Every finding on record at Maximum Home Healthcare LLC

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a recertification assessment was performed in the last 5 days of the certification period for 3 of 4 active clinical records reviewed. (Patients #1, #2, and #7) Findings Include: 1. An undated agency policy titled "Comprehensive Assessment of Patients (OASIS)" indicated but was not limited to, " … 7. Every second calendar month at recertification, a follow-up OASIS assessment will be performed. The follow-up skilled visit assessment shall be performed no earlier than five days prior to the last day of the certification period (between and including days 56-60) …" 2. A review of Patient #1's active clinical record evidenced a document titled "OASIS Assessment" dated 12/18/2025 by the Administrator, the patient's case manager. Patient #1's active clinical record evidenced a POC with a SOC date of 05/01/2025 and a recertification period of 12/27/2025 to 02/24/2026. The active clinical record for Patient #1 failed to evidence the patient's recertification assessment was performed within the last five days of their previous certification period. 3. A review of Patient #2's active clinical record evidenced a document titled "OASIS Assessment" dated 01/11/2026 by the Administrator, the patient's case manager. Patient #2's active clinical record evidenced a POC with a SOC date of 09/19/2025 and a recertification period of 01/17/2026 to 03/17/2026. The active clinical record for Patient #2 failed to evidence the patient's recertification assessment was performed within the last five days of their previous certification period. 4. A review of Patient #7's active clinical record evidenced a document titled "OASIS Assessment" dated 12/18/2025 by the Administrator, the patient's case manager. Patient #7's active clinical record evidenced a POC with a SOC date of 07/01/2025 and a recertification period of 12/28/2025 to 02/25/2026. The active clinical record for Patient #7 failed to evidence the patient's recertification assessment was performed within the last five days of their previous certification period. 5. During an interview with the Administrator on 01/21/2026 at 1:50 PM, they indicated for Patients #1, #2, and #7, they were concerned they would not receive the signed POC in time for the new certification period. They explained they needed the POC signed by the patients' physicians in order to continue services. 410 IAC 17-14-1(a)(1)(B)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 11/20, 11/21, and 11/24/2025 Active Census: 8 At this Emergency Preparedness survey, Maximum Home Healthcare, 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 12/8/2025.

This visit was for an initial Federal Medicaid of a Home Health provider. Survey Dates: 11/20, 11/21, and 11/24/2025 12-Month Unduplicated Skilled Admissions: 11 Fully Extended Survey was announced on 11/24/2025 at 1:50 PM. 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 and 42 CFR 484.105 Organization and Administration of Service. Based on the Condition-level deficiencies during the 11/24/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on [date of the extended survey]. 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 11/24/2025 and continuing through 11/23/2027. 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 QR completed by Area 3 on 12/9/2025.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the patients received and signed consent for treatment upon admission to the agency and received the discharge and transfer policy in the admission packet for 3 of 3 active clinical records reviewed with home visits. (Patient #1, #6, and #7) Findings Include: 1. A review of the agency admission packet on 11/20/2025 failed to evidence a discharge/transfer policy. 2. During a home visit at Patient #1's residence on 11/21/2025 9:30 AM, their admission packet was reviewed and failed to evidence the agency's discharge and transfer policy. 3. During a home visit at Patient #6's residence on 11/21/2025 11:00 AM, their admission packet was reviewed and failed to evidence the agency's discharge and transfer policy. A review of Patient #6's active clinical record evidenced a document titled "OASIS Assessment" dated 10/06/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for recertification. Patient #6's active clinical record included a POC with a SOC date of 10/03/2025 for an initial certification period from 10/03/2025 through 12/01/2025. A review of Patient #6's inactive clinical record evidenced the patient had been admitted on 05/02/2025 as evidenced by admission consent forms signed by Patient #6 on 05/02/2025 and a Start of Care "OASIS Assessment" completed and signed by the Administrator on 05/02/2025. Patient #6's active clinical record failed to evidence the patient signed new consent forms for the new SOC of 10/03/2025. 3. During a home visit at Patient #7's residence on 11/21/2025 11:55 AM, their admission packet was reviewed and failed to evidence the agency's discharge and transfer policy. 4. During an interview with the Administrator on 11/21/2025 at 2:45 PM indicate they were unaware the discharge/transfer policy had to be included in the admission packet. 5. During an interview with the Administrator on 11/24/2025 at 12:05 PM, they indicated they had not had Patient #6 sign new consent forms for Patient #6's new admission date of 10/03/2025. They were unaware they needed new consents signed. 410 IAC 17-12-3(a)1(B)

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients received all services listed on the POC as ordered by the physician for 4 of 5 active clinical records reviewed. (Patients #3, #4, #6, and #7) Findings Include: 1. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 09/08/2025 and a certification period from 11/07/2025 through 01/05/2026. The POC included the following diagnoses: Chronic Obstructive Pulmonary Disease, Chronic embolism and thrombosis in the deep veins of the lower extremities (a blot clot in the vein), and Congestive Heart Failure. The section titled "Orders and Goals" evidenced the patient received SN services every 2 weeks for medication set up and assessment and HHA services 7 days a week for 6 hours a day. A review of Patient #3's active clinical record evidenced an "OASIS Assessment" dated 11/03/2025 by the Administrator, the patient's case manager, for the patient's recertification. The document revealed the patient was hospitalized on 09/15/2025 at Entity 10 (a hospital), went to a rehabilitation facility, and returned home from the rehabilitation facility on 10/31/2025. Patient #3's active clinical record failed to evidence HHA visit notes for the following weeks: The week of 11/02/2025 through 11/08/2025 failed to evidence HHA visit notes on 11/02, 11/03, 11/04, 11/06, 11/07, and 11/08/2025. The week of 11/09/2025 through 11/15/2025 failed to evidence HHA visit notes on 11/09, 11/10, 11/13, 11/14, and 11/15/2025. The week of 11/16/2025 through 11/22/2025 failed to evidence HHA visit notes on 11/16, 11/17, 11/20, 11/21, and 11/22/2025. During an interview with HHA 6 on 11/24/2025 at 1:08 PM, they explained they only worked for Patient #3 and the agency two days a week. During an interview with the Administrator, the patient's case manager, on 11/24/2025 at 1:50 PM, they indicated they had not received orders to change the HHA frequency ordered on the POC. 2. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 10/01/2025 and an initial certification period from 10/01/2025 through 11/29/2025. Chronic Systolic and Diastolic Heart Failure (weakened heart causing the blood to not effectively circulate through the body and the chambers of the heart do not fill properly), Cardiac Pacemaker (a small batter-operated device delivers impulses to ensure the heart beats appropriately), Hypertensive Heart Disease (the heart muscle is weakened due to long term high blood pressure), Methicillin resistant Staphylococcus infection (a bacterial infection which is resistant to antibiotics), and Inguinal Hernia (the abdominal wall is weakened allowing organs or fat to push through into the groin area). The "Orders and Goals" section revealed the patient received SN services every 2 weeks for medication management and HHA services for 7 days a week and 8 hours a day for assistance with ADLs. Patient #4's active clinical record included a verbal order signed by the Administrator, the patient's case manager, on 09/29/2025 indicated the Administrator received a verbal order to perform a SOC assessment for the patient. A review of Patient #4's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/01/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for the SOC. The active clinical record for Patient #4 revealed the next SN visit was conducted on 10/29/2025 by the Administrator. Patient #4's active clinical record evidenced the first HHA visit was conducted on 11/04/2025 by HHA 4. The clinical record for Patient #4 failed to evidence HHA visit notes the weeks of 10/01/2025 through 10/04/2025, 10/05/2025 through 10/11/2025, 10/12/2025 through 10/18/2025, 10/19/2025 through 10/25/2025, and 10/26/2025 through 11/01/2025. Patient #4's clinical record failed to evidence a SN visit note the week of 10/12/2025 through 10/18/2025. The active clinical record for Patient #4 failed to evidence the patient received services as ordered on the POC. 3. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). The "Orders and Goals" revealed the patient received SN services two times a month for assessment and medication management and HHA services seven days a week for six hours a day. Patient #6's active clinical record included a verbal order signed by the Administrator on 10/03/2025 indicated the Administrator, the patient's case manager, received a verbal order to perform a SOC assessment for the patient. A review of Patient #6's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/06/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for recertification. The active clinical record for Patient #6 revealed the next SN visit was conducted on 10/29/2025 by the Administrator. Patient #6's active clinical record evidenced the first HHA visit was conducted on 10/29/2025 by HHA 1. The clinical record for Patient #6 failed to evidence a SN visit note the week of 10/19/2025 through 10/25/2025. The clinical record for Patient #6 failed to evidence HHA visit notes the weeks of 10/01/2025 through 10/04/2025, 10/05/2025 through 10/11/2025, 10/12/2025 through 10/18/2025, and 10/19/2025 through 10/25/2025. The active clinical record for Patient #6 failed to evidence the patient received services as ordered on the POC. 4. A review of Patient #7's active clinical record evidenced a POC with a SOC date of 07/01/2025 and a certification period from 10/29/2025 through 12/27/2025. The POC included the following, but was not limited to, diagnoses: Cerebral Infarction (heart attack), Hypertension, Type 2 Diabetes Mellitus, Blindness in both eyes, Hearing loss, and Dementia (a condition where the person's memory and thinking decline). The "Nutritional Requirement" indicated the patient required assistance with cooking and meal preparation. The section titled "Orders and Goals" revealed the patient received SN services every 2 weeks for assessment and medication set-up and HHA services 5 days a week for 7 hours a day. A review of Patient #7's active clinical record evidenced a verbal order signed by the Administrator, the patient's case manager, on 06/30/2025 indicating they received a verbal order to perform a RN assessment. Patient #7's clinical record included an OASIS Assessment for their SOC dated 07/01/2025 by the Administrator. The clinical record for Patient #7 revealed the next SN visit made after the SOC assessment was on 07/29/2025 by the Administrator. Patient #7's clinical record failed to evidence a SN visit note the week of 07/13/2025 through 07/19/2025. A review of a document titled "Progress Notes" evidenced on 07/18/2025 the Administrator had talked with Patient #7 and their relative, Person 1, and they refused HHA services at the time. Patient #7 only wanted SN services provided by the agency. During an interview with Patient #7 and Person 1 on 11/21/2025 at 11:55 AM, they explained the patient was not receiving HHA services from the agency at the time. The active clinical record for Patient #7 failed to evidence the patient received services as ordered on the POC. 5. During an interview on 11/24/2025 at 9:13 AM, when queried about the POC documentation, the Administrator, who is also the patients' case manager, they explained how they sent the POC to the provider and had to wait for insurance to approve the frequency of services. They indicated they had not reached out to inform the physician they were holding services until they had received insurance approval for Patients #3, #4, #6, and #7. They explained they had forgotten to change the frequency of HHA services for Patient #3. The Administrator had put HHA services for Patient #7 on their POC in case they wanted HHA services later.

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 a RN conducted an initial assessment within 48 hours of referral or a patient's return home for 2 of 5 active clinical records reviewed. (Patients #3 and #6) Findings Include: 1. An undated agency policy titled "Admission Criteria" indicated but was not limited to " … 8. Upon referral, the decision regarding acceptance of and initiation of services by licensed staff will be made within 48 hours, of the referral or within 48 hours of the patients return home or knowledge of return home or on the physicians ordered start of care date. …" 2. A review of Patient #3's active clinical record evidenced a verbal order signed by the Administrator on 09/04/2025 indicated the Administrator received a verbal order to perform a SOC assessment for the patient after the patient was released from the hospital on 09/05/2025. A review of Patient #3's active clinical record evidenced a document titled "OASIS Assessment" dated 09/08/2025 and signed by the Administrator revealed the reason for the completion of the assessment was for the SOC. The clinical record failed to evidence the patient was seen within 48 hours of the referral. 3. A review of Patient #6's active clinical record evidenced a verbal order signed by the Administrator on 10/03/2025 indicated the Administrator received a verbal order to perform a SOC assessment for the patient. A review of Patient #6's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/06/2025 and signed by the Administrator revealed the reason for the completion of the assessment was for recertification. The clinical record failed to evidence the patient was seen within 48 hours of the referral. 4. During an interview with the Administrator on 11/24/2025 at 1:50 PM, they indicated the assessment having recertification on it was a misprint and the assessment on 10/06/2025 was a SOC assessment for Patient #6. When queried regarding why Patient #3 and #6 had not been seen within 48 hours of receiving the referral, they explained when they receive a referral on Friday, they do not see the patient until the next Monday and they only see patients over the weekend unless it was an emergency. They expressed they were off on the weekends. They explained the only orders they had were the ones included in the patient's records. 410 IAC 17-14-1(a)(1)(A)

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to update the comprehensive assessment for the resumption of care following a hospitalization lasting more than 24 hours for 1 of 1 active clinical records reviewed with a hospitalization. (Patient #3) Findings Include: 1. An undated agency policy titled "Comprehensive Assessment of Patients OASIS (sic Outcome and Assessment Information Set)" indicated but was not limited to, " … 6. A Resumption of Care OASIS assessment will be completed within 48 hours (or knowledge of) on every patient following a hospital stay of 24 hours or more for any reason other than diagnostic tests. …" 2. A review of Patient #3's active clinical record evidenced an "OASIS Assessment" dated 11/03/2025 by the Administrator for the patient's recertification revealed the patient was hospitalized on 09/15/2025 at Entity 10 (an acute care hospital), went to a rehabilitation facility, and returned home from the rehabilitation facility on 10/31/2025. The agency failed to ensure the patient was seen within 48 hours of the patient returning home. During an interview with the Administrator, the Case Manager for the patient, on 11/24/2025 at 1:50 PM, when queried regarding why Patient #3 had not been seen within 48 hours of receiving the referral, they explained when they receive a referral on Friday, they do not see the patient until the next Monday. They do not go out to see patients over the weekend unless it is an emergency because they are off on the weekends.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Discharge OASIS comprehensive assessment was completed for 2 of 3 inactive clinical records reviewed. (Patients #6 and #10) Findings Include: 1. An undated agency policy titled "Comprehensive Assessment of Patients (OASIS)" indicated but was not limited to, " … A comprehensive assessment incorporating the … OASIS … utilizing the most current approved version will be performed on qualified patients at: … At discharge …" 2. A review of Patient #6's inactive clinical record evidenced a SOC OASIS Assessment dated 05/02/2025. A discharge summary was completed on 08/29/2025 by the Administrator because the patient wanted to discontinue services until they started with their new insurance. The summary evidenced it was faxed to Patient #6's physician. A review of Patient #6's inactive clinical record with a start date of 05/02/2025 failed to evidence a discharge OASIS comprehensive assessment when they discharged on 08/29/2025. 3. A review of Patient #10's inactive clinical record evidenced a POC with a SOC date of 10/22/2024 and an initial certification period from 10/22/2024 through 12/20/2024. The POC evidenced the following diagnoses: Hypertension, Type 2 Diabetes Mellitus (a disease where the body is not able to regulate insulin appropriately), and Hyperlipidemia. Patient #10 received SN weekly. On 12/20/2024 a discharge summary was completed by the Alternate Administrator, Patient #10 no longer required the agency's services after meeting all of their goals. The summary evidenced it was faxed to Patient #10's physician, Person 3. A review of Patient #10's inactive clinical record with a start date of 10/22/2024 failed to evidence a discharge OASIS comprehensive assessment when they discharged on 12/20/2024. 4. During an interview with the Administrator (the case manager for Patients #6, #9, and #10) on 11/24/2025 at 1:50 PM, they explained a discharge OASIS assessment had not been completed and was unaware they needed to do so.

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 and included service duration, as needed medication indications, diet, and measurable and patient-centered goals ( see G0574), provide services as ordered by physician ( see G0580), obtain physician signatures for all verbal orders received (see G0584), notify the physician of a change in the patient's condition ( see G0590). 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 likelihood to affect all 8 current patients receiving Home Health services from this provider. 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients received all services listed on the POC as ordered by the physician for 4 of 5 active clinical records reviewed. (Patients #3, #4, #6, and #7) Findings Include: 1. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 09/08/2025 and a certification period from 11/07/2025 through 01/05/2026. The POC included the following diagnoses: Chronic Obstructive Pulmonary Disease, Chronic embolism and thrombosis in the deep veins of the lower extremities (a blot clot in the vein), and Congestive Heart Failure. The section titled "Orders and Goals" evidenced the patient received SN services every 2 weeks for medication set up and assessment and HHA services 7 days a week for 6 hours a day. A review of Patient #3's active clinical record evidenced an "OASIS Assessment" dated 11/03/2025 by the Administrator, the patient's case manager, for the patient's recertification revealed the patient was hospitalized on 09/15/2025 at Entity 10 (an acute care hospital), went to a rehabilitation facility, and returned home from the rehabilitation facility on 10/31/2025. Patient #3's active clinical record failed to evidence HHA visit notes for the following weeks: The week of 11/02/2025 through 11/08/2025 failed to evidence HHA visit notes on 11/02, 11/03, 11/04, 11/06, 11/07, and 11/08/2025. The week of 11/09/2025 through 11/15/2025 failed to evidence HHA visit notes on 11/09, 11/10, 11/13, 11/14, and 11/15/2025. The week of 11/16/2025 through 11/22/2025 failed to evidence HHA visit notes on 11/16, 11/17, 11/20, 11/21, and 11/22/2025. During an interview with HHA 6 on 11/24/2025 at 1:08 PM, they explained they only worked for Patient #3 and the agency two days a week. During an interview with the Administrator, the patient's case manager, on 11/24/2025 at 1:50 PM, they indicated they had not received orders to change the HHA frequency ordered on the POC. 2. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 10/01/2025 and an initial certification period from 10/01/2025 through 11/29/2025. The patient's diagnoses included Chronic Systolic and Diastolic Heart Failure (weakened heart causing the blood to not effectively circulate through the body and the chambers of the heart do not fill properly), Cardiac Pacemaker (a small batter-operated device delivers impulses to ensure the heart beats appropriately), Hypertensive Heart Disease (the heart muscle is weakened due to long term high blood pressure), Methicillin resistant Staphylococcus infection (a bacterial infection which is resistant to antibiotics), and Inguinal Hernia (the abdominal wall is weakened allowing organs or fat to push through into the groin area). The "Orders and Goals" section revealed the patient received SN services every 2 weeks for medication management and HHA services for 7 days a week and 8 hours a day for assistance with ADLs. A review of Patient #4's active clinical record included a verbal order signed by the Administrator, the patient's case manager, on 09/29/2025 to perform a SOC assessment for the patient. A review of Patient #4's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/01/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for the SOC. The active clinical record for Patient #4 revealed the next SN visit was conducted on 10/29/2025 by the Administrator. Patient #4's active clinical record evidenced the first HHA visit was conducted on 11/04/2025 by HHA 4. The clinical record for Patient #4 failed to evidence HHA visit notes the weeks of 10/01/2025 through 10/04/2025, 10/05/2025 through 10/11/2025, 10/12/2025 through 10/18/2025, 10/19/2025 through 10/25/2025, and 10/26/2025 through 11/01/2025. Patient #4's clinical record failed to evidence a SN visit note the week of 10/12/2025 through 10/18/2025. The active clinical record for Patient #4 failed to evidence the patient received services as ordered on the POC. 3. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). The "Orders and Goals" revealed the patient received SN services two times a month for assessment and medication management and HHA services seven days a week for six hours a day. A review of Patient #6's active clinical record evidenced a verbal order signed by the Administrator on 10/03/2025. The verbal order was for a SOC assessment for the patient. A review of Patient #6's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/06/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for recertification. The active clinical record for Patient #6 revealed the next SN visit was conducted on 10/29/2025 by the Administrator. Patient #6's active clinical record evidenced the first HHA visit was conducted on 10/29/2025 by HHA 1. The clinical record for Patient #6 failed to evidence a SN visit note the week of 10/19/2025 through 10/25/2025. The clinical record for Patient #6 failed to evidence HHA visit notes the weeks of 10/01/2025 through 10/04/2025, 10/05/2025 through 10/11/2025, 10/12/2025 through 10/18/2025, and 10/19/2025 through 10/25/2025. The active clinical record for Patient #6 failed to evidence the patient received services as ordered on the POC. 4. A review of Patient #7's active clinical record evidenced a POC with a SOC date of 07/01/2025 and a certification period from 10/29/2025 through 12/27/2025. The POC included the following, but was not limited to, diagnoses: Cerebral Infarction (heart attack), Hypertension, Type 2 Diabetes Mellitus, Blindness in both eyes, Hearing loss, and Dementia (a condition where the person's memory and thinking decline). The "Nutritional Requirement" indicated the patient required assistance with cooking and meal preparation. The section titled "Orders and Goals" revealed the patient received SN services every 2 weeks for assessment and medication set-up and HHA services 5 days a week for 7 hours a day. A review of Patient #7's active clinical record evidenced a verbal order signed by the Administrator, the patient's case manager, on 06/30/2025 indicating they received a verbal order to perform a RN assessment. Patient #7's clinical record included an OASIS Assessment for their SOC dated 07/01/2025 by the Administrator. The clinical record for Patient #7 revealed the next SN visit made after the SOC assessment was on 07/29/2025 by the Administrator. Patient #7's clinical record failed to evidence a SN visit note the week of 07/13/2025 through 07/19/2025. A review of a document titled "Progress Notes" evidenced on 07/18/2025 the Administrator had talked with Patient #7 and their relative, Person 1, and they refused HHA services at the time. Patient #7 only wanted SN services provided by the agency. During an interview with Patient #7 and Person 1 on 11/21/2025 at 11:55 AM, they indicated the patient was not receiving HHA services from the agency at the time. The active clinical record for Patient #7 failed to evidence the patient received services as ordered on the POC. 5. During an interview on 11/24/2025 at 9:13 AM, when queried about the POC documentation, the Administrator, who is also the patients' case manager, explained how they sent the POC to the provider and had to wait for insurance to approve the frequency of services. They indicated they had not reached out to inform the physician they were holding services until they had received insurance approval for Patients #3, #4, #6, and #7. They explained they had forgotten to change the frequency of HHA services for Patient #3. The Administrator put HHA services for Patient #7 on their POC in case they wanted HHA services later. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POCs were individualized and included the correct SOC date, duration of services, patient-centered goals, and reasons for why the patient takes the as needed medication for 5 of 5 active clinical records reviewed. (Patients #1, #3, #4, #6, and #7) Findings Include: 1. An undated agency policy titled "Care Planning" indicated but was not limited to, " … H. The plan of care … shall include … Start of care date … Medications: dose/frequency/route … Treatment goals stated in measurable terms … Orders for all disciplines include amount, frequency, duration … Diet and nutritional needs … 2. A review of Patient #1's clinical record evidenced a POC with a SOC date of 05/01/2025 and a certification period from 10/28/2025 through 12/26/2025. The POC included the following diagnoses: Osteoarthritis (a condition where the cartilage between the joints breakdown and cause friction between the joints), Polyneuropathy (numbness and weakness in multiple areas of the body caused by malfunctioning nerves), Chronic Obstructive Pulmonary Disease (a condition which causes difficulty in breathing and shortness of breath), Type 2 Diabetes Mellitus (a disease where the body is unable to appropriately use insulin), and Congestive Heart Failure (the heart muscle is damaged causing it to be weakened and causing the fluid to buildup in the body due to decrease blood flow). The patient's medications included but were not limited to: Albuterol Sulfate Inhalation Nebulization Solution (to treat and prevent spasms in the airway causing wheezing and shortness of breath) (2.5 milligrams (mg)/3 milliliters (ml)) every 6 hours orally; Methocarbamol (to treat pain) 1000 mg 3 times a day orally; Proventil HFA Inhalation Aerosol Solution (to treat and prevent spasms in the airway causing wheezing and shortness of breath) 108 micrograms (mg) 2 puffs every 6 hours orally, and Roxicodone (used to treat pain) 5 mg orally, 2 tablets every 4 hours. The section titled "Orders and Goals" revealed the patient received SN services twice a month for assessment. The goals included but were not limited to, " … Patient/caregiver will verbalize understanding of disease process and current status within (sic blank). Patient/caregiver will verbalize understanding of signs and symptoms to report to SN or physician within (sic blank). Patient/caregiver will verbalize understanding of medication regimen … within (sic blank). … Patient will have better coping behavior evidenced by verbalization and ability to maintain within (sic blank) … Patient will have improved pain status as evidenced by decrease in pain level within (sic blank) … Patient will transfer/ambulate and use assistive devices safely within as evidence by lack of falls and/or other problems and verbalization of increased stability with ambulation within (sic blank) … Patient/caregiver will demonstrate compliance with pain medications as prescribed by doctor within (sic blank) … Patient will demonstrate effective pain control measures within (sic blank) … Patient/caregiver will comply with prescribed medications within (sic blank) … Patient/Caregiver will verbalize understanding of pain control measures within (sic blank) … Patient/Caregiver will verbalize understanding of medication regimen … within (sic blank) … Patient/Caregiver will verbalize understanding of medication safety techniques within (sic blank) … Patient/Caregiver will verbalize understanding of possible side effects of pain medication … within (sic blank) … Patient/Caregiver will understand non-medical pain relief measures within (sic blank) … Patient/Caregiver will verbalize understanding of Infection Control and precautions within (sic blank) … Patient/Caregiver will verbalize understanding of cardiac precautions within (sic blank) … Patient/Caregiver will verbalize understanding and will demonstrate proper use of assistive device within (sic blank) …". Patient #1's active clinical record evidenced a document titled "Medication Profile". The medication profile included but was not limited to: Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligrams (mg)/3 milliliters (ml)) every 6 hours orally as needed for wheezing; Methocarbamol 1000 mg 3 times a day orally for back pain and spasms; Proventil HFA Inhalation Aerosol Solution 108 micrograms (mg) 2 puffs every 6 hours orally for wheezing, and Roxicodone 5 mg orally, 2 tablets every 4 hours for moderate pain. A document titled "Progress Notes" for Patient #1 evidenced on 10/27/2025 the Administrator received a verbal order from the Nurse Practitioner, Person 7, to decrease the patient's HHA hours to 10 hours a week. Patient #1's POC failed to include the correct frequency and duration of services provided, measurable goals, and the reasons for taking the as needed medications. 3. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 09/08/2025 and a certification period from 11/07/2025 through 01/05/2026. The POC included the following diagnoses: Chronic Obstructive Pulmonary Disease, Chronic embolism and thrombosis in the deep veins of the lower extremities (a blot clot in the vein), and Congestive Heart Failure. Under the section "Medications" it included the following medications: Albuterol Inhalation Aerosol Solution 90 micrograms (mcg), 1 puff every 6 hours orally and Atarax (treat anxiety) 50 mg orally at bedtime. The section titled "Orders and Goals" evidenced the patient received SN services every 2 weeks for medication management and assessment and HHA services 7 days a week for 6 hours a day. The goals included but were not limited to, " … Patient will have improved pain status as evidenced by decrease in pain level within (sic blank) …Patient/Caregiver will demonstrate compliance with pain medications, as prescribed by doctor within (sic blank) … Patient's medical condition will remain stabilized within (sic blank) … Patient will demonstrate effective pain control measure within (sic blank) … Patient/caregiver will verbalize knowledge of the signs and symptoms of respiratory distress … within (sic blank) … Patient/Caregiver will verbalize understanding of oxygen use safety within (sic blank) … Patient/caregiver will be knowledgeable of care and safe use of respiratory equipment within (sic blank) … Patient/Caregiver will verbalize understanding of medication regimen … within (sic blank) … Patient/caregiver will verbalize knowledge of inhalation treatment via nebulizer … within (sic blank) … Patient/Caregiver will verbalize understanding of cardiac precautions within (sic blank) … Patient/Caregiver will verbalize understanding of Ambulation … within (sic blank) … Patient/Caregiver will be knowledgeable of s/sx (sic signs/symptoms) of angina (sic chest pain) … within (sic blank) … Patient will transfer/ambulate … within (sic blank) …" Patient #3's active clinical record evidenced a document titled "Medication Profile". The medication profile included but was not limited to: Albuterol Inhalation Aerosol Solution 90 mcg, 1 puff every 6 hours orally as needed for shortness of breath or wheezing and Atarax (treat anxiety) 50 mg orally at bedtime as needed for anxiety. Patient #3's POC failed to include the duration of services provided, measurable goals, and the reasons for taking the as needed medications. 4. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 10/01/2025 and an initial certification period from 10/01/2025 through 11/29/2025. The POC included the following diagnoses: Chronic Systolic and Diastolic Heart Failure (weakened heart causing the blood to not effectively circulate through the body and the chambers of the heart do not fill properly), Cardiac Pacemaker (a small batter-operated device delivers impulses to ensure the heart beats appropriately), Hypertensive Heart Disease (the heart muscle is weakened due to long term high blood pressure), Methicillin resistant Staphylococcus infection (a bacterial infection which is resistant to antibiotics), and Inguinal Hernia (the abdominal wall is weakened allowing organs or fat to push through into the groin area). Under the section titled "Medications" included but was not limited to the following: Albuterol Inhalation Aerosol Solution 90 mcg, 2 puffs orally and Melatonin (aides with sleep) 5 mg orally. The "Orders and Goals" section revealed the patient received SN services every 2 weeks for medication management and HHA services for 7 days a week and 8 hours a day for assistance with ADLs. The goals indicated but were not limited to, " … Patient/caregiver will comply with prescribed medications within (sic blank) … Caregiver will be knowledgeable about disease process and mobility problems by (sic blank) … Patient/caregiver will verbalize knowledge of the signs and symptoms of respiratory disease … within (sic blank) … Patient/Caregiver will verbalize understanding of oxygen use safety within (sic blank) … Patient/caregiver will be knowledgeable of care and safe use of respiratory equipment within (sic blank) … Patient/Caregiver will verbalize understanding of medication safety techniques within (sic blank) … Patient/caregiver will verbalize knowledge of inhalation treatment … within (sic blank) … Patient/caregiver will verbalize understanding of Infection Control and precautions within (sic blank) … Patient/Caregiver will verbalize understanding of Anticoagulation precautions within (sic blank) … Patient/Caregiver will verbalize understanding of Ambulation safety and fall precautions within (sic blank) … Patient/Caregiver will demonstrate and verbalize knowledge of proper administration of oxygen therapy within (sic blank) … Patient/caregiver will verbalize understanding about (sic blank) disease process … within (sic blank) … Patient/caregiver will be knowledgeable of (sic blank) disease process … within (sic blank) … Patient/Caregiver will be knowledgeable of medication administration … within (sic blank) …" Patient #4's active clinical record evidenced a document titled "Medication Profile". The medication profile included but was not limited to: Albuterol Inhalation Aerosol Solution 90 mcg, 2 puffs orally as needed for wheezing and shortness of breath and Melatonin 5 mg orally as needed at bedtime to aide if having difficulty sleeping. The POC failed to evidence the duration of SN and HHA services, the reasons for taking the as needed medications, and patient-centered and measurable goals. 5. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses but not limited to: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). Under the section "Medications" it indicated but was not limited to, " … Voltaren Arthritis Pain External Gel 1% (sic a pain medication applied on the skin) - Apply- oral- …" The "Orders and Goals" revealed the patient received SN services two times a month for assessment and medication management and HHA services seven days a week for six hours a day. The goals included " … Patient will transfer/ambulate and use assistive devices … within (sic blank) … Patient/Caregiver will demonstrate compliance with pain medications … within (sic blank) … Patient/Caregiver will comply with prescribed medications within (sic blank) … Instructions/Teaching Signs and symptoms of (sic blank) to observe and report to nurse or MD (sic Medical Doctor) … Patient/caregiver will verbalize understanding of signs and symptoms of (sic blank) to observe and report to nurse or MD … within (sic blank) … Patient/Caregiver will verbalize understanding of medication safety techniques within (sic blank) … Patient/Caregiver will verbalize understanding … with safety needs within (sic blank) … Patient/Caregiver will be knowledgeable about emergency information … within (sic blank) … Patient/Caregiver will verbalize understanding of Ambulation safety …within (sic blank) … Patient/Caregiver will verbalize understanding … demonstrate proper use of assistive device within (sic blank) …" Patient #6's active clinical record included a verbal order signed by the Administrator on 10/03/2025 indicated the Administrator received a verbal order to perform a SOC assessment for the patient. A review of Patient #6's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/06/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for recertification. The POC failed to include the correct SOC date and certification period, provide the right route for all medications, the duration of services, and individualized and measurable goals. 6. A review of Patient #7's active clinical record evidenced a POC with a SOC date of 07/01/2025 and a certification period from 10/29/2025 through 12/27/2025. The POC included the following diagnoses but was not limited to: Cerebral Infarction (heart attack), Hypertension, Type 2 Diabetes Mellitus, Blindness in both eyes, Hearing loss, and Dementia (a condition where the person's memory and thinking decline). The "Nutritional Requirement" indicated the patient required assistance with cooking and meal preparation. The section titled "Orders and Goals" revealed the patient received SN services every 2 weeks for assessment and medication set-up and HHA services 5 days a week for 7 hours a day. A review of a document titled "Progress Notes" evidenced on 07/18/2025 the Administrator spoke with Patient #7 and their relative, Person 1, and they refused HHA services at the time. Patient #7 only wanted SN services provided by the agency. During an interview with Patient #7 and Person 1 on 11/21/2025 at 11:55 AM, they explained the patient was not receiving HHA services from the agency at the time. The POC for Patient #7 failed to evidence patient-centered and measurable goals, the duration of SN services, the patient's diet, and reflected the patient not receiving HHA services. During an interview with the Administrator on 11/21/2025 at 3:30 PM, when queried regarding the HHA frequency on Patient #7's POC, they explained they wanted to keep the HHA frequency on the patient's POC for when the patient wanted the HHA services. The Administrator confirmed the patient was not receiving HHA services. 7. During an interview with the Administrator, the Case Manager for all active patients, on 11/24/2025 at 1:50 PM, they indicated they were unaware the POCs were missing duration for the services and forgot to include the dates for when goals were expected to be completed. They used the date they received the order for the SOC and the start of the certification period. The patient's diet should be listed on the POC. They thought the POC had included all the medication information from the comprehensive assessment, and confirmed the reason for the as needed medication and the correct route were not on the POC for Patients #1, #3, #4, #6, and #7. 410 IAC 17-13-1(a)(1)(D)(iii, viii, ix, 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 provided all services as ordered by the physician on the POC for 4 of 5 active clinical records reviewed. (Patients #3, #4, #6, and #7) Findings Include: 1. An undated agency policy titled "Care Planning" indicated but was not limited to, " … E. The admitting SN … will initiate the written Plan of Care at the start of care …" 2. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 09/08/2025 and a certification period from 11/07/2025 through 01/05/2026. The POC included the following diagnoses: Chronic Obstructive Pulmonary Disease, Chronic embolism and thrombosis in the deep veins of the lower extremities (a blot clot in the vein), and Congestive Heart Failure. The section titled "Orders and Goals" evidenced the patient received SN services every 2 weeks for medication set up and assessment and HHA services 7 days a week for 6 hours a day. A review of Patient #3's active clinical record evidenced an "OASIS Assessment" dated 11/03/2025 by the Administrator, the patient's case manager, for the patient's recertification. The document revealed the patient was hospitalized on 09/15/2025 at Entity 10 (a hospital), went to a rehabilitation facility, and returned home from the rehabilitation facility on 10/31/2025. Patient #3's active clinical record failed to evidence HHA visit notes for the following weeks: The week of 11/02/2025 through 11/08/2025 failed to evidence HHA visit notes on 11/02, 11/03, 11/04, 11/06, 11/07, and 11/08/2025. The week of 11/09/2025 through 11/15/2025 failed to evidence HHA visit notes on 11/09, 11/10, 11/13, 11/14, and 11/15/2025. The week of 11/16/2025 through 11/22/2025 failed to evidence HHA visit notes on 11/16, 11/17, 11/20, 11/21, and 11/22/2025. During an interview with HHA 6 on 11/24/2025 at 1:08 PM, they explained they only worked for Patient #3 and the agency two days a week. During an interview with the Administrator, the patient's case manager, on 11/24/2025 at 1:50 PM, they indicated they had not received orders to change the HHA frequency ordered on the POC. 3. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 10/01/2025 and an initial certification period from 10/01/2025 through 11/29/2025 evidenced the following diagnoses but was not limited to: Chronic Systolic and Diastolic Heart Failure (weakened heart causing the blood to not effectively circulate through the body and the chambers of the heart do not fill properly), Cardiac Pacemaker (a small batter-operated device delivers impulses to ensure the heart beats appropriately), Hypertensive Heart Disease (the heart muscle is weakened due to long term high blood pressure), Methicillin resistant Staphylococcus infection (a bacterial infection which is resistant to antibiotics), and Inguinal Hernia (the abdominal wall is weakened allowing organs or fat to push through into the groin area). The "Orders and Goals" section revealed the patient received SN services every 2 weeks for medication management and HHA services for 7 days a week and 8 hours a day for assistance with ADLs. A review of Patient #4's active clinical record evidenced a verbal order signed by the Administrator, the patient's case manager, on 09/29/2025 to perform a SOC assessment for the patient. A review of Patient #4's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/01/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for the SOC. A review of the active clinical record for Patient #4 evidenced the next SN visit was conducted on 10/29/2025 by the Administrator. Patient #4's active clinical record evidenced the first HHA visit was conducted on 11/04/2025 by HHA 4. The clinical record for Patient #4 failed to evidence HHA visit notes the weeks of 10/01/2025 through 10/04/2025, 10/05/2025 through 10/11/2025, 10/12/2025 through 10/18/2025, 10/19/2025 through 10/25/2025, and 10/26/2025 through 11/01/2025. Patient #4's clinical record failed to evidence a SN visit note the week of 10/12/2025 through 10/18/2025. The active clinical record for Patient #4 failed to evidence the patient received services as ordered on the POC. 4. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses but not limited to: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). The "Orders and Goals" revealed the patient received SN services two times a month for assessment and medication management and HHA services seven days a week for six hours a day. A review of Patient #6's active clinical record included a verbal order signed by the Administrator, the patient's case manager on 10/03/2025 to perform a SOC assessment for the patient. A review of Patient #6's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/06/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for recertification. A review of the active clinical record for Patient #6 revealed the next SN visit was conducted on 10/29/2025 by the Administrator. Patient #6's active clinical record evidenced the first HHA visit was conducted on 10/29/2025 by HHA 1. The clinical record for Patient #6 failed to evidence a SN visit note the week of 10/19/2025 through 10/25/2025. The clinical record for Patient #6 failed to evidence HHA visit notes the weeks of 10/01/2025 through 10/04/2025, 10/05/2025 through 10/11/2025, 10/12/2025 through 10/18/2025, and 10/19/2025 through 10/25/2025. The active clinical record for Patient #6 failed to evidence the patient received services as ordered on the POC. 5. During an interview on 11/24/2025 at 9:13 AM, when queried about the POC documentation, the Administrator, who is also the patients' case manager, they explained how they sent the POC to the provider and had to wait for insurance to approve the frequency of services. The Administrator indicated there were no orders to hold services until insurance approved the SN frequency for Patients #3, #4, #6, and #7. 410 IAC 17-13-1(a)

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 all verbal orders received were signed by the physician for 5 of 5 active clinical records reviewed (Patients #1, #3, #4, #6, and #7) and 2 of 3 inactive clinical records reviewed. (Patients #6 and #9) Findings Include: 1. An undated agency policy titled "Care Planning" indicated but was not limited to, " … O. Clinicians will inform the patient's physician of any changes … Changes will be written, dated and signed by the qualified clinician and physician making the changes …" 2. A document titled "Progress Notes" for Patient #1 evidenced on 10/27/2025 the Administrator, the patient's case manager, received a verbal order from the Nurse Practitioner (NP), Person 7, to decrease the patient's HHA hours to 10 hours a week. The clinical record failed to evidence Person 7's signature for the order. 3. A review of Patient #3's active clinical record evidenced a verbal order signed by the Administrator, the patient's case manager, on 09/04/2025 indicated the Administrator received a verbal order to perform a SOC assessment for the patient after the patient was released from the hospital on 09/05/2025. The order failed to evidence Person 9's (the patient's physician) signature with the date and from whom they received the order. A review of Patient #3's active clinical record evidenced an "OASIS Assessment" dated 11/03/2025 by the Administrator for the patient's recertification. The document revealed the patient was hospitalized on 09/15/2025 at Entity 10 (a hospital), went to a rehabilitation facility, and returned home from the rehabilitation facility on 10/31/2025. Patient #3's active clinical record failed to evidence orders to hold services when the patient was admitted to the hospital and orders to resume services after the patient was home from the rehabilitation facility. 4. Patient #4's active clinical record included a verbal order signed by the Administrator on 09/29/2025 indicated the Administrator, the patient's case manager, received a verbal order to perform a SOC assessment for the patient. The order failed to evidence Person 11, the patient's Nurse Practitioner, signature and date and from whom the Administrator received the order. A review of Patient #4's active clinical record evidenced a document titled "Progress Notes" revealed the Administrator received verbal orders on 10/17/2025 to change the HHA hours to 5 hours a day, 2 days a week. The note failed to evidence Person 11's signature and from whom they received the order. 5. A review of Patient #6's active clinical record evidenced a verbal order signed by the Administrator, the patient's case manager, on 10/03/2025 indicated the Administrator received a verbal order to perform a SOC assessment for the patient. The order failed to evidence Person 2's (Patient #6's physician) signature and who they had received the order. A review of Patient #6's active clinical record evidenced a document titled "Progress Notes" revealed the Administrator received verbal orders on 10/23/2025 from Person 2 to change the HHA services to two days a week and five hours a day. The order failed to evidence Person 2's signature. 4. A review of Patient #6's inactive clinical record evidenced a SOC OASIS Assessment dated 05/02/2025. A discharge summary was completed on 08/29/2025 by the Administrator, the patient's case manager, the patient wanted to discontinue services until they started with their new insurance. The summary evidenced it was faxed to Patient #6's physician. Patient #6's inactive clinical record failed to evidence discharge orders signed by the patients physician, Person 2. 5. A review of Patient #7's active clinical record evidenced a verbal order signed by the Administrator, the patient's case manager, on 06/30/2025 indicated they received a verbal order to perform a RN assessment. The order failed to evidence the patient's physician's (Person 8) signature and date and from whom they received the order. 5. A review of Patient #9's inactive clinical record evidenced a POC with a SOC date of 10/22/2024 and an initial certification period from 10/22/2024 through 12/20/2024. The POC evidenced the following diagnoses: Hypertension, Hypertensive Heart disease with Heart Failure (a disease where high blood pressure caused damage to the heart making the heart weak and not able to effectively pump), and Hyperlipidemia (high levels of fat in the blood). A document titled "Progress Note" evidenced Person 6, Patient #9's relative, had informed the Administrator, the patient's case manager, on 12/03/2024 of the patient being hospitalized. The clinical record evidenced a discharge summary was completed on 12/20/2024 by the Administrator following Patient #9's admission to Entity 4, a hospital, and hospice services were initiated. The summary evidenced it was faxed to Patient #9's physician on 12/20/2024. Patient #9's inactive clinical record failed to evidence orders for the services to be placed on hold while the patient was in the hospital and discharge orders signed by the patients physician, Person 5. 6. During an interview with the Administrator on 11/24/2025 at 1:50 PM, they indicated they had were unaware they needed to receive and have the physician sign discharge orders for the patient. They explained they were unaware they needed to receive the physician's signature for all verbal orders, receive orders to hold services, and orders to resume services. 410 IAC 17-14-1(H)

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 the physician was notified of a patient's change in condition for 1 of 1 active records reviewed (Patient #3) and 1 of 1 inactive clinical records (Patient #9) for patients requiring a hospitalization. Findings Include: 1. An undated agency policy titled "Care Planning" indicated but was not limited to, " … T. Agency personnel shall promptly notify a patient's physician … of any significant changes observed or reported in the patient's condition …" 2. A review of Patient #3's active clinical record evidenced an "OASIS Assessment" dated 11/03/2025 by the Administrator for the patient's recertification. The document revealed the patient was hospitalized on 09/15/2025, went to rehab, and returned home on 10/31/2025. Patient #3's active clinical record failed to evidence communication notes informing the physician, Person 9, of the patient's hospitalization. 3. A review of Patient #9's inactive clinical record evidenced a POC with a SOC date of 10/22/2024 and an initial certification period from 10/22/2024 through 12/20/2024. The POC evidenced the following diagnoses: Hypertension, Hypertensive Heart disease with Heart Failure (a disease where high blood pressure caused damage to the heart making the heart weak and not able to effectively pump), and Hyperlipidemia (high levels of fat in the blood). A document titled "Progress Note" evidenced Person 6, Patient #9's relative, had informed the Administrator on 12/03/2024 of the patient being hospitalized. A discharge summary was completed on 12/20/2024 by the Administrator for Patient #9 admission to Entity 4, a hospital, and hospice services were initiated. The summary evidenced it was faxed to Patient #9's physician. Patient #9's record failed to evidence Person 5, the patient's physician, was notified of the patient's hospitalization in a timely manner. 4. During an interview with the Administrator on 11/24/2025 at 1:50 PM, they indicated they had not notified the physician of Patient #9's hospitalization until they sent the discharge summary. They explained they had not informed the physician of Patient #3's hospitalization. 410 IAC 17-13-1(a)(2)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medications listed on the medication profile and the POC evidenced the correct route for all medications for 1 of 3 medication profiles reviewed during a home visit. (Patient #6) Findings Include: 1. An undated agency policy titled "Care Planning" indicated but was not limited to, " … H. The plan of care … shall include … Medications: dose/frequency/route …" 2. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). Under the section "Medications" it indicated but was not limited to, " … Voltaren Arthritis Pain External Gel 1% (sic a pain medication applied on the skin) - Apply- oral- …". Patient #6's document titled "Medication Profile evidenced but was not limited to, " … Voltaren Arthritis Pain External Gel 1% (sic a pain medication applied on the skin) - Apply- oral- …". The POC and the medication profile failed to include the correct route of administering Patient #6's medications. During an interview with the Administrator, the Case Manager for the patient, on 11/24/2025 at 1:50 PM, they explained the POC and the medication profile had not included the correct route of the patient's medication and said it should be applied topically (applied to the skin).

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure infection control practices for hand hygiene were utilized for 2 of 2 home visits with HHAs (HHA 1 and 3) providing care and 1 of 1 RN (Administrator) performing an assessment and medication set-up. Findings Include: 1. An undated agency policy titled "Hand Washing" indicated but was not limited to, " … Indications for hand washing and antisepsis … C. Decontaminate hands before having direct contact with patients … F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) … I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves … Q. Before and after gloves are used R. Before, during, and after preparing food … 2. Hand-hygiene technique per CDC (sic Center for Disease Control) … B. … Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet …" 2. During an observation on 11/21/2025 at 9:30 AM, HHA 3 was observed providing care for Patient #1. HHA 3 prepared the patient cereal, washed their hands, and turned the faucet off with their clean hands. During an interview with HHA 3 on 11/21/2025 at 9:40 AM, they explained they needed to wash their hands anytime they touched the patient. They indicated they did not wear gloves when providing personal care because the washcloth became slippery. HHA 3 explained anything they do with the patient would be considered dirty and require hand hygiene. 3. During an observation on 11/21/2025 at 11:00 AM, HHA 1 was observed providing care for Patient #6. They donned gloves without performing hand hygiene and applied lotion to the patient's legs. HHA 1 doffed their used gloves and failed to provide hand hygiene before laying the blanket back on the patient. The HHA donned gloves without performing hand hygiene and applied lotion to the patient's hands, doffed their gloves, performed hand hygiene, and turned the faucet off with their clean hands. During an interview with HHA 1 on 11/21/2025 at 11:20 PM, they explained they were to wash their hands after providing care for the patient. HHA 1 indicated gloves were to be worn when providing care for the patient. When asked what was considered dirty, they stated, "this kitchen". 4. During an observation on 11/21/2025 at 11:55 AM, the Administrator was performing an assessment and medication set-up for Patient #7. The Administrator took the patient's vital signs and set the equipment on a clean barrier. The Administrator proceeded to use disinfecting wipes to wipe their gloves used when they took the patient's vital signs. The Administrator used a disinfectant wipe to clean their temporal thermometer, automatic blood pressure monitor, pulse oximeter, blood pressure cuff, and stethoscope. After cleaning each piece of equipment, the Administrator placed the items back in their bag without allowing time to dry. With gloves, grabbed the patient's medication bottles, retrieved their cellular phone from their bag, and used a disinfectant wipe to clean their gloves. The Administrator was observed placing the patient's Metoprolol (used to treat high blood pressure) into the medication cap and using their gloved finger, took the individual medication out of the cap and into the medication planner. The Administrator proceeded to use the same technique to place the medications in the planner for Lisinopril (treat high blood pressure and heart failure), Amlodipine (works to relax and widen the blood vessels, causing the blood pressure to lower), and Metformin (treat to lower blood sugar). They used the same gloves used to place the medications in the planner, picked up their phone to call the pharmacy to ensure the patient had a refill on their medication. After getting off of the phone, they wiped their gloves with the disinfectant wipes, put the wipes away, and doffed their gloves. During an interview with the Administrator on 11/21/2025 at 2:45 PM, they explained hand hygiene was to be performed prior to making contact with the patient. Hand hygiene was to be performed after gloving and could be done before gloving as well. Hands were considered unclean when there was visible dirt. If there is no visible dirt, no gloves are required, only hand washing needs to be completed. The HHAs should be either wearing gloves or performing hand hygiene after they provide care. They explained they thought they disinfectant wipes dry time was five seconds and found it was to be one minute. They confirmed they had not let the equipment dry for one minute. They thought their gloves were clean if they used the disinfectant wipe on them, and were unaware they could not do that anymore. 410 IAC 17-12-1(m)

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHAs provided care within their scope of practice for 4 of 4 active clinical records reviewed with patients receiving HHA and SN services. (Patients #1, #3, #4, and #6) Findings Include: 1. A review of Patient #1's clinical record evidenced a POC with a SOC date of 05/01/2025 and a certification period from 10/28/2025 through 12/26/2025. The POC included the following diagnoses but was not limited to: Osteoarthritis (a condition where the cartilage between the joints breakdown and cause friction between the joints), Polyneuropathy (numbness and weakness in multiple areas of the body caused by malfunctioning nerves), Chronic Obstructive Pulmonary Disease (a condition which causes difficulty in breathing and shortness of breath), Type 2 Diabetes Mellitus (a disease where the body is unable to appropriately use insulin), and Congestive Heart Failure (the heart muscle is damaged causing it to be weakened and causing the fluid to buildup in the body due to decrease blood flow). The section titled "Orders and Goals" revealed the patient received SN services twice a month for assessment and medication set-up and HHA services 7 days a week 6 hours a day Monday through Friday and 5 hours a day Saturday and Sunday. A document titled "Progress Notes" for Patient #1 evidenced on 10/27/2025 the Administrator received a verbal order from the Nurse Practitioner, Person 7, to decrease the patient's HHA hours to 10 hours a week. The document titled "Aide Plan of Care" with an effective date of 08/29/2025 and 10/24/2025 evidenced Patient #1 received HHA services 7 days a week, 6 hours a day Monday through Friday, and 5 hours a day Saturday and Sunday. The Aide POC revealed the HHA was to transport the patient to doctor's appointments, errands, and shopping. The Aide visit notes dated 09/28, 09/29, 09/30, 10/02, 10/03, 10/04, 10/05, 10/06, 10/07, 10/08, 10/09, 10/10, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16, 10/17, 10/18, 10/19, 10/20, 10/21, 10/22, 10/23, 10/24, 10/25, 10/26, 10/27, 10/28, 10/29, 11/04, 11/06, 11/11, 11/13, 11/18, and 11/20/2025 evidenced HHA 3 indicated they had "completed" the tasks of transporting Patient #6 to the doctor's office, errands, and shopping. The HHA failed to perform tasks within their scope of practice. During an interview with HHA 3 on 11/21/2025 at 9:30 AM, they indicated they drove the patient to the store, to see the patient's family, and to the doctor's office to get their blood sugar checked. 2. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 09/08/2025 and a certification period from 11/07/2025 through 01/05/2026. The POC included the following diagnoses but was not limited to: Chronic Obstructive Pulmonary Disease, Chronic embolism and thrombosis in the deep veins of the lower extremities (a blot clot in the vein), and Congestive Heart Failure. The section titled "Orders and Goals" evidenced the patient received SN services every 2 weeks for medication set up and assessment and HHA services 7 days a week for 6 hours a day for assistance with ADLs and personal care. The Aide visit notes dated 11/04/2025 and 11/05/2025 evidenced HHA 6 indicated they had "completed" the tasks of transporting the patient to their doctor's appointment and shopping. The Aide visit note dated 11/12/2025 evidenced HHA 6 indicated they had "completed" the tasks of transporting the patient to their doctor's appointment, errands, and shopping. The HHA failed to perform tasks within their scope of practice. During an interview with HHA 6 on 11/24/2025 at 1:08 PM, they explained Patient #3 had things delivered to their house. Further indicated as needed they would go to the grocery store, run errands, and take the laundry to the laundry mat. The patient remained at home with a relative while they were away. 3. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 10/01/2025 and an initial certification period from 10/01/2025 through 11/29/2025. The POC included the following diagnoses but was not limited to: Chronic Systolic and Diastolic Heart Failure (weakened heart causing the blood to not effectively circulate through the body and the chambers of the heart do not fill properly), Cardiac Pacemaker (a small batter-operated device delivers impulses to ensure the heart beats appropriately), Hypertensive Heart Disease (the heart muscle is weakened due to long term high blood pressure), Methicillin resistant Staphylococcus infection (a bacterial infection which is resistant to antibiotics), and Inguinal Hernia (the abdominal wall is weakened allowing organs or fat to push through into the groin area). The "Orders and Goals" section revealed the patient received SN services every 2 weeks for medication management and HHA services for 7 days a week and 8 hours a day for assistance with ADLs. The document titled "Aide Plan of Care" with an effective date of 10/27/2025 evidenced Patient #4 received HHA services 5 hours a day, for 2 days a week for the certification period. The Aide POC revealed the HHA was to transport the patient to doctor's appointments, errands, and shopping. The Aide visit note dated 11/11/2025 evidenced HHA 4 to a doctor's appointment, shopping, and errands. The HHA failed to perform tasks within their scope of practice. On 11/24/2025 at 1:02 PM, an attempt to interview HHA 4 was made. HHA 4 indicated they were unavailable. 4. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). The "Orders and Goals" revealed the patient received SN services two times a month for assessment and medication management and HHA services seven days a week for six hours a day. The document titled "Aide Plan of Care" with an effective date of 10/03/2025 evidenced Patient #6 received HHA services 5 hours a day, for 2 days a week. The Aide POC revealed the HHA was to transport the patient to doctor's appointments, errands, and shopping. The Aide visit notes dated 10/29, 11/3, 11/10, 11/12, 11/17, and 11/19/2025 evidenced HHA 1 indicated they had "completed" the tasks of transporting Patient #6 to the doctor's office, errands, and shopping. The HHA failed to perform tasks within their scope of practice. During an interview with HHA 1 on 11/21/2025 at 11:00 AM, they explained if the patient had an appointment or wanted to go to the store during the visit, they would take Patient #6 where they needed to go. 4. During an interview with the Administrator on 11/21/2025 at 2:45 PM, they indicated HHAs were able to perform any task included on the Aide POC. They explained they were unaware HHAs were unable to transport patients. 410 IAC 17-14-1(h)(6)(9)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the administrator was available 24 hours a day, 7 days a week (see G0948), ensure patients' needs were assessed and provided to the patients (see G0966), and had 2 inactive skilled patients and 6 active skilled patients (see G0982). The cumulative effect of these systemic problems has resulted in the home health agency's inability to ensure provision of quality health care in a safe environment for the Condition of Participation 42 CFR 484.105 Organization and Administration of Services. 410 IAC 17-12-1(a)(1)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they were available 24 hours a day, 7 days a week to meet the patient's needs for 2 of 2 active clinical records reviewed who were not seen within 48 hours of the referral. (Patients #3 and #6) Findings Include: 1. An undated agency policy titled "Admission Criteria" indicated but was not limited to " … 8. Upon referral, the decision regarding acceptance of and initiation of services by licensed staff will be made within 48 hours, of the referral or within 48 hours of the patients return home or knowledge of return home or on the physicians ordered start of care date. …" 2. A review of Patient #3's active clinical record evidenced a verbal order signed by the Administrator on 09/04/2025 to perform a SOC assessment for the patient after the patient was released from the hospital on 09/05/2025. A review of Patient #3's active clinical record evidenced a document titled "OASIS Assessment" dated 09/08/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for the SOC. The clinical record failed to evidence the patient was seen within 48 hours of the referral. 3. A review of Patient #6's active clinical record evidenced a verbal order signed by the Administrator on 10/03/2025 to perform a SOC assessment for the patient. A review of Patient #6's active clinical record evidenced a document titled "OASIS (sic Outcome and Assessment Information Set) Assessment" dated 10/06/2025 and signed by the Administrator. The document revealed the reason for the completion of the assessment was for recertification. The clinical record failed to evidence the patient was seen within 48 hours of the referral. 4. During an interview with the Administrator on 11/24/2025 at 1:50 PM, they indicated the assessment having recertification on it was a misprint and the assessment on 10/06/2025 was a SOC assessment for Patient #6. When queried regarding why Patient #3 and #6 had not been seen within 48 hours of receiving the referral, they explained when they receive a referral on Friday, they do not see the patient until the next Monday and they only see patients over the weekend unless it was an emergency. They expressed they were off on the weekends. They explained the only orders they had were the ones included in the patient's records. 410 IAC 17-12-1(c)(1)

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure the patients were assessed and received services to meet their needs in 3 of 3 active clinical records reviewed who had an unauthorized decrease in HHA service frequency. (Patients #1, #4, and #6) Findings Include: 1. A review of Patient #1's clinical record evidenced a POC with a SOC date of 05/01/2025 and a certification period from 10/28/2025 through 12/26/2025. The POC included the following diagnoses: Osteoarthritis (a condition where the cartilage between the joints breakdown and cause friction between the joints), Polyneuropathy (numbness and weakness in multiple areas of the body caused by malfunctioning nerves), Chronic Obstructive Pulmonary Disease (a condition which causes difficulty in breathing and shortness of breath), Type 2 Diabetes Mellitus (a disease where the body is unable to appropriately use insulin), and Congestive Heart Failure (the heart muscle is damaged causing it to be weakened and causing the fluid to buildup in the body due to decrease blood flow). The section titled "Orders and Goals" revealed the patient received SN services twice a month for assessment and HHA services 7 days a week, 6 hours a day Monday through Friday, and 5 hours a day Saturday through Sunday for assistance with ADLs. A document titled "Progress Notes" for Patient #1 evidenced on 10/27/2025 the Administrator, the patient's case manager, received a verbal order from the Nurse Practitioner (NP), Person 7, to decrease the patient's HHA hours to 10 hours a week until the Medicaid survey was completed. 2. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 10/01/2025 and an initial certification period from 10/01/2025 through 11/29/2025. Chronic Systolic and Diastolic Heart Failure (weakened heart causing the blood to not effectively circulate through the body and the chambers of the heart do not fill properly), Cardiac Pacemaker (a small batter-operated device delivers impulses to ensure the heart beats appropriately), Hypertensive Heart Disease (the heart muscle is weakened due to long term high blood pressure), Methicillin resistant Staphylococcus infection (a bacterial infection which is resistant to antibiotics), and Inguinal Hernia (the abdominal wall is weakened allowing organs or fat to push through into the groin area). The "Orders and Goals" section revealed the patient received SN services every 2 weeks for medication management and HHA services for 7 days a week and 8 hours a day for assistance with ADLs. A review of Patient #4's active clinical record evidenced a document titled "Progress Notes" revealed the Administrator, the patient's case manager, received verbal orders on 10/17/2025 to change the HHA hours to 5 hours a day, 2 days a week until the Medicaid survey was completed. 3. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). Under the section "Medications" it indicated but was not limited to, " … Voltaren Arthritis Pain External Gel 1% (sic a pain medication applied on the skin) - Apply- oral- …" The "Orders and Goals" revealed the patient received SN services two times a month for assessment and medication management and HHA services seven days a week for six hours a day. A review of Patient #6's active clinical record evidenced a document titled "Progress Notes" revealed the Administrator, the patient's case manager, received verbal orders on 10/23/2025 from Person 2 to change the HHA services to two days a week and five hours a day until the Medicaid survey was completed. 4. During an interview with the Administrator on 11/20/2025 at 9:10 AM, they indicated they had to stop providing services as originally ordered as they were not being reimbursed for the hours. They explained the services were based on what the private insurance said the services the patients could receive. 5. During an interview with the Administrator on 11/24/2025 at 9:13 AM, they explained the original frequency was not covered by private insurance and they would not be paid for all visits completed unless they decreased the patient's HHA hours to the hours the private insurance approved.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure they provided SN services for 2 of 2 active clinical records (Patient #1 and #6) reviewed and 2 of 2 inactive clinical records (Patients #6 and #10). Findings Include: 1. A review of Patient #1's active clinical record evidenced a POC with a SOC date of 05/01/2025 and a certification period from 10/28/2025 through 12/26/2025. The POC included the following diagnoses: Osteoarthritis (a condition where the cartilage between the joints breakdown and cause friction between the joints), Polyneuropathy (numbness and weakness in multiple areas of the body caused by malfunctioning nerves), Chronic Obstructive Pulmonary Disease (a condition which causes difficulty in breathing and shortness of breath), Type 2 Diabetes Mellitus (a disease where the body is unable to appropriately use insulin), and Congestive Heart Failure (the heart muscle is damaged causing it to be weakened and causing the fluid to buildup in the body due to decrease blood flow). The section titled "Orders and Goals" revealed the patient received SN services twice a month for assessment. The POC failed to include the nurse provided medication set-up for the patient and how the nurse would assess the patient. During an interview with Patient #1 on 11/21/2025 at 9:30 AM, they explained the Administrator was their nurse who set-up their medication planner. 2. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 10/03/2025 and a certification period from 10/03/2025 through 12/01/2025. The POC included the following diagnoses: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). Under the section "Medications" it indicated but was not limited to, " … Voltaren Arthritis Pain External Gel 1% (sic a pain medication applied on the skin) - Apply- oral- …" The "Orders and Goals" revealed the patient received SN services two times a month for assessment and medication management and HHA services seven days a week for six hours a day. The POC failed to include what the medication management entailed. A review of Patient #6's inactive clinical record evidenced a POC with a SOC of 05/01/2025 and a recertification period from 06/30/2025 to 08/28/2025. The POC included the following diagnoses: Hypertension (high blood pressure), Rheumatoid Arthritis (inflammation in the joints causing swelling and pain), Mild cognitive impairment (declining memory), Insomnia (difficult time falling asleep or staying asleep), and Depression (loss of interest and causing sadness). The POC revealed the patient received SN services every 2 weeks for assessment. The POC included the patient's non-compliance with their medication regimen. The POC failed to evidence how the SN assessments would assist the patient with medication management. The SOC "OASIS" Assessment dated 05/02/2025 evidenced Patient #6 was not motivated to learn. 3. A review of Patient #10's inactive clinical record evidenced a POC with a SOC date of 10/22/2024 and an initial certification period from 10/22/2024 through 12/20/2024. The POC evidenced the following diagnoses: Hypertension, Type 2 Diabetes Mellitus (a disease where the body is not able to regulate insulin appropriately), and Hyperlipidemia. Patient #10 received SN weekly. The POC evidenced the patient had medication management performed by the Administrator, their case manager, but failed to evidence they had orders for medication set-up. 4. During the entrance conference with the Administrator on 11/20/2025 at 9:25 AM, they indicated they provided medication set-up for all of their active patients.

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 a transfer summary was completed and sent to the location the patients were admitted for 1 of 1 active clinical records (Patient #3) reviewed with a hospitalization and 1 of 1 inactive clinical records reviewed with a hospitalization. (Patient #9) Findings Include: 1. An undated agency policy titled "Discharge/Transfer from Service" indicated but was not limited to, " … 6. A completed discharge or transfer summary is sent to the primary care practitioner or other health care professional who will be responsible for providing care … within 2 business days of the patient's discharge or transfer. …" 2. A review of Patient #3's active clinical record evidenced an "OASIS Assessment" dated 11/03/2025 by the Administrator for the patient's recertification. The document revealed the patient was hospitalized on 09/15/2025, went to rehab, and returned home on 10/31/2025. Patient #3's clinical record failed to evidence a transfer summary was sent to Entity 10, a hospital, when the patient was admitted for shortness of breath. During an interview with the Administrator on 11/24/2025 at 1:50 PM, they indicated they were unsure of what a transfer summary was and were unaware they needed to send one to the entity taking over the care for Patient #3. 3. A document titled "Progress Note" evidenced Person 6, Patient #9's relative, had informed the Administrator on 12/03/2024 of the patient being hospitalized. A discharge summary was completed on 12/20/2024 by the Administrator, Patient #9 was admitted to Entity 4, an acute care hospital, and hospice services were initiated. The summary evidenced it was faxed to Patient #9's physician. The agency failed to complete and send a transfer summary to Entity 4 when Patient #9 was admitted into Entity 4. During an interview with the Administrator on 11/24/2025 at 1:50 PM, they indicated they had not sent a transfer summary to Entity 4, an acute care hospital, for Patient #9 and were unaware one had to be sent. 410 IAC 17-15-1(a)(7)