Every finding on record at Our Compassion Home Health Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 01/13/2026, 01/14/2026, 01/15/2026, and 01/16/2026 Active Census: 7 At this Emergency Preparedness survey, Our Compassion Home Health Care, LLC was found to be in compliance with Emergency Preparedness Requirements for Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 1/21/2026.

This visit was for an Initial Federal Medicaid survey for a Home Health provider. Survey Dates: 01/13/2026, 01/14/2026, 01/15/2026, and 01/16/2026 12 Month Unduplicated Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Our Compassion Home Health Care, LLC is precluded from providing its own home health aide training and competency evaluation program for a period of 2 years beginning 01/16/2026 through 01/15/2028 for being found out of compliance with the Conditions of Participation 42 CFR 484.60 Care Planning, coordination, quality of care. Abbreviations: HHA Home Health Aide SN Skilled Nursing RN Registered Nurse CM Clinical Manager POC Plan of Care SOC Start of care QR completed by Area 3 on 1/21/2026.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge notice was provided to notify the patient/patient’s representative of discharge, before services were discontinued for 3 of 3 inactive patients (Patients #2, 6, and 8) Findings include: 1. A review of an untitled policy stated, “When the patient’s POC changes and this change results in discharge or reduction of services, the patient, … primary medical provider will be notified and involved in planning decisions, including discharge from the Agency in accordance with federal and state regulation … a. The agency will, verbally and in writing, notify the patient of the decision to terminate/reduce services at least 5 days prior to the change in service … “ A review of ‘Patients’ Rights and Responsibilities’ stated, “Receive proper written notice … in advance of the Agency reducing or terminating on-going care …” 2. A review of the clinical record of Patient #2 contained a POC dated 12/17/2025 for the initial certification period of 12/17/2025 through 02/14/2026 indicated Patient #2 was to receive SN services 1 time a week for a medication set-up and HHA services 1 time a week for assistance with personal care and activities of daily living. The clinical record contained a SN visit note dated 12/22/2025, signed by the Administrator/CM on 12/22/2025 which indicated Patient #2 was going on a family vacation and therefore the next SN visit was scheduled for 01/05/2026, and Patient #2 was progressing slowly through goals, remained dependent on activities of daily living and Person 1, a family member had been unsure of medications and did not want the responsibility of the medications due to frequency and number of medications the patient was on. The clinical record contained a SN visit note dated 01/05/2026, signed by the Administrator/CM on 01/05/2026 which indicated Patient #2 was progressing well with their SN and HHA need goals and is comfortable discharging today, to remain dependent on activities of daily living but Person 1 is present and able to assist. A discharge physician’s verbal order and discharge summary was completed on 01/05/2026 by the Administrator/CM. The record failed to evidence a written notice was provided to the patient/caregiver. 3. A review of the clinical record of Patient #6 contained a POC dated 12/16/2025 and signed by the Administrator/CM indicated Patient #6 was to receive SN visits 1 time a week for diabetic oversight, education, check blood sugar, review blood sugar logs, left knee dressing/wound and complete medication refills. The clinical record evidenced a discharge verbal order and discharge summary was written on 12/30/2025 for Patient #6, which indicated progress towards meeting goals to be monitored at SN visits had been achieved along with Patient #6 able to move around to assist with activities of daily living adequately. A review of Patient #6 inactive clinical record failed to evidence a written notice was provided to the patient/caregiver. 4. A review of the clinical record of Patient #8 contained a POC dated 12/11/2025 and signed by the Administrator/CM indicated Patient #8 diagnoses were but not limited to Parkinson’s Disease (a progressive brain disorder which affects the nervous system), was to receive SN visits 1 time a week for monitor vital signs, to apply Vyalev (a wearable, portable pump that delivers levodopa-based medication [to treat Parkinson’s Disease] continuously under the skin for adults with advanced Parkinson’s disease, providing a steady 24/7 flow to smooth out "on" and "off" time) pump once a week, to teach caregiver how to change syringe every 24 hours and HHA visits 1 time a week for assistance with activities of daily living, medication reminders, and meal preparation. The clinical record evidenced a SN visit note dated 12/30/2025 which indicated Patient #8 was a partial assist and ambulated with a rollator walker and required someone to assist when ambulating, and Patient #8 had not received their new Parkinson’s medication which was to be administered via pump, Pharmacy/HHA was to provide training to Person 2, a family member. The record evidenced a physician’s verbal order and a discharge summary dated 01/07/2026 and signed by the Administrator/CM to discharge Patient #8. The record failed to evidence a written notice was provided to the patient/caregiver. 5. During the entrance conference on 01/13/2026 at 1:04 PM when queried of the discharge policy and procedure for discharge from care, the Administrator/CM indicated 3 days’ notice was provided. On 01/15/2026 at 3:35 PM, Patients #2, 6, and 8 were called, left voice messages with no return calls. During an interview on 01/16/2026 at 9:45AM when queried of the above findings, the Administrator/CM didn't think a notice would be required with the discharged patients.

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 comprehensive assessment was completed within 48 hours with 1 of 1 patient hospitalized. (Patient #3) Findings include: 1. A review of a policy titled, 'Assessments' dated 04/2025 stated, "... update of the comprehensive assessment will be performed ... within 48 hours of the patient's return home from a hospital admission of 24 hours or more ..." 2. A review of the clinical record of Patient #3 contained a skilled nursing note dated 01/09/2026 signed by the Administrator/CM indicated Patient #3 admitted to Entity 8, an acute care hospital, for pneumonia, sepsis, blood clots, and COVID, and had been in the hospital for 4 days. 3. On 01/16/2026 at 9:30 when queried of the above finding, the Administrator indicated they should have completed discharge assessment when Patient #3 was admitted to the hospital and completed a resumption assessment when they returned. 410 IAC 17-14-1(a)(1)(A)

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 within 48 hours (2 days) of discharge for 3 of 3 inactive clinical records reviewed. (Patients #2, 6, and 8) Findings include: 1. A review of a policy titled ‘OASIS’ dated 04/2025 stated, “… 5. Discharge … must be completed within 48 hours of discharge of a patient …” 2. A review of the clinical record of Patient #2 contained a POC dated 12/17/2025 for the initial certification period of 12/17/2025 through 02/14/2026 indicated Patient #2 was to receive SN services 1 time a week for a medication set-up and HHA services 1 time a week for assistance with personal care and activities of daily living. The clinical record contained a SN visit note dated 12/22/2025, signed by the Administrator/CM on 12/22/2025 which indicated Patient #2 was going on a family vacation and therefore the next SN visit was scheduled for 01/05/2026, and Patient #2 was progressing slowly through goals, remained dependent on activities of daily living and Person 1, a family member had been unsure of medications and did not want the responsibility of the medications due to frequency and number of medications the patient was on. The clinical record contained a SN visit note dated 01/05/2026, signed by the Administrator/CM on 01/05/2026 which indicated Patient #2 was progressing well with their SN and HHA need goals and was comfortable discharging today, to remain dependent on activities of daily living but Person 1 was present and able to assist. A discharge physician’s verbal order and discharge summary was completed on 01/05/2026 by the Administrator/CM. A review of the clinical record failed to evidence a discharged OASIS comprehensive assessment was completed within 2 days of Patient #2 discharge on 01/05/2026. 3. A review of the clinical record of Patient #6 contained a POC dated 12/16/2025 and signed by the Administrator/CM indicated Patient #6 was to receive SN visits 1 time a week for diabetic oversight, education, check blood sugars, review blood sugar logs, left knee dressing/wound and complete medication refills. The clinical record evidenced a discharge verbal order and discharge summary was written on 12/30/2025 for Patient #6, which indicated progress towards meeting goals to be monitored at SN visits had been achieved along with Patient #6 able to move around to assist with activities of daily living adequately. A review of the clinical record failed to evidence a discharge OASIS comprehensive assessment was completed within 2 days of Patient #6 discharge on 12/30/2025. 4. A review of the clinical record of Patient #8 contained a POC dated 12/11/2025 and signed by the Administrator/CM indicated Patient #8 diagnoses were but not limited to Parkinson’s Disease (a progressive brain disorder which affects the nervous system), was to receive SN visits 1 time a week for monitor vital signs, to apply Vyalev (a wearable, portable pump that delivers levodopa-based medication [to treat Parkinson’s Disease] continuously under the skin for adults with advanced Parkinson’s disease, providing a steady 24/7 flow to smooth out "on" and "off" time) pump once a week, to teach caregiver how to change syringe every 24 hours and HHA visits 1 time a week for assistance with activities of daily living, medication reminders, and meal preparation. The clinical record evidenced a SN visit note dated 12/30/2025 which indicated Patient #8 was a partial assist and ambulated with a rollator walker and required someone to assist when ambulating, and Patient #8 had not received their new Parkinson’s medication which was to be administered via pump, Pharmacy/HHA was to provide training to Person 2, a family member, with no mention of discharge. The record evidenced a physician’s verbal order and a discharge summary dated 01/07/2026 and signed by the Administrator/CM to discharge Patient #8. A review of the clinical record failed to evidence a discharge OASIS comprehensive assessment was completed within 2 days of Patient #8 discharge on 01/07/2026. 5. During an interview with the Administrator/CM on 01/15/2026 at 2:40 PM, indicated they knew discharge OASIS comprehensive assessments had to be completed with each discharge but failed to do them as they didn’t want to transmit them as they had not sent the OASIS on admission. When queried how they conducted their admission assessments, they indicated there was a button to not transmit. When queried if there was a button to not transmit the discharge OASIS, they indicated they were not sure. 410 IAC 17-12-2(i) 410 IAC 17-15-1(a)(6)

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, failed to ensure orders were obtained to conduct SN medication set-up, injections, and HHA services (see G0572), failed to ensure all elements were included in the POC (see G0574), failed to ensure care coordination with other Agency (see G0608) The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.60, Care Planning, Coordination of Care, and Quality of Care, with the potential to affect all 7 current patients receiving Home Health services from this provider. Findings include: 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure orders were obtained to conduct SN medication set-up, injections, and HHA services with 6 of 7 active clinical record reviewed. (Patients #1, 3, 4, 5, 7, and 9) Findings include: 1. A review of a policy titled, ‘Plan of Care’ dated 04/2025 stated, “… when the POC cannot be completed until after an assessment visit, the medial provider's verbal orders will be documented and will constitute the POC until the 485 is completed, signed by the medical provider, and returned to the agency ..." 2. A review of the clinical record of Patient #1 contained a POC signed by the Administrator/CM on 12/15/2025 for the initial certification period of 12/15/2025 through 02/12/2026, Patient #1 was to receive SN services 1 time a week for medication set-up and blood sugar monitoring; HHA services to assist with personal care, meal preparation, light housekeeping and medication reminders; signed by Person 3, the ordering provider on 12/17/2025. Further review of the clinical record evidenced a SN visit note completed on the day of the initial assessment completed by the Administrator and signed on 12/15/2025 indicated interventions a medication set-up would occur weekly by the SN. The SN visit note evidenced a blood sugar was obtained but failed to evidence a medication set-up was provided. The record failed to evidence a verbal order for the SN visit on 12/15/2025. 3. A review of the clinical record of Patient #3 contained a POC signed by the Administrator/CM on 12/16/2025 for the initial certification period of 12/16/2025 through 02/13/2026, Patient #3 was to receive SN services 1 time a week for medication set-up and to apply Libre sensor (a continuous glucose monitoring device for diabetes management, applied to the upper arm, and continuously sends blood sugar results to a smartphone) and HHA services to assist with personal care, meal preparation, and light housekeeping; signed by Person 4, the ordering provider on 12/18/2025. Further review of the clinical record evidenced a SN visit note on 12/16/2025 which evidenced a medication set-up was provided and Libre sensor was applied. The record failed to evidence verbal orders for the SN visit on 12/16/2025. 4. A review of the clinical record of Patient #4 contained a POC signed by the Administrator/CM on 12/23/2025 for the initial certification period of 12/23/2025 through 02/20/2026, Patient #4 was to receive SN services 1 time every 30 days to change a gastrostomy tube (a g-tube, a feeding tube which is inserted through a small opening through the abdomen directly into the stomach, used to deliver nutrition, fluids, and medicine when a person can't eat or drink enough orally, often due to swallowing problems or inadequate calorie intake) and HHA services to provide personal care and light housekeeping; signed by Person 5, the ordering provider on 12/26/2025. 4. A review of the clinical record of Patient #5 contained a POC signed by the Administrator/CM on 12/17/2025 for the initial certification period of 12/17/2025 through 02/14/2026 indicated Patient #5 was to receive SN services 1 time a week for medication set-up and to apply the Dexcom sensor every 2 weeks and HHA services 1 time a week and was signed by Person 5, the ordering provider on 01/07/2026. Further review of the clinical record evidenced the following SN visit notes: on 12/17/2025 signed by the Administrator/CM which evidenced a medication set-up was provided and Dexcom sensor was applied, on 12/23/2025 signed by the Administrator/CM evidenced a medication set-up was provided and Dexcom sensor was applied, and on 01/06/2026 signed by the Administrator/CM which evidenced a medication set-up was provided and Dexcom sensor was applied. The clinical record of Patient #5 evidenced the following HHA visit notes: on 12/20/2025 signed by HHA 1 indicated but not limited to personal care, bed linen change, and meal preparation was provided; on 12/23/2025 HHA 1 indicated but not limited to personal care, bed linen change, and meal preparation was provided; and on 01/06/2026 HHA 1 indicated but not limited to personal care, bed linen change, and meal preparation was provided. The record failed to evidence verbal orders for the SN and HHA visits conducted on 12/17/2025, 12/23/2025, and 01/06/2026. 5. A review of the clinical record of Patient #7 contained a POC signed by the Administrator/CM on 12/11/2025 for the initial certification period of 12/11/2025 through 02/08/2026 indicated Patient #7 was to receive SN services 1 time a week for a medication set-up and HHA services 1 time a week to provide personal care, meal preparation, and light housekeeping; and was signed by Person 6, the ordering provider on 12/31/2025. Further review of the clinical record contained the following SN visit notes: on 12/18/2025 which evidenced a medication set-up was provided, on 12/22/205 which evidenced a medication set-up was provided, and on 12/30/2025 which evidenced a medication set-up was provided. The record failed to evidence verbal orders for the SN visits conducted on 12/18/2025, 12/22/2025, and 12/30/2025. 6. A review of the clinical record of Patient #9 contained a POC signed by the Administrator/CM on 12/11/2025 for the initial certification period of 12/11/2025 through 02/08/2025 indicated medications were but not limited to Ozempic (a prescription injectable medication for adults with type 2 diabetes, used with diet and exercise to improve blood sugar control, reduce cardiovascular risks (heart attack, stroke), and lower kidney disease progression) 2 milligram/dose subcutaneous Solution Pen-injector 8 milligrams/3 milliliters, to give 0.5 mg subcutaneous 1 time a week for Diabetes (a chronic condition where the body has trouble regulating blood sugar because the pancreas doesn't produce enough insulin or the body can't use insulin effectively Patient #9 was to receive SN services 1 time a week for Ozempic injections and was signed by Person 7, the ordering physician on 01/09/2026. Further review of the clinical record contained the following SN visit notes signed by the Administrator/CM: on 12/17/2025 which evidenced the Ozempic injection was provided, on 12/23/2025 which evidenced the Ozempic injection was provided, 12/30/2025 which evidenced the Ozempic injection was provided, and on 01/06/2026 which evidenced the Ozempic injection was provided. The record failed to evidence verbal orders for the SN visits conducted on 12/17/2025, 12/23/2025, 12/30/2025, and 01/06/2026. 7. On 01/15/2026 at 2:46 PM, when queried of the above findings the Administrator/CM indicated they had not realized the initial assessment verbal order from the ordering providers would not be considered an order to treat. 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 all elements were included in the POC with 4 of 7 active patient clinical records reviewed. (Patients #1, 3, 4, and 10) Findings include: 1. A review of a policy titled, ‘Plan of Care’ dated 04/2025 stated, “… must contain the following: … (3) services to be provided (4) The frequency and duration of visits … h. Required to include … the types of services, supplies … nutritional requirements … safety measures to protect against injury … any additional interventions …” 2. A review of the clinical record of Patient #1 contained a comprehensive assessment dated 12/15/2025 for the initial certification period of 12/15/2025 through 02/12/2026 signed by the Administrator/CM indicated Patient #1 received Boost Health Shakes three times a day due to limited food intake. A review of the clinical record of Patient #1 contained a POC dated 12/15/2025 for the initial certification period of 12/15/2025 through 02/12/2026 indicted Patient #1 received a regular diet and was to receive assistance with personal care, meal preparation, light housekeeping and medication reminders. The record failed to provide evidence of the type of service which was to provide personal care, meal preparation, light housekeeping and medication reminders, and failed to identify Boost Health Shakes as a nutritional requirement on the POC. 3. A review of the clinical record of Patient #3 contained a POC signed and dated 12/16/2025 by the Administrator/CM indicated Patient #3 had seizure and aspiration precautions. The record failed to evidence the specific seizure and aspiration safety measures on the POC. 4. A review of the clinical record of Patient #4 contained a POC signed and dated 12/23/2025 by the Administrator/CM indicated the following diagnoses but not limited to Conversion Disorder with seizures/convulsions (involves seizure-like episodes like jerking, limb shaking, altered consciousness which are triggered by psychological distress and are a real physical manifestation of mental conflict, often following trauma, requiring therapy to address underlying issues and manage symptoms)and Spastic Quadriplegia Cerebral Palsy (the most severe form of CP, characterized by severe muscle stiffness affecting all four limbs, the trunk, and often the face, usually preventing independent walking and causing developmental delays and potential intellectual, speech, vision, or hearing issues), had aspiration and seizure precautions; discharge plans: when patient returns to independent level of care. The record failed to include specific seizure and aspiration safety measures nor accurate discharge plans on the POC. 5. A review of the clinical record of Patient #10 contained a comprehensive assessment dated 12/08/2025 for the initial certification period of 12/08/2025 through 02/05/2026, signed by the Administrator/CM, indicated Patient #10 utilized a brace to lower left extremity. A review of the clinical record of Patient #10 contained a POC for the initial certification period of 12/08/2025 through 02/05/2026 signed and dated 12/08/2025 by the Administrator/CM indicated the following durable medical equipment: CPAP, rollator, rolling walker, and oxygen. The record failed to include the brace to lower left extremity as durable medical equipment. 5. On 01/16/2026 at 9:15 AM, when queried of the above findings, the Administrator indicated they had not realized the items were missing or the specific seizure and aspiration precautions were required and was not sure how often or if Patient #10 wore their brace on the left lower extremity, and was not sure how to write discharge plans for patients who weren’t going to be independent. 410 IAC 17-13-1(a)(1)(D)(i-xiii)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure care coordination with 1 of 1 patient who received services from a personal service company. (Patient #3) Findings include: 1. A review of a policy titled ‘Coordination of Care/Patient Education’ dated 04/2025 stated, “… integrate service whether the services are provided direct or by contract … validation of these activities are: clinical record documentation, progress note documentation case conference minutes …” 2.A review of the clinical record of Patient #3 contained an initial comprehensive assessment dated 12/16/2025 for the initial certification period of 12/16/2025 through 02/13/2026 indicated Patient #3 received services from a personal service agency but did not indicate what agency or how many hours Patient #3 received. The record failed to contain documentation of coordination notes with a personal service agency. 3. On 01/16/2026 at 9:30 AM, the Administrator indicated they were not sure which personal service agency was used and did not know how many hours Patient #3 received. 410 IAC 17-14-1(a)(1)(F)

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 2 of 2 HHA’s followed the accepted standards of practice for infection control. (HHA 1 and HHA 2) Findings include: 1. During a home observation visit on 01/14/2026 at 9:50 AM, HHA 1 had items set up prior to surveyor arrival. Notebook on counter. HHA 1 had taken Patient # 10 vital signs, without performing hand hygiene, reached into their bag to retrieve wipes to clean equipment, then washed hands at the kitchen sink. HHA 1 went into the bathroom to gather supplies for shower, turned on lights, gathered wash cloths, and towels. HHA 1 went to their nursing bag, reached in for the gait belt, created barriers on bathroom counter for wash cloths/towels, ended up placing towels on counter. They reached into their bag to retrieve gloves and assisted Patient #10 out of chair with the use of a gait belt, into extra bedroom looking for another towel for Patient #10 to use, HHA 1 moved shoes out of the Patient #10’s way to ambulate safely through the bedroom. HHA 1 assisted Patient #10 into the bathroom, donned a pair of gloves, assisted Patient #10 removing clothing, brief, and assisted to shower bench. HHA 1 doffed, then donned a clean pair of gloves, assisted Patient #10 with shower, then assisted with drying Patient #10. After drying, HHA 1 doffed gloves and donned a clean pair of gloves, then applied lotion and assisted with dressing Patient #10. Then assisted Patient #10 to the living room. During the home visit observation, HHA 1 failed to perform hand hygiene at the required intervals between glove changes and when they reached into their bag. 2. During a home observation visit on 01/15/2026 at 11 AM, HHA 2 began the visit by placing their bag on a chair, pulled out a barrier, placed the bag on the barrier, washed their hands at the kitchen sink, took supplies out of bag, placed on barrier, then Patient #1 indicated they had already showered before HHA 2 had arrived. HHA 2 donned a clean pair of gloves, took vital signs. HHA 2 reached into their bag for wipes to clean equipment. HHA 2 cleaned the blood pressure cuff, dropped the blood pressure container on the floor, HHA 2 picked it up and placed it on the chair, took thermometer out of their bag, took Patient #1 temperature, then cleaned the thermometer and left everything to air dry. HHA 2 doffed their gloves, assisted Patient #1 with their ROM exercises. When exercises completed, HHA 2 washed their hands at the kitchen sink and used bare hands to turn the water off. HHA 2 began putting equipment away, put blood pressure cuff into container and placed it in their bag. During the home visit observation, HHA 2 failed to create a barrier prior to placing their bag on the chair, failed to perform hand hygiene at the required intervals between glove changes and when they reached into their bag. 3. On 12/15/2026 at 11:35, when queried, HHA 2 indicated they should have used a paper towel to turn the water off and further indicated they had not realized they should clean the container that fell onto the floor, would now need to clean all items in the bag and the bag itself. 4. On 01/16/2026 at 9:45 AM, when the above home visit observations was discussed with the Administrator/CM, they indicated additional training would be required for hand hygiene and bag technique. 410 IAC 17-12-1(m)