high blood pressure). The POC revealed the patient received SN services once a week for 8 weeks for the assessment of all body systems, knowledge of their disease, medication regimen, and signs and symptoms of complications. The section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … Maximize function, improve independence, and prevent complications (falls), no recent hospitalizations …" Patient #3's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 10/29/2025 by the Administrator/CM. The assessment revealed the patient was a hospitalization risk because they took more than 5 medications and needed assistance with ADLs. The assessment revealed the patient's rehabilitation potential was fair. The POC failed to evidence Patient #3's psychosocial status, patient-specific and measurable goals, the education provided to the patient, the rehabilitation potential, advance directive information, risk for hospitalization and emergency room visit, and what the SN will do to assess the patient's medication regimen and the patient's knowledge of the disease process. 5. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 11/01/2025 and an initial certification period from 11/01/2025 to 12/30/2025. The POC included the following diagnoses: Malignant Neoplasm of the right Bronchus (a cancer growing in the right lung), Chronic Respiratory Failure with hypoxia (a condition where the lungs do not take in enough oxygen to oxygenate the blood), chronic pain, and Insomnia (difficulty falling or staying asleep). The POC revealed the patient received SN services weekly for 8 weeks for medication setup, assessment of the patient, and assessment of the patient's knowledge of the disease process. The DME and supplies section evidenced the patient had a wheelchair, walker, and an oxygen tank. The section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " Clear walk ways clutter free space 1 week. The pt (sic patient)/caregiver will demonstrate compliance with use of assistive device, the patient/caregiver will verbalize 2 methods to decrease or prevent falls within 1 week. The pt/caregiver will verbalize signs and symptoms of increased depression within 1 week. The pt's pain will be controlled and manageable within 6 weeks. Pt will reduce cigarette smoking from 5 days to 3 days within 4 weeks …" A review of the document titled "Medication Profile" for Patient #4 failed to evidence the patient's oxygen, the liters they were on, and if they used it as needed or continuously. A review of Patient #4's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/01/2025 by the Administrator/CM. The "Respiratory" section failed to evidence the breath sounds of the lungs and if the patient had a cough. It also revealed the patient was on 3-4 liters of Oxygen through a nasal cannula. The "Psychosocial Status" evidenced the patient required assistance with shopping, ADLs, and medication assistance from their caregiver, Person 11 (the patient's relative). The patient's risk of hospitalization included taking more than 5 medications, shortness of breath occurring quickly, increased risk of infection, and needing assistance with ADLs. The patient's rehabilitation potential was listed as moderate. The POC failed to evidence Patient #4's psychosocial status, patient-specific and measurable goals, the education provided to the patient, the rehabilitation potential, advance directive information, risk for hospitalization and emergency room visit, included the Oxygen on the medication list, and the supplies needed for their oxygen. 6. A review of Patient #5's active clinical record evidenced a POC with a SOC date of 11/02/2025 and an initial certification period from 11/02/2025 to 12/31/2025. The POC included the following diagnoses: Injury of the left shoulder. The section titled "DME and Supplies" included but was not limited to a wheelchair and walker. The sections "Nutritional Req. (sic Requirements), "Allergies", "Functional Limitations", "Activities Permitted", "Mental Status", and "Prognosis" were blank. The POC evidenced the patient received 20 hours a week for 8 weeks of HHA services for ADL assistance and SN services once every two weeks for 8 weeks for medication setup and assistance with smoking cessation. The POC revealed the patient had fall precautions. The section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but were not limited to, " … Pain reduction, improved comfort, preparedness for surgical clearance, progress toward smoking cessation, increased independence w/ (sic with) ADL's …" A review of Patient #5's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/02/2025 by the Administrator/CM. The assessment evidenced the patient had the diagnoses: Chronic Obstructive Pulmonary Disease (COPD, a condition which causes difficulty in breathing and shortness of breath), Hypertension (high blood Pressure), and Hyperlipidemia (condition where there are high levels of fat in the blood). The comprehensive assessment evidenced the patient's hospitalization risks included the patient's difficulty with complying with medical instruction, taking more than five medications. The patient's prognosis was deemed as "fair" by the CM. The assessment revealed the patient had Advance Directive information. The patient's diet was marked as regular. The section titled "Orders for Discipline and Treatments" evidenced the patient received HHA services four times a week for a total of 20 hours a week. The patient's rehabilitation potential was labeled "Fair". The patient's goal were listed as them wanting to decrease their pain and be eligible to have surgery on their left shoulder. During an interview with Patient #5 on 12/18/2025 at 12:45 PM, they explained they were able to manage most things on their own, but with their left arm injury, it has been increasingly difficult to perform basic tasks. They indicated they used a cane and rollator to move around and they fall often. They explained the RN educated them and ensured they had all their medications. The POC failed to evidence Patient #5's psychosocial status, patient-specific and measurable goals, the education provided to the patient, the rehabilitation potential, advance directive information, risk for hospitalization and emergency room visit, the specific frequency of days the HHA provided services, diet, allergies, all DME and supplies, and all pertinent diagnoses. 7. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/31/2025 and an initial certification period from 10/31/2025 to 12/29/2025. The POC included the following diagnosis: COPD. The POC evidenced the patient received SN services once a week for 8 weeks to monitor breathing and vitals and HHA services 15 hours a week for 8 weeks for assistance with ADLs. The DME and supplies included but was not limited to the patient's oxygen tank and tubing. The patient's diet was listed as a regular, mechanical soft diet. The section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but were not limited to, " … The patient's skin will remain intact, the patient will remain free from falls, and discharge from HHA to remain at home with family. Pt (sic patient)/caregiver will demonstrate inhaler/nebulizer education, understanding of exacerbation action plan, and proper breathing techniques. …" A review of the document titled "Medication Profile" for Patient #6 failed to evidence the patient's oxygen, the liters they were on, and if they used it as needed or continuously. A review of Patient #6's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 10/31/2025 by the Administrator/CM. It also revealed the patient was on Oxygen through a nasal cannula. The patient's diet was listed as both regular and low fat. The POC revealed for the patient's psychosocial status they required assistance for finances, shopping, medication assistance, and ADLs. The following diagnoses were listed in the assessment: Malignant Neoplasm of Prostate (cancerous tumors found in the prostate gland), Hyperlipidemia (condition where there are high levels of fat in the blood), and Hypertension (high blood pressure). The CM evidenced the patient was a risk for hospitalization because they had a history of falls, taking more than 5 medications, a diagnosis of COPD, and needed assistance with ADLs and taking medication. The POC failed to evidence Patient #6's psychosocial status, patient-specific and measurable goals, the education provided to the patient, the rehabilitation potential, advance directive information, risk for hospitalization and emergency room visit, the specific frequency of days the HHA provided services, diet, the oxygen listed as a medication with the liters and the indication for when the patient needed it, and all pertinent diagnoses. 8. A review of Patient #7's active clinical record evidenced a POC with a SOC date of 11/08/2025 and an initial certification period from 11/08/2025 to 01/06/2026. The POC evidenced the following diagnoses: Dissociative and Conversion disorders (a mental health condition caused by stress or trauma causing a disruption of consciousness or paralysis), Social Phobia (anxiety condition caused by fear of being judged in a social situation), Tourette's disorder (a neurological disorder which causes repeating, involuntary movements like blinking or throat clearing), and Major Depressive Disorder (a disorder causing sadness and fatigue, and lack of interest in activities once found enjoyable). The POC revealed the patient received SN services weekly for 14 weeks for assessment of the medication regimen, knowledge of disease process, and vital signs. The POC evidenced the patient was on a regular diet. The section titled "Goals/Rehabilitation Plans/Discharge Plans" indicated but was not limited to, " … A clear medication plan and compliance with medications, and a strategy for managing symptoms and stress at home. Remain free from injury. … emergency plan developed …" Patient #7's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/08/2025 by the Administrator/CM. The section titled "Psychosocial Status" evidenced the patient was dependent on their caregiver, Person 4 (their relative) for their finances. Person 4 assisted the patient with their shopping, ADLs, and medication assistance. The assessment revealed the patient had a fluid limit of 1,200 milliliters (ml) a day and was on a Diabetic (a disease where the body is unable to appropriately use insulin) and low sugar diet. The patient's rehabilitation potential was good. The patient's hospitalization risks included the patient took more than 5 medications and needs assistance with medications and ADLs. During an interview with Patient #7's caregiver, Person 4, they indicated the patient had a walker and wheelchair to be used as needed. They indicated the patient was not on a specific diet. The POC failed to evidence Patient #7's psychosocial status, patient-specific and measurable goals, the education and interventions provided to the patient, the rehabilitation potential, discharge planning, advance directive information, risk for hospitalization and emergency room visit, the diet the SN was teaching the patient to adhere, and include the patient's walker. 9. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, the CM explained the POC should include the patient's medications, diagnoses, pt name, address, admission date, DME, allergies, mental status, orders, and goals. They indicated Patient #2's seizure protocol was to lay the patient on their side, move items away, and protect the patient's head, and administer their medication. They explained Patient #7 was on a Diabetic, low salt diet. The Administrator indicated Patient #6 was on a regular diet. The Administrator indicated they needed to add more detail to their POC with the orders they had for the patient, education provided, and the goals. They were unaware they needed to include advance directives, psychosocial status, frequency of the HHA visits, rehabilitation potential, the diet reflected in the comprehensive assessment, risk for emergency room visits or hospitalizations, and education and training. 410 IAC 17-13-1(a)(1)(D)(i, ii, iii, iv, v, vi, vii, viii, ix, x, and 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 ensure they received orders from the patients' physicians after the SOC comprehensive assessment and before the physician signed the POC for 6 of 7 active clinical records reviewed. (Patients #1, #2, #3, #4, #5, and #6) Findings Include: 1. An undated policy titled "Physician/Allowed Non-Physician Practitioner (NPP) Orders" indicated but was not limited to, " … All medications, treatments and services provided to clients must be ordered by a physician/allowed non-physician practitioner (NPP). The orders may be initiated via telephone or in writing and must be countersigned by the provider in a timely manner. 2. A review of Patient #1’s Plan of care indicated a start of care of 11/04/2025 and contained a signature of the Administrator/Case Manager but failed to evidence a physician signed order or verbal order at the start of care. The physician signed the POC on 12/10/2025. Patient #1 was seen 11/04/2025, 11/18/2025, and 12/02/2025 for skilled nursing to assess blood sugars and educate patient on hypoglycemic management. The agency failed to evidence signed or verbal order for home health services. 3. A review of Patient #2's active clinical record evidenced a POC with a SOC date of 11/18/2025 and an initial certification period from 11/18/2025 to 01/16/2025. The POC included the following diagnoses: Symptomatic Epilepsy with Complex Seizures (a brain disorder causing sudden electrical activity in the brain causing disruptions in awareness, staring spells, and violent jerking), Presence of a Neurostimulator (a device used to monitor the electrical patterns in the brain to see when a seizure is starting and send pulses to the brain to stop the seizure), Altered Mental Status (a change in the person's brain function impacting their memory), and Hyperlipidemia (condition where there are high levels of fat in the blood). The POC revealed the patient received 20 hours a week for 8 weeks of HHA services and SN visits every 2 weeks for 8 weeks for vital sign assessment, patient education, and medication set-up. The POC was signed by the patient's physician on 12/10/2025. A SN visit note was evidenced on 12/02/2025. HHA visit notes were evidenced for the following dates: 11/19, 11/20, 11/24, 11/25, 11/26, 11/27, 12/01, 12/02, 12/03, 12/04, 12/08, and 12/09/2025. Patient #2's clinical record failed to evidence an order to the physician, to receive the services listed in the POC, after the SOC assessment and before the agency received the signed POC. 4. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 10/29/2025 and an initial certification period from 10/29/2025 to 12/27/2025. The POC included the following diagnoses: Idiopathic Autonomic Neuropathy (condition where nerve damage affects heart rate, blood pressure, and other body functions), Abnormalities of gait and mobility, and Hypertension (high blood pressure). The POC revealed the patient received SN services once a week for 8 weeks for the assessment of all body systems, knowledge of their disease, medication regimen, and signs and symptoms of complications. The POC was signed by the physician, Person 7, on 12/02/2025. SN visit notes were evidenced for the following dates: 11/05, 11/12, and 11/29/2025. Patient #3's clinical record failed to evidence an order to the physician, to receive the services listed in the POC, after the SOC assessment and before the agency received the signed POC. 5. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 11/01/2025 and an initial certification period from 11/01/2025 to 12/30/2025. The POC included the following diagnoses: Malignant Neoplasm of the right Bronchus (a cancer growing in the right lung), Chronic Respiratory Failure with hypoxia (a condition where the lungs do not take in enough oxygen to oxygenate the blood), chronic pain, and Insomnia (difficulty falling or staying asleep). The POC revealed the patient received SN services weekly for 8 weeks for medication setup, assessment of the patient, and assessment of the patient's knowledge of the disease process. The POC was signed by the physician, Person 10, on 12/06/2025. SN visit notes were evidenced for the following dates: 11/10, 11/17, and 11/24/2025. Patient #4's clinical record failed to evidence an order to the physician, to receive the services listed in the POC, after the SOC assessment and before the agency received the signed POC. 6. A review of Patient #5's active clinical record evidenced a POC with a SOC date of 11/02/2025 and an initial certification period from 11/02/2025 to 12/31/2025. The POC included the following diagnoses: Injury of the left shoulder (related to rotator cuff). The POC evidenced the patient received 20 hours a week for 8 weeks of HHA services for ADL assistance and SN services once every two weeks for 8 weeks for medication setup and assistance with smoking cessation. The POC was signed by the patient's physician, Person 8, on 12/08/2025. SN visit notes was evidenced on 11/07/2025, 11/21/2025, and 12/04/2025. HHA visit notes were evidenced for the following dates: 11/03, 11/07, 11/08, 11/09, 11/10, 11/13, 11/14, 11/15, 11/16, 11/17, 11/21, 11/22, 11/23, 11/24, 11/28, 11/ 29, 11/30, 12/02, 12/05, 12/06, and 12/07/2025. Patient #5's clinical record failed to evidence an order to the physician, to receive the services listed in the POC, after the SOC assessment and before the agency received the signed POC. 7. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/31/2025 and an initial certification period from 10/31/2025 to 12/29/2025. The POC included the following diagnosis: Chronic Obstructive Pulmonary Disease (COPD, a condition which causes difficulty in breathing and shortness of breath). The POC evidenced the patient received SN services once a week for 8 weeks to monitor breathing and vitals and HHA services 15 hours a week for 8 weeks for assistance with ADLs. The POC was signed by the patient's physician, Person 9, on 12/04/2025. SN visit notes were evidenced on 11/07, 11/13, 11/20, and 11/27/2025. HHA visit notes were evidenced on 11/03, 11/04, 11/10, 11/11, 11/17, 11/18, 11/24, 11/25, 12/01, and 12/02/2025. Patient #6's clinical record failed to evidence an order to the physician, to receive the services listed in the POC, after the SOC assessment and before the agency received the signed POC. 8. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, the CM indicated once they completed the SOC comprehensive assessment they completed the POC and faxed it to the physician. When queried when they receive the order to provide the services listed in the POC, they explained they had the order when the POC was signed and sent back to the agency by the physician. They indicated they had not called the physician's office after they completed the comprehensive assessment to receive orders to provide care while waiting on the physician's signature on the POC. 410 IAC 17-13-1(a)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they notified the physician of the missed visits for 2 of 2 active clinical records reviewed who refused SN visits. (Patients #3 and #4) Findings Include: 1. A review of an undated policy titled "Plan of Care" indicated but was not limited to, " … 10. Professional staff shall promptly alert the physician/allowed non-physician practitioner (NPP) to any changes that suggest a need to alter the Plan of Care. …" 2. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 10/29/2025 and an initial certification period from 10/29/2025 to 12/127/2025. The POC included the following diagnoses: Idiopathic Autonomic Neuropathy (condition where nerve damage affects heart rate, blood pressure, and other body functions), Abnormalities of gait and mobility, and Hypertension (high blood pressure). The POC revealed the patient received SN services once a week for 8 weeks for the assessment of all body systems, knowledge of their disease, medication regimen, and signs and symptoms of complications. The POC was signed by the physician, Person 7, on 12/02/2025. A review of a document titled "Nurse's Notes" in Patient #3's clinical record evidenced on 11/19/2025, the Administrator/CM called the patient and they requested to be seen on the weekends. Patient #3's clinical record failed to evidence SN visits were made for the weeks of 11/14/2025 to 11/20/2025 and 11/21/2025 to 11/27/2025. The clinical record failed to evidence the physician was notified the change in the visits due to the patient's refusal. 3. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 11/01/2025 and an initial certification period from 11/01/2025 to 12/30/2025. The POC included the following diagnoses: Malignant Neoplasm of the right Bronchus (a cancer growing in the right lung), Chronic Respiratory Failure with hypoxia (a condition where the lungs do not take in enough oxygen to oxygenate the blood), chronic pain, and Insomnia (difficulty falling or staying asleep). The POC revealed the patient received SN services weekly for 8 weeks for medication setup, assessment of the patient, and assessment of the patient's knowledge of the disease process. A review of a document titled "Nurse's Notes" in Patient #4's clinical record evidenced on 12/01 and 12/15/2025 the patient refused SN visits. The clinical record failed to evidence the physician was notified the change in the visits due to the patient's refusal. 4. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, the Administrator indicated when the patient refused a visit, they would try to reschedule the visit and notify the physician of the change in the frequency. They explained there was no communication note evidencing they informed the physician of the patient's refusal of visits or change in the POC. 410 IAC 17-13-1(a)(2)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they coordinated care and documented the coordination with other agencies providing services to patients for 4 of 4 active clinical records reviewed with patients who had other entities providing services. (Patients #2, #3, #4, #5, and #6) Findings Include: 1. An undated policy titled "Clinical Documentation" indicated but was not limited to, " … 4. Telephone or other communication with clients, physicians/allowed non-physician practitioner (NPP), families, or other members of the health care team will be documented in clinical progress notes or other interagency communication form. …" 2. A review of Patient #2's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/18/2025 by the Administrator/CM. The assessment revealed the patient received attendant care services from Entity 2, a Personal Service Agency. The assessment failed to indicate the hours Entity 2 provided services for the patient. During an interview with HHA 3 at Patient #2's residence on 12/17/2025 at 11:00 AM, they indicated Entity 2 came to help the patient every day from 4:00 PM to 8:00 PM. Patient #2's clinical record failed to evidence the Administrator/CM's coordination of care with Entity 2 and confirmed their hours. 3. A review of Patient #3's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 10/29/2025 by the Administrator/CM. The assessment revealed the patient received attendant care services from Entity 1, a Personal Service Agency. The assessment failed to indicate the hours Entity 1 provided services to the patient. Patient #3's clinical record failed to evidence the Administrator/CM's coordination of care with Entity 1 and confirmed their hours. 4. A review of Patient #4's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/01/2025 by the Administrator/CM. The assessment revealed the patient received attendant care services from Entity 1, a Personal Service Agency. The assessment failed to indicate the hours Entity 1 provided services to the patient. Patient #4's clinical record failed to evidence the Administrator/CM's coordination of care with Entity 1 and confirmed their hours. 5. Patient #5's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 11/02/2025 by the Administrator/CM. The assessment revealed the patient received attendant care services from Entity 1, a Personal Service Agency. The assessment failed to indicate the hours Entity 1 provided services to the patient. Patient #5's clinical record failed to evidence the Administrator/CM's coordination of care with Entity 1 and confirmed their hours. 6. Patient #6's clinical record included a Comprehensive OASIS Assessment for the patient's SOC on 10/31/2025 by the Administrator/CM. The assessment revealed the patient received attendant care services from Entity 1, a Personal Service Agency. The assessment failed to indicate the hours Entity 1 provided services to the patient. Patient #6's clinical record failed to evidence the Administrator/CM's coordination of care with Entity 1 and confirmed their hours. 7. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, the CM indicated they had contacted Entity 1 and Entity 2 to confirm the patients' hours with their agency and services. They explained there was no evidence of the communication notes to the personal service agencies because they had not documented them. They indicated if it was not documented, it was not done. 410 IAC 17-14-1(a)(1)(F)

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide was following the HHA care plan, maintained an open communication with the patient, family, and caregivers, performed tasks appropriately, followed infection control practices, reported changes in condition, and honored patient rights for 3 of 3 active clinical records reviewed with patients receiving HHA services. (Patients #2, #5, and #6) Findings Include: 1. A review of Patient #2's active clinical record evidenced a POC with a SOC date of 11/18/2025 and an initial certification period from 11/18/2025 to 01/16/2025. The POC included the following diagnoses: Symptomatic Epilepsy with Complex Seizures (a brain disorder causing sudden electrical activity in the brain causing disruptions in awareness, staring spells, and violent jerking), Presence of a Neurostimulator (a device used to monitor the electrical patterns in the brain to see when a seizure is starting and send pulses to the brain to stop the seizure), Altered Mental Status (a change in the person's brain function impacting their memory), and Hyperlipidemia (condition where there are high levels of fat in the blood). The POC revealed the patient received 20 hours a week for 8 weeks of HHA services and SN visits every 2 weeks for 8 weeks for vital sign assessment, patient education, and medication set-up. The SN visit dated 12/02/2025 evidenced a supervisory note was completed by the Administrator/CM for Patient #2. The note evidenced they observed the aide perform safe transfer and they followed the POC. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. 2. A review of Patient #5's active clinical record evidenced a POC with a SOC date of 11/02/2025 and an initial certification period from 11/02/2025 to 12/31/2025. The POC included the following diagnoses: Injury of the left shoulder. The POC evidenced the patient received 20 hours a week for 8 weeks of HHA services for ADL assistance and SN services once every two weeks for 8 weeks for medication setup and assistance with smoking cessation. The SN visit dated 11/21/2025 evidenced a supervisory note was completed by the Administrator/CM for Patient #5. The note evidenced they observed the aide followed the POC and Patient #5 had no concerns. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. The SN visit dated 12/04/2025 evidenced a supervisory note was completed by the Administrator/CM for Patient #5. The note evidenced they observed the aide following the POC and educated on safe transfers and fall prevention. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. 3. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/31/2025 and an initial certification period from 10/31/2025 to 12/29/2025. The POC included the following diagnosis: COPD. The POC evidenced the patient received SN services once a week for 8 weeks to monitor breathing and vitals and HHA services 15 hours a week for 8 weeks for assistance with ADLs. The SN visit dated 11/13/2025 evidenced a supervisory note was completed by the Administrator/CM for Patient #6. The note evidenced they observed the aide following the POC and educated the family on breathing techniques. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. The SN visit dated 11/27/2025 evidenced a supervisory note was completed by the Administrator/CM for Patient #6. The note evidenced they observed the aide following the POC and educated on safe transfers. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. The SN visit dated 12/11/2025 evidenced a supervisory note was completed by the Administrator/CM for Patient #6. The note evidenced they reviewed the aide POC and educated on safe transfers. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. 4. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, the CM indicated when they completed HHA supervisory visit notes, they verified the patient was satisfied with the care and the aide followed the POC. They explained they were unaware they needed to verify the aide protected the patient's rights, kept open communication with the patient and caregivers, and ensured the HHA performed infection control appropriately. 410 IAC 17-14-1(n)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge summary contained the patients' discharge dates, the physician, current medications, and patients' discharge condition for 3 of 3 inactive clinical records reviewed. (Patients #8, #9, and #10) Findings Include: 1. An undated policy titled "Discharge Summary" indicated but was not limited to, " … 2. The Discharge Summary will incorporate findings from the discharge OASIS assessment and shall include, but not be limited to: a. Admission and discharge dates. … e. A current accurate reconciled list of all Medications the client is on at the time of discharge. f. Client discharge condition. g. Outcomes in meeting the goals in the plan of care. h. Client and family post-discharge instruction. i. Reason for discharge. j. Transfer information …" 2. A review of Patient #8's inactive clinical record evidenced a document titled "Discharge Summary" dated 03/06/2025 by the Administrator/CM. The document revealed the patient had an SOC of 01/25/2025 and a discharge date of 03/10/2025. The section titled "Physical/Psychosocial Status" indicated but was not limited to, " … Alert x3 (sic times 3), age appropriate. …" The discharge summary failed to evidence the patient's health condition at discharge, the patient's primary physician, and the medications they took at discharge. 3. A review of Patient #9's inactive clinical record evidenced a document titled "Discharge Summary". The document was undated and unsigned. The document evidenced the patient was admitted to the agency on 01/03/2025. The discharge date was blank. The discharge summary failed to evidence the patient's discharge date, primary physician, and the medications they took at discharge. 4. A review of Patient #10's inactive clinical record evidenced a document titled "Discharge Summary" dated 05/08/2025 by the Administrator/CM. The document revealed the patient had an SOC of 03/11/2025 and a discharge date of 05/08/2025. The discharge summary failed to evidence the patient's primary physician and the medications they took at discharge. 5. During an interview with the Administrator/CM and the Alternate Administrator on 12/18/2025 at 1:40 PM, the CM confirmed they completed all of the discharge summaries for the patients. The CM indicated when discharging the patients, they send the discharge summary and the discharge order to the patients' physicians. They explained they were unaware they needed to have the patients' full health condition summarized, physicians' name, and medication list. They indicated they forgot to put the patient's discharge date for Patient #9. 410 IAC 17-15-1(a)(6)