Every finding on record at Pediatric Plus Home Healthcare Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 08/11/2025 - 08/14/2025 Active Census: 56 At this Emergency Preparedness survey, Pediatric Plus Home Healthcare Services LLC was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure policy and procedure was followed to maintain an updated and current log of patients with special needs during emergencies for 1 of 1 home health agency. Findings include: A review of a document titled, “Emergency Operations Plan,” revised on 01/01/2024, indicated but was not limited to: “The Clinical Supervisors are responsible for maintaining an updated and current log of patients with special needs. The log should be updated at least monthly and more frequently as necessary…” The Emergency Operations Plan failed to evidence a current log of patients with special needs during an emergency. During an interview on 08/14/2025 at 2:50 PM, the Alternate Administrator indicated there is no list or log of patients’ needs consolidated into the Emergency Operations Plan per the plan’s outline. He indicated the list needs to be incorporated into the plan.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to create and put into effect emergency preparedness policies and procedures based on the agency’s emergency preparedness plan and facility/community based all hazards assessment conducted for 1 of 1 home health agency. Findings include: A review of a document titled, “Emergency Operations Plan,” revised on 01/01/2024, indicated but was not limited to: “For each emergency/disaster identified in the HHA’s Hazard Vulnerability Analysis, the following shall be defined: Mitigation activities that are designed to reduce the risk of and potential damage due to an emergency/disaster; preparedness activities that organize and mobilize essential resources; response strategies and actions to be activated during the emergency/disaster; recovery strategies/actions that help to restore systems that are critical to resuming normal operations of the HHA…...list the potential disasters and emergencies that are specific to each location. 1. Tornadoes 2. Flash Floods 3. Hail 4. Snow…” A review of a document titled “Emergency Management Hazard Vulnerability Analysis Worksheet for Pediatric Plus Home Healthcare Services, LLC,” updated 12/2024, indicated the agency’s top 4 identified disaster risks as: Tornado, Acts of Terrorism, Fire, and Ice Storm. A review of a policy titled “Hazard Vulnerability Analysis (HVA),” indicated but was not limited to: “…Information gleaned from the Hazard Vulnerability Analysis shall be used to develop the Emergency Operations Plan…” The documents failed to evidence the Emergency Operations Plan had been updated to include the most recent Hazard Vulnerability Analysis (HVA) data of the disasters most likely to affect the home health agency’s operations. It also failed to evidence policies and procedures had been created based on the results of the HVA. During an interview on 08/14/2025 at 2:50PM, the Alternate Administrator indicated the Hazard Vulnerability Analysis (HVA) for the agency was most recently updated 12/2024; the Emergency Operations Plan was last updated on 01/01/2024. He indicated the Emergency Operations Plan has not been updated with the most recent analysis of the agency’s top identified disaster risks.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to create and put into effect policies and procedures addressing the medical record documentation process the agency has adopted to preserve, secure, and maintain patient records during an emergency for 1 of 1 home health agency. Findings include: A review of a document titled, “Emergency Operations Plan,” revised on 01/01/2024, indicated but was not limited to: “The HHA must comply with all applicable Federal, State, and local emergency preparedness requirements…” The document failed to include policies and procedures concerning the preservation, security, and maintenance of patient records during an emergency. During an interview on 08/14/2025 at 2:25 PM, the Alternate Administrator indicated the agency uses Microsoft Teams as their backup documentation platform. He indicated the agency does not currently have a specific policy or procedure describing the process for clinical record accessibility and security during an emergency.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain documentation of staff emergency preparedness training conducted upon hire for 8 of 10 personnel records reviewed (HHA 1, 2, 3, 4, LPN 1, RN 2, 3, Alternate Clinical Supervisor) and annually for 6 of 10 personnel records reviewed (HHA 1, 2, 3, 4, LPN 1, Alternative Clinical Supervisor). Findings include: 1. A review of a document titled, “Emergency Operations Plan,” revised on 01/01/2024, indicated but was not limited to: “Staff shall attend orientation upon hire and annually updated of their specific roles and responsibilities and the skills they require to perform their duties during an emergency…” 2. A personnel record review for HHA 1, date of hire 05/22/2023, failed to evidence emergency preparedness orientation upon hire and annually. 3. A personnel record review for HHA 2, date of hire 11/21/2023, failed to evidence emergency preparedness orientation upon hire and annually. 4. A personnel record review for HHA 3, date of hire 05/16/2022, failed to evidence emergency preparedness orientation upon hire and annually. 5. A personnel record review for HHA 4, date of hire 02/01/2023, failed to evidence emergency preparedness orientation upon hire and annually. 6. A personnel record review for LPN 1, date of hire 06/19/2025, failed to evidence emergency preparedness orientation upon hire. 7. A personnel record review for RN 2, date of hire 01/13/2025, failed to evidence emergency preparedness orientation upon hire. 8. A personnel record review for RN 3, date of hire 01/02/2025, failed to evidence emergency preparedness orientation upon hire. 9. A personnel record review for the Alternate Clinical Supervisor, date of hire 11/02/2022, failed to evidence emergency preparedness orientation upon hire and annually. 10. During an interview on 08/14/2025 at 2:25 PM, the Alternate Administrator indicated that staff conduct drills in the patients’ homes related to emergency preparedness. He indicated there is staff emergency preparedness training upon hire or annually, but it is not documented.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure policy and procedure was followed to conduct an agency-wide training and testing program based on the emergency preparedness plan for 1 of 1 home health agency. Findings include: A review of a document titled, “Emergency Operations Plan,” revised on 01/01/2024, indicated but was not limited to: “Implementation of the HHA’s Emergency Operations Plan shall be conducted at least annually, either in response to an emergency or as a planned drill. If applicable, the HHA shall participate in at least one community wide drill annually that is relevant to the priority of emergencies identified in the hazard vulnerability analysis…” The review failed to evidence documentation of training and testing drills for the agency’s Emergency Operations Plan. During an interview on 08/14/2025 at 2:50 PM, the Alternate Administrator indicated the agency is not currently conducting annual or biennial training and testing drills related to the Emergency Operations Plan.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 08/11/2025 - 08/14/2025 12-Month Unduplicated Skilled Admissions: 11 Partially Extended on 08/12/2025 at 3:07PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse CM Clinical Manager LPN Licensed Practical Nurse POC Plan of Care HHA Home Health Aide SOC Start of Care EMR Electronic Medical Record EP Emergency Preparedness QR Completed on 08/25/2025 by A4.

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 an initial RN assessment was completed within 48 hours of referral for 8 of 11 clinical records reviewed (Patient #1, #2, #3, #5, #7, #9, #10, #11). Findings include: 1.The clinical record for Patient #1, SOC date 05/22/2023, evidenced a referral date of 05/19/2023 and an initial/comprehensive assessment dated 05/22/2023. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 2. The clinical record for Patient #2, SOC date 01/03/2025, evidenced a referral date of 11/21/2024 and an initial /comprehensive assessment dated 01/03/2025. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 3. The clinical record for Patient #3, SOC date 11/21/2023, evidenced a referral date of 10/30/2023 and an initial /comprehensive assessment dated 11/21/2023. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 4. The clinical record for Patient #5, SOC 2/11/2025, evidenced a referral date of 12/31/2024 and an initial/comprehensive assessment dated 02/11/2025. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 5. The clinical record for Patient #6, SOC 09/03/2023, evidenced a referral date of 08/28/2023 and an initial/comprehensive assessment dated 09/01/2023. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 6. The clinical record for Patient #7, SOC date 12/05/2024, evidenced a referral date of 10/08/2024 and an initial /comprehensive assessment dated 11/05/2024. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 7. The clinical record for Patient #9, SOC 06/05/2024, evidenced a referral date of 04/25/2024 and an initial/comprehensive assessment dated 06/05/2024. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 8. The clinical record for Patient #10, SOC date 03/10/2025, evidenced a referral date of 03/03/2025 and an initial /comprehensive assessment dated 03/07/2025. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 9. The clinical record for Patient #11, SOC date 06/24/2024, evidenced a referral date of 10/23/2024 and an initial/comprehensive assessment dated 12/06/2024. The record failed to evidence documentation an initial assessment was performed within 48 hours of referral. 10. During an interview on 08/12/2025 at 2:05 PM, the Director of Clinical Services indicated the documents “SN Pediatric Assessment” and/or “Pediatric Start of Care” indicate the first day hands-on care is provided to patients, the agency doesn’t complete a separate initial and comprehensive assessment, they are performed at the same time. She indicated she was not aware the start of care date was the first date hands on care is provided per regulations and indicated the agency’s SOC process is incorrect if that is the case. 410 IAC 17-14-1(a)(1)(A)

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to document annual 12 hours of in-service training for 4 of 4 home health aide records reviewed (HHA 1,2,3,4) Findings include: 1. A personnel record review of HHA 1, date of hire 05/22/2023, evidenced a document titled “In-Home Annual Inservice Completion” which included in-service topics, but the agency failed to document in-service hours of training. 2. A personnel record review of HHA 2, date of hire 11/21/2023, evidenced a document titled “In-Home Annual Inservice Completion” which included in-service topics, but the agency failed to document in-service hours of training. 3. A personnel record review of HHA 3, date of hire 05/16/2022, evidenced a document titled “In-Home Annual Inservice Completion” which included in-service topics, but the agency failed to document in-service hours of training. 4. A personnel record review of HHA 4, date of hire 02/01/2023, evidenced a document titled “In-Home Annual Inservice Completion” which included in-service topics, but the agency failed to document in-service hours of training. 5. During an interview on 08/14/2025 at 1:10 PM, the Director of Clinical Services indicated that the document that was provided to surveyors documents annual in-service trainings and that each topic is considered equal to 1 hour of training, but she could not provide a document stating that each topic was equal to 1 hour. 410 IAC 17-14-1(h)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure all agency policies and procedures were complete and thoroughly customized to the agency’s operations for 1 of 1 home health agency. Findings include: A review of a document titled “Home Health Administrator Job Description,” indicated but was not limited to: “Job Summary: …Develops policies and procedures…Responsibilities include: …Interprets and implements policies for guidance of staff, patients and public…” A review of multiple policies provided by the home health agency titled, “Discharge/Transfer/Referral of Patients,” “Comprehensive Assessment,” “Care Planning,” “Care Plan Implementation,” “Scheduling and Coordinating Patient Visits,” and “Governance – Governing Body/Management Company,” all revised 01/01/2024. The agency failed to ensure that all blank fields were appropriately completed and tailored to reflect its operational practices. During an interview on 08/13/2025 at 3:00 PM, the Alternate Administrator indicated the policies that had been originally provided were not correct. He indicated there is a large regulatory binder with interpretive guidance plus policy and procedure bullet points that is also referenced by the agency for regulatory compliance. He indicated the regulatory binder was last approved/reviewed by the Administrator in 2021, and the policies originally provided by the agency were approved in 2024. He provided the binder for review. The original policies provided were provided by the Administrator, Alternate Administrator; the Alternate Administrator indicated the policies were printed by other staff and he wasn't sure why complete policies weren't provided. 410 IAC 17-12-1(c)(1)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure discharge orders from the physician were included in the clinical record for 1 of 2 closed clinical records reviewed (Patient #10). Findings include: A review of a policy titled “Discharge/Transfer/Referral of Patients,” indicated but was not limited to: “The physician(s) involved in the patient’s Plan of Care, treatment and/or services shall be notified of the patient transfer or discharge, and appropriate orders obtained and documented in the medical record…” The clinical record for Patient #10, discharge date 03/21/2025, evidenced a discharge assessment completed on 03/21/2025. The record failed to evidence a physician’s order to discharge the patient from HHA services. During an interview on 08/14/2025 at 12:02 PM, the Director of Clinical Services indicated the agency doesn’t usually obtain a discharge order prior to the discharge of a patient. She indicated the agency sends the discharge summary to the physician for signature and to return, although it is not required. 410 IAC 17-15-1(a)(3)

This visit was for a Federal and State Re-licensure Survey of a Home Health Agency. Survey Dates: December 8th, 9th, 12th, 13th, & 14th of 2022. Facility ID: 012370 Active census: 40 The Survey was Partially Extended on 12/13/2022 at 10:00 a.m. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. QR Completed 12/19/2022 A4

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 include each patient's specific risk for hospitalization/rehospitalization and the interventions to reduce the risk for 7 of 7 clinical records reviewed (Patients 1, 2, 3, 4, 5, 6, and 7). Findings include: 1. A policy titled “Plan of Care” was provided by the Governing Body Chair on 12/13/2022 at 9:53 a.m. The document indicated but was not limited to: “The individualized plan of care must include the following … (xii) A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factor.” 2. The clinical record for patient #1 for the certification period 11/24/2022 through 1/22/2022 was reviewed on 12/9/2022 and failed to include the patient’s risk for emergency room visits or re-hospitalization. 3. The clinical record for patient #2 for the certification period 10/06/2022 through 12/04/2022 was reviewed on 12/9/2022 and failed to include the patient’s risk for emergency room visits or re-hospitalization. 4. The clinical record for patient #3 for the certification period 10/16/2022 through 12/04/2022 was reviewed on 12/13/2022 and failed to include the patient’s risk for emergency room visits or re-hospitalization. 5. The clinical record for patient #4 for the certification period 10/09/2022 through 12/07/2022 was reviewed on 12/12/2022 and failed to include the patient’s risk for emergency room visits or re-hospitalization. 6. The clinical record for patient #5 for the certification period 10/14/2022 through 12/12/2022 was reviewed on 12/12/2022 and failed to include the patient’s risk for emergency room visits or re-hospitalization. 7. The clinical record for patient #6 for the certification period 08/03/2022 through 10/01/2022 was reviewed on 12/09/2022 and failed to include the patient’s risk for emergency room visits or re-hospitalization. 8. The clinical record for patient #7 for the certification period 11/27/2022 through 1/25/2022 was reviewed on 12/9/2022 and failed to include the patient’s risk for emergency room visits or re-hospitalization. 9. During an interview on 12/13/2022 the Governing Body Chair stated that the hospitalization risk was built in based on all the risks listed throughout but there was not a specific emergency room risk and rehospitalization section specifically on the plan of care. 410 IAC 17-13-1(a)(1)(D)(xiii)

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure additional mitigation efforts were enforced for unvaccinated employees to prevent the spread of COVID-19 for 3 of 3 unvaccinated employees reviewed. (RN 3, LPN 8, and LPN 31). Findings include: A policy titled "COVID Policy" was provided by the Governing Body Chairman on 12/13/2022 at 9:47 a.m. The policy indicated, but was not limited to: "The Director of Clinical Services shall have overall responsibility for the COVID-19 vaccination program for staff, including ... Control measure if staff are not vaccinated (i.e., use of Standard and Transmission-based Precautions)." During an interview on 12/13/2022 at 10:00 a.m., the Governing Body Chairman stated they follow the CDC (Centers for Disease Control) guidelines, and all staff are provided masks but not required to wear them. He stated there were no specific additional measures above the measures required of vaccinated employees that are required of the unvaccinated employees. 410 IAC 17-12-1(m)