Every finding on record at Mama Annies Home Health Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 06/18, 06/19, and 06/22/2026 Active Census: 6 At this Emergency Preparedness survey, Mama Annie’s was found to be out of compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 6/24/2026.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness training was completed for all existing staff for 1 of 1 home health agencies. Findings Include: 1. Review of an agency document dated 08/11/2025 and titled “Emergency Preparedness Plan” indicated but was not limited to, “ … 10. Training & Testing Program A. Training Emergency preparedness training provided: Upon hire, Annually, when plan changes. 2. On 06/19/2026 at 2:47 PM, the Administrator reviewed the binder containing emergency preparedness documentation. The Administrator was unable to locate the emergency preparedness training for staff. 3. During an interview on 06/19/2026 at 3:28 PM, the Administrator/DON indicated they were unable to locate the emergency preparedness personnel training. When asked how often training was completed, the Administrator/DON indicated annually, and upon hire.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an exercise was performed to test the emergency preparedness plan and an after-action plan was completed for 1 of 1 home health agencies. Findings Include: 1. Review of an agency document dated 08/11/2025 and titled “Emergency Preparedness Plan” indicated but was not limited to, “ … 10. Training & Testing Program … B. Testing At least one emergency preparedness exercise annually … Documentation of training and testing is maintained …” 2. On 06/19/2026 at 2:30 PM, the emergency preparedness exercise was requested. The Administrator/DON and RN 1 indicated the tabletop was completed during an in-service. 3. On 06/19/2026 at 2:47 PM, the Administrator reviewed the binder containing emergency preparedness documentation. The Administrator was unable to locate the exercise and indicated they would continue looking for the documentation. 3. During an interview on 06/19/2026 at 3:28 PM, the Administrator indicated they were unable to locate the documentation of the emergency preparedness exercise completed by the agency. When queried how often the agency completed an exercise, the Administrator/DON indicated annually. When queried about the difference between a tabletop drill versus a full scale exercise, the Administrator/DON indicated they were unaware of the difference.

This visit was for a State Re-Licensure and Initial Medicaid Certification survey for a Home Health provider. Survey Dates: 06/18, 06/19, and 06/22/2026 12-Month Unduplicated Skilled Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA - Home Health Aide SN- Skilled Nurse RN- Registered Nurse POC- Plan of Care SOC- Start of Care DC - Discharge DON- Director of Nursing DME- Durable Medical Equipment ADL- Activities of Daily Living QAPI- Quality Assurance Performance Improvement OASIS- Outcome and Assessment Information Set QR completed by Area 3 on 6/24/2026.

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 a seizure plan, rehabilitation potential, and/or discharge planning for 10 of 10 clinical records reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). Findings Include: 8. A review of the inactive record for Patient #7 with a SOC date of 11/19/2025 and a discharge date of 02/12/2026, contained a POC for the recertification period 01/18/2026 through 03/18/2026, signed by RN 1. The POC indicated Patient #7 had a primary diagnosis of Congestive Heart Failure (a chronic progressive condition when the heart muscle is unable to effectively pump enough blood to meet the body’s needs). The section titled “Goals/Rehabilitation Potential/Discharge Plans” listed Patient #7’s goals but failed to provide evidence of rehabilitation potential and discharge plans. 9. A review of the inactive record for Patient #8 with a SOC date of 10/24/2025 and a discharge date of 02/28/2026, contained a POC for the recertification period 12/25/2025 through 02/20/2026 signed by the Administrator/Clinical Supervisor. The POC indicated Patient #8 had a primary diagnosis of Hyperlipidemia (high cholesterol). The section titled “Goals/Rehabilitation Potential/Discharge Plans” listed Patient #8’s goals but failed to provide evidence of rehabilitation potential and discharge plans. 10. A review of the inactive record for Patient #9 with a SOC date of 02/27/2026 and a discharge date of 04/28/2026, contained a POC for the initial certification period 02/27/2026 through 04/28/2026 signed by the Administrator/Clinical Supervisor. The POC indicated Patient #9 had a primary diagnosis of Hypotension (low blood pressure), and pertinent diagnoses of End Stage Renal Failure (ESRD) (a condition where the kidneys have lost their function to remove waste, excess fluids form the blood), Cardiac Dysrhythmia (a condition of an abnormal or irregular heartbeat), and Breast Cancer (a condition where cells in the breast grow out of control creating a mass). The section titled “Nutrition Requirements” listed regular but failed to list renal and fluid restrictions Patient #9 had. The section titled “Goals/Rehabilitation Potential/Discharge Plans” listed Patient #9’s goals but failed to provide evidence of rehabilitation potential and discharge plans. 11. A review of the inactive record for Patient #10 with a SOC date of 04/14/2026 and a discharge date of 06/11/2026, contained a POC for the initial certification period 04/14/2026 through 06/12/2026 signed by the Administrator/Clinical Supervisor. The POC indicated Patient #10 had a primary diagnosis of Shortness of Breath. The section titled “Goals/Rehabilitation Potential/Discharge Plans” listed Patient 10’s goals but failed to evidence rehabilitation potential and discharge plans. During an interview on 06/18/2026 at 1:00 PM, when asked about the location of the POCs for the rehabilitation potential and discharge plans for Patients #1 through #10, the Administrator/Clinical Supervisor and RN 1 confirmed that the rehabilitation potential and discharge plans had been omitted and were not included in the POCs. When asked about Patient #9's nutritional requirements, the Administrator/Clinical Supervisor stated, "It should have been listed as renal diet and fluid restrictions. " 410 IAC 17-13-1(a)(i-xiii) 1. Review of an agency policy dated 01/20/202 and titled “Plan of Care” indicated but was not limited to, “ … The Plan of Care shall be completed to in full to include: i. Rehabilitation potential … m. … procedures … s. Discharge plans …” 2. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/02/2026 for the certification period of 05/03/2026 through 07/01/2026 and signed by RN 1. The POC indicated Patient #1 had, but was not limited to, Hypotension (low blood pressure), Asthma (chronic inflammatory disease of the lungs that causes the airways to swell, tighten, and fill with extra mucus), CAD in native artery (Coronary Artery Disease, condition where plaque (a mix of cholesterol, calcium, and fat) builds up and narrows the natural arteries that supply oxygen-rich blood to your heart muscle), Chronic Kidney Disease (long-term condition where your kidneys are damaged and lose their ability to filter waste and excess fluid from your blood), and Depression with Anxiety (state where symptoms of depression such as persistent sadness and low energy occur simultaneously with high level anxiety such as excessive worry and tension). The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" stated but was not limited to, "The patient will remain safe and free from falls, maintain stable BP [blood pressure] without symptoms of hypotension [low blood pressure], stay compliant with medications through consistent use of a pill organizer, remain compliant with [their] Physical Therapy, and regain baseline mobility of [their] right dominant hand to support safe participation in ADLs …” The POC failed to evidence the rehabilitation potential and discharge plan. 3. Review of Patient #2's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 02/26/2026 for the certification period of 04/27/2026 through 06/25/2026 and signed by RN 1. The POC indicated Patient #2 had, but was not limited to, Open wound of toe of left foot, Peripheral Vascular Disease (low, progressive circulation disorder characterized by the narrowing, blockage, or spasm of blood vessels outside the heart and brain), Atrial Fibrillation (most common type of irregular heartbeat), and Epilepsy (chronic neurological disorder characterized by recurrent, unprovoked seizures). The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" stated but was not limited to, "The client is expected to remain free from infections and falls, avoid the formation of any new pressure injuries, and maintain overall skin health without additional breakdown during the 60-day recertification period. The client will show understanding of strategies to keep the current skin breakdown from getting worse and will also express knowledge of methods that support improved circulation in the left foot …” The POC failed to evidence the rehabilitation potential discharge plan, and a seizure plan. During an interview on 06/19/2026 at 4:05 PM, with the Administrator/DON, Alternate Administrator/Alternate DON, and RN 1, indicated a seizure plan should be included on the POC. 4. Review of Patient #3's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/31/2026 for the certification period of 03/31/2026 through 05/29/2026 and signed by RN 1. The POC indicated Patient #3 had, but was not limited to, Ulcer of right leg, Lymphedema (chronic condition characterized by painful swelling, typically in the arms or legs, caused by a buildup of lymph fluid), Anemia (blood condition where you lack enough healthy red blood cells or hemoglobin to carry oxygen to your body's tissues), Peroneal DVT (blood clot located in the deep peroneal veins of the lower leg), and Obstructive Sleep Apnea (occurs when the upper airway repeatedly collapses or becomes blocked during sleep, cutting off or reducing airflow and causing you to wake up briefly to resume breathing). The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" stated but was not limited to, "The client will remain free from infections and falls while maintaining overall skin integrity and avoiding any additional wounds. The client will verbalize understanding of how to prevent current wounds from worsening through proper care and early reporting of changes. The clients personal goal is to experience less shortness fo breath with short-distance ambulation and improve activity tolerance …” The POC failed to evidence the rehabilitation potential and discharge plan. 5. Review of Patient #4's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/02/2026 for the certification period of 04/02/2026 through 05/31/2026 and signed by RN 1. The POC indicated Patient #4 had, but was not limited to, Essential Hypertension (high blood pressure), Multiple Sclerosis (a chronic, unpredictable autoimmune disease of the central nervous system (brain, spinal cord, and optic nerves)), Urge Incontinence (sudden, uncontrollable need to urinate, followed by involuntary leakage before you can reach the bathroom), GERD with esophagitis (chronic condition where stomach acid frequently flows back into the esophagus causing inflammation of the esophagus), and overactive bladder. The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" stated but was not limited to, “Patient will remain safe and free of falls during the recert period … will adhere to [their] medication regimen … receive education on hypertension and nutrition to support BP [blood pressure] control and [their] goal to lose 5-10 pounds … goals include ambulating short distances without shortness of breath while monitoring for edema [swelling] and elevated BP each visit …” The POC failed to evidence the rehabilitation potential and discharge plan. 6. Review of Patient #5's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/07/2026 for the certification period of 05/07/2026 through 07/05/2026 and signed by the Administrator. The POC indicated Patient #5 had, but was not limited to, Right carpal tunnel release surgery (a surgical procedure used to treat carpal tunnel syndrome, relieves pressure on the median nerve in the wrist by cutting the transverse carpal ligament, which creates more space and eliminates symptoms like pain, numbness, and tingling), Elbow decompression surgery (procedure to relieve pressure on the ulnar nerve (the "funny bone" nerve) as it passes through the inside of your elbow), Degenerative Disc Disease (age-related condition that occurs when the soft, rubbery cushions between your spinal vertebrae wear down), Lumbar Radiculopathy (set of symptoms caused by the compression or inflammation of a nerve root in your lower back), and Type 2 Diabetes Mellitus (chronic metabolic condition where the body resists the effects of insulin and fails to produce enough to maintain normal glucose levels causing high blood sugar). The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" stated but was not limited to, “Patient will remain free from falls within the recirc period … will demonstrate proper circulation to right extremity and resume performing ADLs as tolerated by the end of the recirc period. Patient will be able to verbalize signs of poor neurovascular status … vocalizes wanting to achieve a goal weight of 220 lbs(pounds).” The POC failed to evidence the rehabilitation potential and discharge planning. 7. Review of Patient #6's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/07/2026 for the certification period of 05/07/2026 through 07/05/2026 and signed by the Administrator. The POC indicated Patient #6 had, but was not limited to, Unspecified vision loss, Cataract Surgery (outpatient procedure to remove a cloudy, natural eye lens, and replace it with a clear artificial lens), Other specified Glaucoma (group of eye diseases that damage the optic nerve, which connects your eye to the brain),Essential Hypertension (high blood pressure), and COPD (Chronic Obstructive Pulmonary Disease, progressive incurable group of lung diseases that cause obstructed airflow and make it difficult to breathe). The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" stated but was not limited to, “Client will maintain safe medication compliance through weekly skilled-nursing setup, demonstrate stable vital signs, and improve safety awareness related to visual impairment and fall risk …” The POC failed to evidence the rehabilitation potential and discharge planning. During an interview on 06/19/2026 at 3:50 PM, the Administrator/DON indicated there was not enough room on the POC to include the rehabilitation potential and discharge planning. The Administrator/DON indicated the rehabilitation potential, and discharge plan should be included on the POC.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were documented as an order and authenticated by the physician for 1 of 4 active clinical records review with patients receiving medication set up (Patient #1). Findings Include: 1. Review of an agency policy dated 01/20/2025 and titled “Physician/Allowed Non-Physician Practitioner (NPP) Orders” indicated but was not limited to, “ … When the nurse or therapist receives a verbal order from the physician … shall write the order as given … The verbal order shall verify that the order was taken and verified by documenting this on thh form and signing the form. The order must include the date, specific order, be signed with the full name and title of the person receiving the order and be sent to the physician … for signature and date. 2. All orders for medications must contain the name of the drugs, dosage, route of administration, and directions for use. … 7. If the client or caregiver initiates changes that have been communicated to them by the physician … the nurse … will write and date the order the day he/she is informed of the change but shall indicate on the order the actual day the change was made …” 2. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/02/2026 for the certification period of 03/03/2026 through 05/02/2026 and signed by RN 1. The POC indicated Patient #1 received biweekly SN visits for medication set-up and education. The POC failed to evidence the agency may accept orders from other providers. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/02/2026 for the certification period of 05/03/2026 through 07/01/2026 and signed by RN 1. The POC indicated Patient #1 received biweekly SN visits for medication set-up and education. The POC failed to evidence the agency may accept orders from other providers. Review of Patient #1’s active clinical record revealed a document titled “Physician Order”. The orders dated 03/03/2026 through 06/19/2026 failed to evidence signed physician orders to update medications on the POC. Review of Patient #1’s active clinical record revealed a document titled “Narrative Charting”. The note dated 04/03/2026 and signed by RN 1 indicated but was not limited to, “ … ER [emergency room] physician made the following changes: Midodrine [medication used to increase blood pressure]: Discontinued the three-time-daily dosage, changing the frequency to as needed. Keflex [antibiotic used to treat bacterial infection] … : Prescribed three times daily for five days … The psychiatric provider … prescribed Propranolol [medication used to treat high blood pressure or symptoms of anxiety (excessive worry) such as racing heart] …” The note dated 04/18/2026 and signed by RN 1 indicated but was not limited to, “ … Contact was established with [Person 4, Patient #1’s physician responsible for the POC] … The primary goal … were to update the client’s current medication list, clarify specific prescriptions , and provide the updated order received from the psychologist … office was informed that the dosage of Propranolol has been increased …” The note dated 05/14/2026 and signed by RN 1 indicated but was not limited to, “ … Nurse confirmed Propranolol dose change from three times daily to twice daily …” The note dated 05/28/2026 and signed by RN 1 indicated but was not limited to, “ … a call was placed to … [Person 6, Patient #1’s Psych Nurse Practitioner (NP)], to reconcile mediation changes made … The NP was available .. and confirmed the following updates Escitalopram [antidepressant medication] decreased … Clonazepam [medication used to treat panic attacks] changed from scheduled to 0.5 mg [milligrams] up to twice daily as needed Propranolol discontinued Pregabalin [medication used as an anticonvulsant or to treat nerve pain] 150 mg capsule take one capsule three times daily Lamotrigine [anticonvulsant and mood-stabilizing medication] 25 mg take one tablet by mouth daily Hydroxyzine HCL 25 mg take one tablet by mouth three times daily as needed (not scheduled) … [Person 4, Patient #1’s physician responsible for the POC] was contacted to update them on these medication changes … Additionally Metoprolol Succinate ER [medication used to lower heart rate and blood pressure] was confirmed as a new prescription from [Person 7, Patient #1’s cardiologist (heart doctor)] …” The note dated 06/10/2026 and signed by RN 1 indicated but was not limited to, “ … Discontinued medications include: Escitalopram 20 mg Escitalopram 10 mg Metoprolol Succinate Clonazepam 0.5 mg Clonazepam 1 mg tablet … New and adjusted orders: Clonazepam 0.25 mg … Lamotrigine 25 mg tablet …” During an interview on 06/19/2026 at 12:44 PM, with the Administrator/DON and RN 1, they indicated when a change takes place they notify the physician but do not send an order to be signed. RN 1 indicated they document the change in a note.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a performance improvement project was conducted for 1 of 1 agency QAPI program. Findings Include: 1. Review of an agency policy dated 01/20/2025 and titled “Quality Assessment and Performance Improvement (QAPI)” indicated but was not limited to, “ … Performance Improvement Projects … agencies must conduct performance improvement projects. A. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the agency services and operations. B. The agency must document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects …” 2. Review of an agency binder revealed the QAPI program. The binder failed to evidence documentation of a performance improvement project. 3. On 06/19/2026 at 3:45 PM, the Administrator/DON was requested to provide documentation of the performance improvement project the agency was working on. During an interview on 06/19/2026 at 3:45 PM, the Administrator/DON asked for clarification. The Administrator/DON indicated a performance improvement project was not formally created and was unaware of the requirement.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN’s initial comprehensive assessment and ongoing patient assessments accurately reflected the client’s health status for 1 of 1 patients with an AV (arteriovenous) fistula. (Patient: #9) Findings Include: 1. A review of an undated agency policy titled “Comprehensive Client Assessment” indicated, but was not limited to, “ To determine the appropriate care, treatment and services … collect data about the client’s health … a. The Comprehensive Assessment must accurately reflect the client’s status … Assessment Strategies: … Direct observation. Inspection. Clinical measurements … ” 2. Quality of Nursing Practice in Arteriovenous Fistula Care at kidneyregistrylb.com/wp-content/uploads/2021/05/AVF-NursingCare dated 5/10/2012, indicated “ ... Inspection: look for ecchymosis/discoloration, breaks in the skin, erythema, aneurysm, hematoma formations, curves/ flat spots ... hand or arm or limb swelling, discoloration of nail beds, presence of accessory veins. Palpation: Feel thrill or pulsation ... Vein diameter, flat spots, aneurysms, skin temperature [warm - infection? cold - steal syndrome]. Auscultation: … listen to the quality and amplitude of bruit: sounds should be continuous ... Vascular access remains the single most important and modifiable risk factor for death and illness in the hemodialysis population. Preserving vascular access patency strongly influences treatment outcomes for patients ... ” 3. A review of the inactive clinical record for Patient #9, with a SOC date of 02/27/2026 and a discharge date of 04/28/2026, contained an initial comprehensive SOC assessment dated 02/27/2026 and signed by the Administrator/Clinical Supervisor. The initial comprehensive assessment, as evidenced in the section titled “Special Treatment, Procedures, and Programs,” Patient #9 received hemodialysis three times a week, and Entity 2 on the first shift every Monday, Wednesday, and Friday, and noted Person 3, the nephologist, for Patient #9. The initial comprehensive assessment failed to evidence Patient #9’s AV fistula had been assessed for bruit, thrill, signs of bleeding, and infection. A review of the weekly skilled visit notes dated 03/12, 03/19, 03/26, 04/02, 04/09, 04/16, and 04/23/2026, and signed by RN 1 and the Administrator/Alternate Clinical Supervisor. The Skilled visit notes failed to evidence Patient #9’s arteriovenous (AV) fistula (an abnormal connection between an artery and vein) had been assessed for bruit, thrill, signs of bleeding and infection. During an interview on 06/18/2026 at 12:35 PM, when asked about the lack of documentation regarding the AV fistula assessments being completed in Patient #9’s chart on the initial assessment and on the SN visit notes, the Administrator/Clinical Supervisor and RN 1 stated, “Yes, we assess for bruit and thrill, but did not document it. Yes, if it is not documented, it was not done.”