Every finding on record at Personal Care Concepts Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: April 3, 4, 7, 8, 9, 10, 2025 Active Census: 55 At this Emergency Preparedness survey, Able Hands Homecare was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an EP plan which included strategies for addressing emergency events identified by the hazards risk assessment (see Tag E0006), type of services the agency would have the ability to provide in an emergency (see tag E0007), a process to collaborate with state, tribal, and federal officials’ efforts to maintain an integrated response during a disaster or emergency (see Tag E0009); failed to develop and implement EP policies and procedures which addressed a system for medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records (see Tag E0023), the use of volunteers in an emergency or other emergency staffing strategies (see Tag E0024); failed to develop and maintain an EP communication plan which included included names and contact information for all patients’ physicians (see Tag E0030), alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency management agencies (see Tag E0032), a method for sharing information and medical documentation for patients under the agency’s care with other health providers to maintain the continuity of care (see Tag E0033); and failed to conduct a variety of exercises to test the emergency plan annually and failed to document an after-action review of the testing exercise (see Tag E0039). The cumulative effect of these systemic issues evidenced Able Hands Homecare failed to establish and maintain a comprehensive emergency preparedness plan, which resulted in the agency being found of compliance with Condition of Participation 42 CFR 484.102 Emergency Preparedness.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop an EP plan which included strategies for addressing emergency events identified by the hazards risk assessment, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP plan indicated a hazard risk assessment was last completed by Administrator on 3/13/25. The plan and policies failed to evidence strategies to address emergency events identified by the risk assessment. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the agency’s EP plan did not have strategies to address emergency events identified by the risk assessment.

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 home health agency failed to develop and maintain an emergency preparedness plan which included the type of services the agency would have the ability to provide in an emergency, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP plan failed to evidence the type of services the agency would have the ability to provide in an emergency. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the agency’s EP plan did not indicate the types of services the agency would have the ability to provide in an emergency. Administrator reported the services the agency would be able to provide would depend on the type of emergency.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an emergency preparedness plan which included a process to collaborate with state, tribal, and federal officials’ efforts to maintain an integrated response during a disaster or emergency, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP plan failed to evidence a process to collaborate with state, tribal, and federal officials. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported she would be responsible for collaborating with state, tribal, and federal EP officials, however the EP plan did not reflect this assignment and/or process. When asked who in the community the agency had reached out regarding its EP planning, Administrator reported the agency had only coordinated with one other home health agency to conduct testing drills.

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 home health agency failed to develop and implement EP policies and procedures which addressed a system for medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP policies and procedures failed to evidence the policies addressed the agency’s system for medication documentation which preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the agency’s plan for medication documentation during an emergency was for staff to in the EMR. If there was no internet access, the staff would document visit notes and communication on paper. Administrator stated the agency’s EP policies failed to evidence this plan as well as the steps the agency would take to protect confidentiality of patient information and maintain availability of records.

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 home health agency failed to develop and implement EP policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP policies and procedures failed to evidence the policies addressed the agency’s use of volunteers in an emergency or other emergency staffing strategies. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the EP policies did not address the use of volunteers in an emergency. She stated the agency would not utilize volunteers during an emergency.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and implement EP policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP policies and procedures failed to evidence the policies addressed the agency’s use of volunteers in an emergency or other emergency staffing strategies. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the EP policies did not address the use of volunteers in an emergency. She stated the agency would not utilize volunteers during an emergency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an EP communication plan which included names and contact information for all patients’ physicians, with the potential to affect all agency patients and staff. Findings include: The review of the agency’s EP communication plan failed to evidence the names and contact information for all patients’ physicians. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the agency’s EP plan did not include contact information for all patients’ physicians.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an EP communication plan which included alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency management agencies, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP communication plan failed to evidence alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency management agencies. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the agency did not have any alternative method for communicating with staff and emergency management officials/agencies.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an EP communication plan which included a method for sharing information and medical documentation for patients under the agency’s care with other health providers to maintain the continuity of care, with the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP communication plan failed to evidence a method for sharing information and medical documentation with other health providers to maintain continuity of care. During an interview on 4/10/25 beginning at 2:34 PM, Administrator reported the agency did not have a method for sharing information and medical documentation with other health providers.

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 home health agency failed to conduct a variety of exercises to test the emergency plan annually and failed to document an after-action review of the testing exercise, which had the potential to affect all agency patients and staff. Findings include: 1. The review of the agency’s EP plan evidenced the agency conducted tabletop tornado drills in 2024 and 2025. The documentation of the drill procedures evidenced the same drill was completed both years. The EP documentation failed to evidence the HHA analyzed the response to the drills and revised the EP plan as needed. During an interview on 4/10/25 beginning at 1:05 PM, Administrator reported the agency had only tested its EP plan by conducting a tabletop tornado drill for several years. Administrator stated the agency had not analyzed its response to the drills and revised its EP plan as there had been no issues with the drill.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider in conjunction with 1 complaint. Survey Dates: April 3, 4, 7, 8, 9 and 10, 2025 Complaint: IN113837 with related and unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 6 Survey was announced as fully extended on 4/04/24 at 3:35 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. During this Federal Recertification Survey, Able Hands Homecare was found to be out of compliance with Conditions of Participation §484.60 Care planning, coordination, quality of care; §484.80 Home Health Aide Services and §484.102 Emergency Preparedness. Based on the Condition-level deficiencies during the April 10, 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 April 10, 2025. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation program for a period of two years beginning April 10, 2025 and continuing through April 9, 2027. Abbreviations ATTC-Attendant Care CM-Clinical Manager EP-Emergency Preparedness HHA-Home Health Aide HMK-Homemaker LPN-Licensed Practical Nurse NP-Nurse Practitioner RN-Registered Nurse OASIS-Outcome and Assessment Information Set POC-Plan of Care PSA-Personal Service Agency QAPI-Quality Assurance Performance Improvement SN-Skilled Nurse SOC-Start of Care

Transmit data using compliant software CFR(s): 484.45(c)(2) Transmit data using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the HHA or the HHA contractor to the CMS collection site. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure OASIS transmissions were submitted on time for 1 of 1 agency. Findings include: 1. The “OASIS Error Summary by Agency Report” evidenced a 10.00% late submission rate for the period of 1/01/24 to 12/31/24. 2. The “OASIS Error Detail Report” evidenced 9 late submissions (10.00%) for the period 1/01/24 to 12/31/24 as follows: On 3/02/24 an OASIS assessment of Patient #3 was completed. This assessment was transmitted on 4/29/24, 58 days later. On 5/03/24 an OASIS assessment of Patient #3 was completed. This assessment was transmitted on 7/21/24, 79 days later. On 2/10/24 an OASIS assessment of Patient #9 was completed. This assessment was transmitted on 3/17/24, 36 days later. On 2/19/24 an OASIS assessment of Patient #10 was completed. This assessment was transmitted on 4/07/24, 48 days later. On 6/14/24 an OASIS assessment of Patient #10 was completed. This assessment was transmitted on 7/21/24, 37 days later. On 10/16/24 an OASIS assessment of Patient #10 was completed. This assessment was transmitted on 11/24/24, 39 days later. On 3/21/24 an OASIS assessment of Patient #11 was completed. This assessment was transmitted on 4/29/24, 39 days later. On 4/28/24 an OASIS assessment of Patient #12 was completed. This assessment was transmitted on 6/10/24, 43 days later. On 5/30/24 an OASIS assessment of Patient #13 was completed. This assessment was transmitted on 7/21/24, 52 days later. 3. During an interview on 4/03/25 at 2:12 PM, the CM relayed she was responsible for submitting the OASIS reports within 30 days of the assessment. 4. During an interview on 4/10/25 at 10:20 AM, the CM verified the above late submission errors for Patients #3, 9, 10, 11, 12 and 13 and she was unsure why she submitted them late.

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 home health agency failed to ensure the patient received all visits as ordered for 1 of 2 records reviewed of patients receiving home health aide, attendant care, and homemaker services (Patient #4). Findings include: 1. The undated agency policy C-680 titled “Clinical Documentation” indicated “services not provided and the reason for the missed visits will be documented and reported to the physician.” 2. Patient #4’s clinical record included a POC for the recertification period of 2/02/25 – 4/02/25, which included orders for home health aide services, attendant care services, and homemaker services. The record evidenced the agency failed to provide all services according to the ordered frequency during the weeks of 3/10/25 – 3/16/25 and 3/24/25 – 3/30/25. The record failed to evidence the reason the visits were missed nor Patient's physician was notified of the missed visits. During an interview on 4/09/25 beginning at 12:00 PM, CM was unsure of the reason Patient’s visit frequency was not met during the weeks of 3/10/25 – 3/16/25 and 3/24/25 – 3/30/25. She reported the missed visit documentation did not adhere to agency’s “Clinical Documentation” policy.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to collaborate with the patient and physician regarding possible discharge for cause/ noncompliance for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7). Findings include: 1. The undated agency policy “Patient Discharge Process” indicated patients are informed of the reason of discharge and anticipated needs for services after discharge; the physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan and to avoid charges of “abandonment” at the time of discharge agency documentation will include the following: evidence that the decision was not made unilaterally. The patient, family and physician participated in the decision to discharge the patient from the agency and documentation of all communication with the patient, including the rationale for discharge, will be kept in the patient file with copies sent to the primary physician. 2. The undated agency policy “Patient Rights & Responsibilities” indicated the agency must do the following before it discharges a client for cause: advise the client, representative (if applicable), the physician issuing orders for the home health POC, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the client after discharge from the agency (if any) that a discharge for cause is being considered; make efforts to resolve the problem(s) presented by the client’s behavior, provide the client and representative (if any) with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical record. 3. Patient #7’s clinical record included a Plan of Care (POC) for the certification period 10/24/24 to 12/22/24. The clinical record failed to evidence collaboration with the patient or physician regarding a possible discharge for cause/noncompliance. 4. During an interview on 4/08/25 at 9:48 AM, the CM relayed Patient #7 was notified of discharge by phone on the same day it occurred. 5. During an interview on 4/08/25 at 10:45 AM, Patient #7 relayed the home health agency did not give any notice of discharge, did not give any resources for other home health agencies and did not send any information after discharge. 6. During an interview on 4/08/25 at 11:35 AM, the CM confirmed the clinical record for Patient #7 failed to include any documentation of collaboration with the patient or physician prior to discharge. 410 IAC 17-12-2(i)

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to make efforts to resolve the problem in the patient home for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7). Findings include: 1. The undated agency policy “Patient Rights & Responsibilities” indicated the agency must do the following before it discharges a client for cause: advise the client, representative (if applicable), the physician issuing orders for the home health POC, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the client after discharge from the agency (if any) that a discharge for cause is being considered; make efforts to resolve the problem(s) presented by the client’s behavior, provide the client and representative (if any) with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical record. 2. The review of the agency complaint log evidenced a complaint filed by HHA 9 on 12/06/24. The complaint indicated HHA 9 initially cancelled the 12/06/24 shift with Patient #7 due to transportation issues. HHA 9 was able to show up to the visit 45 minutes late. Patient #7 made discouraging comments to HHA 9 during the visit. HHA 9 left the visit and did not want to return to Patient #7’s home. The home health agency discharged Patient #7 on 12/06/24 after the incident. 3. Patient #7’s clinical record included a SOC on 11/04/22 and a POC for the certification period 10/24/24 to 12/22/24. The POC indicated the patient was to receive HHA services one to two days a week for one week then four to five days a week for 8 weeks. The record included HHA visit notes on 10/24/24, 10/25/24, 10/29/24, 10/30/24, 10/31/24, 11/01/24, 11/04/24, 11/05/24, 11/06/24, 11/07/24, 11/08/24, 11/11/24, 11/12/24, 11/13/24, 11/14/24, 11/15/24, 11/18/24, 11/19/24, 11/20/24, 11/21/24, 11/22/24, 11/25/24, 11/26/24, 12/02/24, 12/03/24, 12/04/24, 12/05/24 and 12/06/24. The HHA visit notes dated 10/24/24 to 12/05/24 did not evidence any problems. The HHA visit note dated 12/06/24 evidenced the patient refused all HHA interventions. The clinical record for Patient #7 failed to evidence documentation that the patient was contacted to make efforts to resolve the problem prior to discharge and failed to evidence the home health agency made any other efforts to resolve the problem. 4. During an interview on 4/08/25 at 10:45 AM, Patient #7 relayed the home health agency did not make any attempts to resolve the problem or hear their version of the situation. 5. During an interview on 4/08/25 at 11:35 AM, the CM relayed the home health agency did not make efforts to resolve the problem with Patient #7.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the patient with contact information for other home health agencies who may be able to provide care for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7). Findings include: 1. The undated agency policy “Patient Rights & Responsibilities” indicated the agency must do the following before it discharges a client for cause: advise the client, representative (if applicable), the physician issuing orders for the home health POC, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the client after discharge from the agency (if any) that a discharge for cause is being considered; make efforts to resolve the problem(s) presented by the client’s behavior, provide the client and representative (if any) with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical record. 2. Patient #7’s clinical record included a SOC on 11/04/22 and a discharge on 12/06/24. The clinical record failed to include documentation that Patient #7 was provided with discharge information or contact information for other home health agencies or providers in the area. 3. During an interview on 4/08/25 at 10:45 AM, Patient #7 relayed the home health agency did not give any notice of discharge, did not provide any resources for other home health agencies and did not send any information after discharge. 4. During an interview on 4/08/25 at 11:35 AM, the CM relayed the home health agency did not give Patient #7 any resources for other home health agencies in the area and did not send any information after discharge.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to document the efforts made to resolve the problem for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7). Findings include: 1. The undated agency policy “Patient Rights & Responsibilities” indicated the agency must do the following before it discharges a client for cause: advise the client, representative (if applicable), the physician issuing orders for the home health POC, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the client after discharge from the agency (if any) that a discharge for cause is being considered; make efforts to resolve the problem(s) presented by the client’s behavior, provide the client and representative (if any) with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical record. 2. The review of the agency complaint log evidenced a complaint filed by HHA 9 on 12/06/24. The complaint indicated HHA 9 initially cancelled the 12/06/24 shift with Patient #7 due to transportation issues. HHA 9 was able to show up to the visit 45 minutes late. Patient #7 made discouraging comments to HHA 9 during the visit. HHA 9 left the visit and did not want to return to Patient #7’s home. The home health agency discharged Patient #7 on 12/06/24 after the incident. 3. Patient #7’s clinical record included a SOC on 11/04/22 and a discharge on 12/06/24. The clinical record failed to include documentation of efforts made to resolve the problem. 4. During an interview on 4/08/25 at 10:45 AM, Patient #7 relayed the home health agency did not give any notice of discharge and did not try to resolve the problem with HHA 9. 5. During an interview on 4/08/25 at 11:35 AM, the CM confirmed the clinical record for Patient #7 failed to include any documentation of efforts to resolve the problem.

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 home health agency failed to conduct an initial assessment to determine the patient's immediate care and support needs within 48 hours of referral for 1 of 2 discharged records reviewed (Patients #7). Findings include: 1. The undated agency policy “Patient Admission Process” indicated each patient referred to the agency shall be evaluated by a RN to determine the immediate care and support needs of the patient. The initial assessment will be completed within forty-eight (48) hours of referral. 2. Patient #7’s clinical record evidenced a referral was received on 10/26/22 and an initial assessment/SOC visit was conducted on 11/04/22. The record failed to evidence the reason for delay in conducting an initial assessment. 3. During an interview on 4/08/25 at 11:35 AM, the CM was unsure of the reason for the delay in SOC and she confirmed the clinical record failed to include documentation of the delay. 410 IAC 17-14-1(a)(1)(A)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure an accurate review of all medications for 4 of 4 records reviewed with home visit observations (Patient #1, 2, 3 and 5). 4. Patient #2’s clinical record indicated a recertification comprehensive assessment was completed on 3/23/25 by RN 1. The nurse documented Patient’s medications were reviewed and no new medications were identified. A home visit observation was conducted on 4/04/25 beginning at 12:00 PM. Review of Patient’s medication bottles compared to the agency’s medication list evidenced the following discrepancies: a. Mirtazapine (a medication used to treat depression) was observed in the home. Patient reported he/she was currently taking the medication. The medication bottle was dated as filled on 3/08/25. The agency’s medication list failed to evidence Mirtazapine. b. Valsartan-Hydrochlorothiazide (a combination of two medications used to treat high blood pressure) was observed in the home. Patient reported he/she was currently taking the medication. The medication bottle was dated as filled on 1/29/25. The agency’s medication list failed to evidence Valsartan-Hydrochlorothiazide. c. A multivitamin was observed in the home. Patient reported he/she was currently taking the medication. The agency’s medication list failed to evidence a multivitamin. d. A Calcium Citrate – Vitamin D supplement was observed in the home at a dosage of 400 milligrams (mg) of calcium and 12.5 micrograms (mcg) of vitamin D. Patient reported he/she was currently taking the medication. The agency’s medication list indicated the supplement dosage was 600 mg of calcium and 20 mcg of vitamin D. e. A Vitamin D3 supplement was observed in the home at a dosage of 12.5 mcg. Patient reported he/she was currently taking the medication three days a week. The agency’s medication list failed to evidence this additional dose of Vitamin D3. f. A Vitamin B12 supplement was observed in the home at a dosage of 5000 mcg. Patient reported he/she was currently taking the medication. The agency’s medication list indicated the dosage of the vitamin was 1500 mg once a day. Patient’s record evidenced the last drug interactions check was completed on 12/02/22. The agency’s medication list included Allopurinol (a medication to treat gout) started on 3/25/23, Jardiance (a medication used to treat diabetes) and Spirinolactone (a diuretic) started on 4/09/24, and Coreg (a medication used to treat high blood pressure) started on 5/14/24. The record failed to evidence a drug interaction check was performed for the new medications using a current and accurate medication list. During an interview on 4/08/25 beginning at 3:08 PM, RN 1 reported he reviewed Patient’s medications for accuracy at each recertification visit and completed a medication setup weekly for Patient. The nurse stated Patient was currently taking Mirtazapine and he did not realize it was discontinued off the agency’s medication list. The nurse was unaware Patient was taking Valsartan-Hydrochlorothiazide and a multivitamin, and reported Patient’s dosage of calcium, Vitamin D, and Vitamin B12 supplements varied depending on the bottle Patient’s caregiver purchased. RN 1 stated he would run a drug interaction check with any new medication and it had been “awhile” since he had last completed this check. 5. Patient #3’s clinical record indicated a recertification comprehensive assessment was completed on 2/26/25 by Alternate CM. The nurse documented Patient’s medications were reviewed and no new medications were identified. A home visit observation was conducted on 4/07/25 beginning at 11:58 AM. Review of Patient’s medications found in the home compared to the agency’s medication list evidenced the following discrepancies: a. Zolpidem (a medication used to treat insomnia) was observed in the home to be taken as-needed (PRN) for insomnia. The agency’s medication list indicated the medication was to be taken daily. b. Hydrocodone-acetaminophen (a combination medication used to treat pain) was included on the agency’s medication list but was not found in the home. Patient reported he/she was taking oxycodone-acetaminophen (a combination medication used to treat pain, with a more potent opioid pain reliever) instead of Hydrocodone-acetaminophen. During an interview on 4/10/25 beginning at 11:35 AM, Alternate CM reported she thought Patient was taking oxycodone-acetaminophen for pain, but hydrocodone-acetaminophen was indicated on the agency’s medication list. Findings include: 1. The undated agency policy “Comprehensive Patient Assessment” indicated the comprehensive assessment will include a review of all medications the patient is using. 2. The undated agency policy “Plan of Care” indicated the plan of care shall be completed in full to include all medications, treatments and procedures. 3. Patient #1’s clinical record evidenced a SOC on 11/15/23, a recertification comprehensive assessment completed by the Alternate CM on 3/05/25 and included an active medication list as of 4/03/25. The clinical record failed to evidence the Alternate CM conducted a medication review or reconciliation of Patient #1’s medications. During a home visit observation conducted with Patient #1 and LPN 1 on 4/04/25 at 11:25 AM, Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Vitamin D3 (used as a supplement) 2000 units, two capsules daily was found in the home. The home health agency’s medication profile failed to evidence an order for Vitamin D3. b) Ferrous sulfate (used to treat anemia) 325 milligram (mg), one tablet three times a day was found in the home. The home health agency’s medication profile failed to evidence an order for Ferrous sulfate. c) Furosemide (used to treat hypertension, swelling) 40 mg, one tablet three times a week was found in the home. The home health agency’s medication profile failed to evidence an order for Furosemide. d) Prednisone (used to treat inflammation) 10 mg was found in the home. The home health agency’s medication profile failed to evidence an order for Prednisone. e) Levothyroxine (used to treat hypothyroidism)175 micrograms (mcg), one tablet daily in the morning. The home health agency’s records failed to evidence the correct prescribed dose for Levothyroxine. f) Hydrocodone-Acetaminophen (used to treat pain) 7.5/325 mg, one tablet every four to six hours as needed, was listed on Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. g) Metformin (used to treat diabetes) 500 mg, one tablet two times a day, was listed on Patient 1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. h) Farxiga (used to lower blood sugar levels) 5 mg, one tablet daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. i) Rosuvastatin (used to lower cholesterol) 40 mg, one tablet daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. j) Hydrochlorothiazide (used to treat hypertension) 50 mg, one tablet daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. k) Icosapent Ethyl (used to treat high triglyceride levels) 1 gram, two capsules daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are unsure if this is an active medication. l) Ropinirole (used to treat restless leg syndrome) 0.25 mg, one tablet daily at bedtime was found in the home. The home health agency’s medication profile listed the medication as 0.25 mg tablet three times a day. Per Patient #1, they only take this medication once a day at bedtime. m) Hydroxizine hydrochloride (used to treat anxiety) 50 mg, one tablet at bedtime as needed, was found in the home. The home health agency’s medication profile listed the medication as 25 mg tablet at bedtime as needed for anxiety. Per Patient #1, they are taking the 50 mg tablet as needed at bedtime. During an interview on 4/04/25 at 11:35 AM, Patient #1 relayed the home health agency nurses had not reviewed the medications in the home with them during the recertification comprehensive assessment. During an interview on 4/04/25 at 3:09 PM, the Alternate CM relayed Patient #1 did not have any changes during the comprehensive assessment and the recertification POC was not reviewed with the physician. 4. Patient #5’s clinical record evidenced a SOC on 5/17/13, a recertification comprehensive assessment completed by RN 1 on 3/14/25 and included an active medication list as of 4/07/25. The clinical record failed to evidence RN 1 conducted a medication review or reconciliation of Patient #5’s medications. During a home visit observation conducted with Patient #5 and HHA 2 on 4/09/25 at 8:30 AM, Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Fexofenadine Hydrochloride (used to treat allergies) 180 mg, one tablet daily was listed on Patient #5’s active medication list. This medication was not found in the home. b) Mucinex (used to clear congestion) 600 mg, two tablets daily was listed on Patient #5’s active medication list. This medication was not found in the home. Per Person A, Patient #5 only takes one 600 mg tablet every 12 hours as needed for congestion and has not used the medication in over two months. c) Miralax (used to treat constipation) 17 grams/kilogram (g/kg) daily was listed on Patient #5’s active medication list. Per Person A, Patient #5 only takes 17 g as needed for constipation and has not used the medication in over two months. d) Tylenol Extra Strength (used to treat pain) 500 mg oral powder, 1000 mg every 6 hours was listed on Patient #5’s active medication list. This medication was not found in the home. e) Cetirizine (used to treat allergies) 10 mg, one tablet daily, was found in the home. The home health agency’s medication profile failed to evidence an order for Cetirizine. f) Famotidine (used to treat acid reflux) 20 mg, one tablet twice a day, was found in the home. The home health agency’s medication profile failed to evidence an order for Famotidine. g) Ipratropium Bromide/Albuterol (used to treat bronchitis) 0.5 mg/3m/3 milliliter (ml) vial, 3 ml every 6 hours as needed via nebulizer, prescribed 11/11/24 was found in the home. The home health agency’s medication profile failed to evidence an order for Ipratropium Bromide/Albuterol. h) Mucinex (used to clear congestion) 600 mg, one tablet every 12 hours as needed was found in the home. The home health agency’s medication profile failed to evidence an order for this dosage of Mucinex. i) Pantoprazole (used to treat heartburn/acid reflux) 40 mg, one tablet daily, was found in the home. The home health agency’s medication profile failed to evidence an order for Pantoprazole. During an interview on 4/09/25 at 8:30 AM, Person C relayed the home health agency nurse had not reviewed the medications in the home and didn’t ask about what medications the patient was taking during the last nurse assessment. During an interview on 4/04/25 at 3:25 PM, RN 1 relayed Patient #5 did not have any changes throughout the certification period and they did not review Patient #5’s medications during the recertification comprehensive assessment visit. 410 IAC 17-14-1(a)(1)(B) Findings include: 1. The undated agency policy “Comprehensive Patient Assessment” indicated the comprehensive assessment will include a review of all medications the patient is using. 2. The undated agency policy “Plan of Care” indicated the plan of care shall be completed in full to include all medications, treatments and procedures. 3. Patient #1’s clinical record evidenced a SOC on 11/15/23, a recertification comprehensive assessment completed by the Alternate CM on 3/05/25 and included an active medication list as of 4/03/25. The clinical record failed to evidence the Alternate CM conducted a medication review or reconciliation of Patient #1’s medications. During a home visit observation conducted with Patient #1 and LPN 1 on 4/04/25 at 11:25 AM, Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Vitamin D3 (used as a supplement) 2000 units, two capsules daily was found in the home. The home health agency’s medication profile failed to evidence an order for Vitamin D3. b) Ferrous sulfate (used to treat anemia) 325 milligram (mg), one tablet three times a day was found in the home. The home health agency’s medication profile failed to evidence an order for Ferrous sulfate. c) Furosemide (used to treat hypertension, swelling) 40 mg, one tablet three times a week was found in the home. The home health agency’s medication profile failed to evidence an order for Furosemide. d) Prednisone (used to treat inflammation) 10 mg was found in the home. The home health agency’s medication profile failed to evidence an order for Prednisone. e) Levothyroxine (used to treat hypothyroidism)175 micrograms (mcg), one tablet daily in the morning. The home health agency’s records failed to evidence the correct prescribed dose for Levothyroxine. f) Hydrocodone-Acetaminophen (used to treat pain) 7.5/325 mg, one tablet every four to six hours as needed, was listed on Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. g) Metformin (used to treat diabetes) 500 mg, one tablet two times a day, was listed on Patient 1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. h) Farxiga (used to lower blood sugar levels) 5 mg, one tablet daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. i) Rosuvastatin (used to lower cholesterol) 40 mg, one tablet daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. j) Hydrochlorothiazide (used to treat hypertension) 50 mg, one tablet daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are no longer taking this medication. k) Icosapent Ethyl (used to treat high triglyceride levels) 1 gram, two capsules daily, was listed Patient #1’s active medication list. This medication was not found in the home. Per Patient #1, they are unsure if this is an active medication. l) Ropinirole (used to treat restless leg syndrome) 0.25 mg, one tablet daily at bedtime was found in the home. The home health agency’s medication profile listed the medication as 0.25 mg tablet three times a day. Per Patient #1, they only take this medication once a day at bedtime. m) Hydroxizine hydrochloride (used to treat anxiety) 50 mg, one tablet at bedtime as needed, was found in the home. The home health agency’s medication profile listed the medication as 25 mg tablet at bedtime as needed for anxiety. Per Patient #1, they are taking the 50 mg tablet as needed at bedtime. During an interview on 4/04/25 at 11:35 AM, Patient #1 relayed the home health agency nurses had not reviewed the medications in the home with them during the recertification comprehensive assessment. During an interview on 4/04/25 at 3:09 PM, the Alternate CM relayed Patient #1 did not have any changes during the comprehensive assessment and the recertification POC was not reviewed with the physician. 4. Patient #5’s clinical record evidenced a SOC on 5/17/13, a recertification comprehensive assessment completed by RN 1 on 3/14/25 and included an active medication list as of 4/07/25. The clinical record failed to evidence RN 1 conducted a medication review or reconciliation of Patient #5’s medications. During a home visit observation conducted with Patient #5 and HHA 2 on 4/09/25 at 8:30 AM, Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Fexofenadine Hydrochloride (used to treat allergies) 180 mg, one tablet daily was listed on Patient #5’s active medication list. This medication was not found in the home. b) Mucinex (used to clear congestion) 600 mg, two tablets daily was listed on Patient #5’s active medication list. This medication was not found in the home. Per Person A, Patient #5 only takes one 600 mg tablet every 12 hours as needed for congestion and has not used the medication in over two months. c) Miralax (used to treat constipation) 17 grams/kilogram (g/kg) daily was listed on Patient #5’s active medication list. Per Person A, Patient #5 only takes 17 g as needed for constipation and has not used the medication in over two months. d) Tylenol Extra Strength (used to treat pain) 500 mg oral powder, 1000 mg every 6 hours was listed on Patient #5’s active medication list. This medication was not found in the home. e) Cetirizine (used to treat allergies) 10 mg, one tablet daily, was found in the home. The home health agency’s medication profile failed to evidence an order for Cetirizine. f) Famotidine (used to treat acid reflux) 20 mg, one tablet twice a day, was found in the home. The home health agency’s medication profile failed to evidence an order for Famotidine. g) Ipratropium Bromide/Albuterol (used to treat bronchitis) 0.5 mg/3m/3 milliliter (ml) vial, 3 ml every 6 hours as needed via nebulizer, prescribed 11/11/24 was found in the home. The home health agency’s medication profile failed to evidence an order for Ipratropium Bromide/Albuterol. h) Mucinex (used to clear congestion) 600 mg, one tablet every 12 hours as needed was found in the home. The home health agency’s medication profile failed to evidence an order for this dosage of Mucinex. i) Pantoprazole (used to treat heartburn/acid reflux) 40 mg, one tablet daily, was found in the home. The home health agency’s medication profile failed to evidence an order for Pantoprazole. During an interview on 4/09/25 at 8:30 AM, Person C relayed the home health agency nurse had not reviewed the medications in the home and didn’t ask about what medications the patient was taking during the last nurse assessment. During an interview on 4/04/25 at 3:25 PM, RN 1 relayed Patient #5 did not have any changes throughout the certification period and they did not review Patient #5’s medications during the recertification comprehensive assessment visit. 4. Patient #2’s clinical record indicated a recertification comprehensive assessment was completed on 3/23/25 by RN 1. The nurse documented Patient’s medications were reviewed and no new medications were identified. A home visit observation was conducted on 4/04/25 beginning at 12:00 PM. Review of Patient’s medication bottles compared to the agency’s medication list evidenced the following discrepancies: a. Mirtazapine (a medication used to treat depression) was observed in the home. Patient reported he/she was currently taking the medication. The medication bottle was dated as filled on 3/08/25. The agency’s medication list failed to evidence Mirtazapine. b. Valsartan-Hydrochlorothiazide (a combination of two medications used to treat high blood pressure) was observed in the home. Patient reported he/she was currently taking the medication. The medication bottle was dated as filled on 1/29/25. The agency’s medication list failed to evidence Valsartan-Hydrochlorothiazide. c. A multivitamin was observed in the home. Patient reported he/she was currently taking the medication. The agency’s medication list failed to evidence a multivitamin. d. A Calcium Citrate – Vitamin D supplement was observed in the home at a dosage of 400 milligrams (mg) of calcium and 12.5 micrograms (mcg) of vitamin D. Patient reported he/she was currently taking the medication. The agency’s medication list indicated the supplement dosage was 600 mg of calcium and 20 mcg of vitamin D. e. A Vitamin D3 supplement was observed in the home at a dosage of 12.5 mcg. Patient reported he/she was currently taking the medication three days a week. The agency’s medication list failed to evidence this additional dose of Vitamin D3. f. A Vitamin B12 supplement was observed in the home at a dosage of 5000 mcg. Patient reported he/she was currently taking the medication. The agency’s medication list indicated the dosage of the vitamin was 1500 mg once a day. Patient’s record evidenced the last drug interactions check was completed on 12/02/22. The agency’s medication list included Allopurinol (a medication to treat gout) started on 3/25/23, Jardiance (a medication used to treat diabetes) and Spirinolactone (a diuretic) started on 4/09/24, and Coreg (a medication used to treat high blood pressure) started on 5/14/24. The record failed to evidence a drug interaction check was performed for the new medications using a current and accurate medication list. During an interview on 4/08/25 beginning at 3:08 PM, RN 1 reported he reviewed Patient’s medications for accuracy at each recertification visit and completed a medication setup weekly for Patient. The nurse stated Patient was currently taking Mirtazapine and he did not realize it was discontinued off the agency’s medication list. The nurse was unaware Patient was taking Valsartan-Hydrochlorothiazide and a multivitamin, and reported Patient’s dosage of calcium, Vitamin D, and Vitamin B12 supplements varied depending on the bottle Patient’s caregiver purchased. RN 1 stated he would run a drug interaction check with any new medication and it had been “awhile” since he had last completed this check. 5. Patient #3’s clinical record indicated a recertification comprehensive assessment was completed on 2/26/25 by Alternate CM. The nurse documented Patient’s medications were reviewed and no new medications were identified. A home visit observation was conducted on 4/07/25 beginning at 11:58 AM. Review of Patient’s medications found in the home compared to the agency’s medication list evidenced the following discrepancies: a. Zolpidem (a medication used to treat insomnia) was observed in the home to be taken as-needed (PRN) for insomnia. The agency’s medication list indicated the medication was to be taken daily. b. Hydrocodone-acetaminophen (a combination medication used to treat pain) was included on the agency’s medication list but was not found in the home. Patient reported he/she was taking oxycodone-acetaminophen (a combination medication used to treat pain, with a more potent opioid pain reliever) instead of Hydrocodone-acetaminophen. During an interview on 4/10/25 beginning at 11:35 AM, Alternate CM reported she thought Patient was taking oxycodone-acetaminophen for pain, but hydrocodone-acetaminophen was indicated on the agency’s medication list. 7. 6. During an interview on 4/04/25 at 2:45 PM, the CM relayed medications should have been reviewed during every recertification visit and anytime a new medication is found in the home.

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 home health agency failed to ensure the POC was established and reviewed with the physician at SOC and recertification (See G572); failed to ensure the POC included measures to address all safety concerns, patient-specific interventions, measurable outcomes and goals; and failed to clearly identify SN interventions (See G574); failed to ensure services were provided only as ordered by a physician or allowed practitioner (See G580); failed to ensure all verbal orders were signed by the ordering provider within 30 days (See G 584). Findings include: The cumulative effect of these systemic problems had the potential to impact all 55 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.

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 POC was established and reviewed by the attending physician/practitioner for 5 of 7 patient records reviewed (Patient 1, 3, 5, 6 and 7). 3. Patient #3’s clinical record indicated a SOC date of 7/14/22. Alternate CM conducted a recertification comprehensive assessment on 2/26/25 for the recertification period of 2/28/25 – 4/28/25. CM signed the POC on 3/03/25. The record failed to evidence the recertification POC was reviewed with Patient’s physician at the time of recertification. Patient’s POC was not signed as reviewed by Patient’s provider until 4/04/25. During an interview on 4/08/25 beginning at 10:15 AM, when asked how Patient’s POC was reviewed with the physician at recertification, CM reported the nurse case manager was to contact the provider with any patient changes. CM would create the POC after the comprehensive assessment was completed by the nurse case manager. CM reported the record failed to evidence review of the POC with Patient’s provider at recertification. During an interview on 4/10/25 beginning at 11:35 AM, Alternate CM reported at Patient’s recertification, she had reviewed Patient’s POC with Patient’s physician office. The record failed to evidence the POC review with the provider. Findings include: 1. The undated agency policy “Plan of Care” indicated the total plan of care shall be reviewed by the attending physician and agency personnel as often as the severity of the patient’s condition requires, but at least one time every 60 days. 2. The undated agency policy “Physician Orders” indicated all medications, treatments and services provided to patients must be ordered by a physician. 3. Patient #1’s clinical record evidenced a SOC date of 11/15/23. The Alternate CM conducted a recertification comprehensive assessment on 3/05/25. The POC for the recertification period of 3/09/25 to 5/07/25 was created and signed by the CM on 3/10/25 and evidenced Person D as the attending practitioner. The POC was signed on 4/04/25 by attending practitioner E, 26 days after the recertification period started. The record failed to evidence the recertification POC was reviewed with the attending practitioner at the time of recertification. During an interview on 4/04/25 at 2:45 PM, the CM relayed she was unsure when the attending NP changed from NP D to NP E and she verified the clinical record for Patient #1 did not include documentation of when the attending practitioner changed. During an interview on 4/04/25 at 3:09 PM, the Alternate CM relayed she did not collaborate with the attending practitioner regarding the recertification and did not receive any recertification POC orders for Patient #1. 4. 5. Patient 5’s clinical record evidenced a SOC date of 5/17/13. RN 1 conducted a recertification comprehensive assessment on 3/14/25. The POC for the recertification period of 3/15/25 to 5/13/25 was created and signed by the CM on 3/18/25. The record failed to evidence the recertification POC was reviewed with the attending practitioner at the time of recertification. During an interview on 4/07/25 at 12:45 PM, RN 1 relayed the patient didn’t have any changes and he did not collaborate with the attending practitioner at recertification. He also relayed the POC was redone and sent to the practitioner for signature. 6. Patient #6’s clinical record evidenced a SOC date of 12/15/24. RN 1 conducted an initial comprehensive assessment on 12/15/24. The POC for the period of 12/15/24 to 2/12/25 was created and signed by the CM on 1/04/25. The record failed to evidence the POC was reviewed with the physician at SOC. Patient #6’s POC was not signed as reviewed by the physician until 1/16/25. During an interview on 4/07/25 at 12:30 RM, RN 1 relayed they contacted the community nurse at Entity F to inform Physician G of Patient #6 returning from another state and home health care was restarted. 6. Patient #7’s clinical record evidenced a SOC date of 11/04/22. RN 1 conducted a recertification comprehensive assessment on 10/23/24. The POC for the recertification period of 10/24/24 to 12/22/24 was created and signed by the CM on 11/17/24. The POC was signed on 11/21/24 by the attending physician, 28 days after the recertification period started. The record failed to evidence the recertification POC was reviewed with the attending physician at the time of recertification. During an interview on 4/07/25 at 12:40 PM, RN 1 relayed they did not collaborate with the attending physician for recertification POC orders. 410 IAC 17-13-1(a) Findings include: 1. The undated agency policy “Plan of Care” indicated the total plan of care shall be reviewed by the attending physician and agency personnel as often as the severity of the patient’s condition requires, but at least one time every 60 days. 2. The undated agency policy “Physician Orders” indicated all medications, treatments and services provided to patients must be ordered by a physician. 3. Patient #1’s clinical record evidenced a SOC date of 11/15/23. The Alternate CM conducted a recertification comprehensive assessment on 3/05/25. The POC for the recertification period of 3/09/25 to 5/07/25 was created and signed by the CM on 3/10/25 and evidenced Person D as the attending practitioner. The POC was signed on 4/04/25 by attending practitioner E, 26 days after the recertification period started. The record failed to evidence the recertification POC was reviewed with the attending practitioner at the time of recertification. During an interview on 4/04/25 at 2:45 PM, the CM relayed she was unsure when the attending NP changed from NP D to NP E and she verified the clinical record for Patient #1 did not include documentation of when the attending practitioner changed. During an interview on 4/04/25 at 3:09 PM, the Alternate CM relayed she did not collaborate with the attending practitioner regarding the recertification and did not receive any recertification POC orders for Patient #1. 4. Patient #3’s clinical record indicated a SOC date of 7/14/22. Alternate CM conducted a recertification comprehensive assessment on 2/26/25 for the recertification period of 2/28/25 – 4/28/25. CM signed the POC on 3/03/25. The record failed to evidence the recertification POC was reviewed with Patient’s physician at the time of recertification. Patient’s POC was not signed as reviewed by Patient’s provider until 4/04/25. During an interview on 4/08/25 beginning at 10:15 AM, when asked how Patient’s POC was reviewed with the physician at recertification, CM reported the nurse case manager was to contact the provider with any patient changes. CM would create the POC after the comprehensive assessment was completed by the nurse case manager. CM reported the record failed to evidence review of the POC with Patient’s provider at recertification. During an interview on 4/10/25 beginning at 11:35 AM, Alternate CM reported at Patient’s recertification, she had reviewed Patient’s POC with Patient’s physician office. The record failed to evidence the POC review with the provider. 5. Patient 5’s clinical record evidenced a SOC date of 5/17/13. RN 1 conducted a recertification comprehensive assessment on 3/14/25. The POC for the recertification period of 3/15/25 to 5/13/25 was created and signed by the CM on 3/18/25. The record failed to evidence the recertification POC was reviewed with the attending practitioner at the time of recertification. During an interview on 4/07/25 at 12:45 PM, RN 1 relayed the patient didn’t have any changes and he did not collaborate with the attending practitioner at recertification. He also relayed the POC was redone and sent to the practitioner for signature. 6. Patient #6’s clinical record evidenced a SOC date of 12/15/24. RN 1 conducted an initial comprehensive assessment on 12/15/24. The POC for the period of 12/15/24 to 2/12/25 was created and signed by the CM on 1/04/25. The record failed to evidence the POC was reviewed with the physician at SOC. Patient #6’s POC was not signed as reviewed by the physician until 1/16/25. During an interview on 4/07/25 at 12:30 RM, RN 1 relayed they contacted the community nurse at Entity F to inform Physician G of Patient #6 returning from another state and home health care was restarted. 7. Patient #7’s clinical record evidenced a SOC date of 11/04/22. RN 1 conducted a recertification comprehensive assessment on 10/23/24. The POC for the recertification period of 10/24/24 to 12/22/24 was created and signed by the CM on 11/17/24. The POC was signed on 11/21/24 by the attending physician, 28 days after the recertification period started. The record failed to evidence the recertification POC was reviewed with the attending physician at the time of recertification. During an interview on 4/07/25 at 12:40 PM, RN 1 relayed they did not collaborate with the attending physician for recertification POC orders. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the POC included patient-specific interventions, measurable outcomes and goals for 6 of 7 patient records reviewed (Patient #1, 2, 3, 5, 6 and 7). Findings include: 3. Patient #2’s record included a POC for the recertification period of 3/24/25 – 5/22/25. RN 1 completed a recertification comprehensive assessment on 3/23/25 and CM signed the POC on 3/23/25. The POC indicated the agency’s goals for Patient included but were not limited to “Patient will be able to demonstrate improved safety awareness as evidenced by:; [sic] Target Date: 5/22/25 … Anxiety/agitation controlled through course of care ….” The POC failed to evidence all goals were measurable. During an interview on 4/08/25 beginning at 10:06 AM, CM reported all goals in the POC were not measurable. 4. Patient #3’s record included a POC for the recertification period of 2/28/25 – 5/28/25. Alternate CM completed a recertification comprehensive assessment on 2/26/25 and CM signed the POC on 3/03/25. The POC included six goals with a target date of 9/11/22, one goal with a target date of 9/19/22, one goal with a target date of 11/10/22, and one goal with a target date of 1/09/23. The POC failed to evidence all patient goals were individualized and active. During an interview on 4/08/25 beginning at 12:00 PM, CM reported it was the nurse case manager’s responsibility to review and update a patient’s goals at recertification. During an interview on 4/10/25 beginning at 11:35 AM, Alternate CM reported she was Patient’s nurse case manager. Alternate CM stated the expired goals on the POC were from Patient’s SOC and should be updated. Findings include: 1. The undated agency policy “Plan of Care” indicated the Plan of Care shall be completed in full to include: instructions to patient/caregiver, as applicable and treatment goals. 2. Patient #1’s clinical record included a POC for the recertification period of 3/09/25 to 5/07/25. The Alternate CM completed a recertification comprehensive assessment on 3/05/25. The recertification POC was created and signed by the CM on 3/10/25. The POC indicated the agency’s goals for Patient #1 included but were not limited to “Patient/caregiver can identify signs and symptoms of hypoglycemia and hyperglycemia and appropriate actions to take; Target Date 1/13/24; Blood glucose will be stabilized within therapeutic range as appropriate for stage of disease process; Target date 1/13/24. Anxiety/agitation controlled through course of care ….” The POC failed to evidence all goals were measurable and active. During an interview on 4/04/25 at 2:45 PM, the CM confirmed the goals were not measurable and relayed the POC goals and target dates should have been updated when the recertification POC was created. During an interview on 4/04/25 at 3:09 PM, the Alternate CM relayed the CM was responsible for updating the POC. 5. Patient #5’s clinical record included a POC for the recertification period of 3/15/25 to 5/13/25. RN 1 conducted a recertification comprehensive assessment on 3/14/25. The POC was created and signed by the CM on 3/18/25. The POC indicated the agency’s goals for Patient #5 included but were not limited to “Patient/caregiver will perform ADL’s with optimal ability; Urinary output will be appropriate for stage of disease process; and Caregiver will be able to demonstrate improved safety awareness as evidenced by…” The POC failed to evidence all goals were appropriate and measurable for Patient #5. During an interview on 4/09/25 at 12:10 PM, the CM confirmed the above goals for Patient #5 were not appropriate and measurable. 6. Patient #6’s clinical record included a POC for the certification period of 12/15/24 to 2/12/25. RN 1 conducted an initial comprehensive assessment on 12/15/24 and the POC was created and signed by the CM on 1/04/25. The POC indicated the agency’s goals for Patient #6 included but were not limited to “Patient/caregiver will perform ADL’s with optimal ability.” This goal was listed on the POC twice. The POC failed to evidence the goal was measurable for Patient #5. During an interview on 4/07/25 at 11:43 AM, the CM confirmed the ADL goal for Patient #6 was not measurable and should not be a duplicate goal on the POC. 7. Patient #7’s clinical record included a POC for the recertification period of 10/24/24 to 12/22/24. RN 1 conducted a recertification comprehensive assessment on 10/23/24. The recertification POC was created and signed by the CM on 11/17/24. The POC indicated the agency’s goals for Patient #7 included but were not limited to “Patient/caregiver will perform ADL’s with optimal ability; Patient’s respiratory status is stable; Patient free of any signs/symptoms of infection; and an HHA goal of “Patient/caregiver will perform ADL’s with optimal ability; Target Date 1/2/2023.” The POC failed to evidence all goals were measurable and active. During an interview on 4/08/25 at 9:48 AM, the CM confirmed the goals for Patient #7 were not measurable and should have been updated to reflect the current certification period. 410 IAC 17-13-1(a)(1)(C)

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 home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 1 of 1 active patient records reviewed with SN only services (Patient #1) and 2 of 2 discharged records reviewed (Patient #6 and 7). Findings include: 1. The undated agency policy “Plan of Care” indicated the total plan of care shall be reviewed by the attending physician and agency personnel as often as the severity of the patient’s condition requires, but at least one time every 60 days. 2. The undated agency policy “Physician Orders” indicated all medications, treatments and services provided to patients must be ordered by a physician. 3. Patient #1’s clinical record included a POC for certification period 3/09/25 to 5/07/25 with orders for SN visit frequencies of three visits a day for nine weeks. The record evidenced SN visits were performed two times a day on 3/11/25 and three times a day on 3/09/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, 3/15/25, 3/16/25, 3/17/25, 3/18/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/26/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, 3/31/25, 4/01/25, 4/02/25, 4/03/25 and 4/04/25. The POC was signed by NP E on 4/04/25. The clinical record for Patient #1 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 4/04/25 at 3:09 PM, the Alternate CM relayed she did not receive any recertification POC orders for Patient #1. 4. Patient #6’s clinical record included a POC for certification period 12/15/24 to 2/12/25 with orders for HHA visit frequencies of two visits a day, five to seven days a week for eight weeks and then two times a day, two to three days a week for one week. The record evidenced HHA visits were performed two times a day on 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/20/24 and 1/01/25 and one time a day on 12/21/24, 12/22/24, 12/23/24, 12/24/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24 and 1/03/24. The clinical record for Patient #6 failed to include a verbal or signed written order for the HHA frequencies was obtained prior to the above visits performed. During an interview on 4/07/25 at 12:30 RM, RN 1 relayed they contacted the community nurse at Entity F to inform Physician G of Patient #6 returning from another state and home health care was restarted. RN 1 relayed they did not receive any orders from Physician G at SOC. 5. Patient #7’s clinical record included a POC for certification period 10/24/24 to 12/22/24 with orders for HHA visit frequencies of one to two visits a week for one week; then four to five visits a week for eight weeks. The record evidenced HHA visits were performed 10/24/24, 10/25/24, 10/29/24, 10/30/24, 10/31/24, 11/01/24, 11/04/24, 11/05/24, 11/06/24, 11/07/24, 11/08/24, 11/11/24, 11/12/24, 11/13/24, 11/14/24, 11/15/24, 11/18/24, 11/19/24, 11/20/24 and 11/21/24. The clinical record for Patient #7 failed to include a verbal or signed written order for the HHA frequencies was obtained prior to the above visits performed. During an interview on 4/07/25 at 12:40 PM, RN 1 relayed they did not collaborate with the attending physician for recertification POC orders. 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 home health agency failed to ensure all verbal orders were signed by the ordering provider within 30 days for 1 of 1 active records reviewed with Person H listed as the attending physician (Patient #3). Findings include: 1. An agency policy C-635 “Physician Orders” indicated when a nurse received a verbal order from a physician, the order should be written as given and “sent to the physician for signature.” The agency was to utilize a “system … to ensure the telephone orders are signed and dated by the physician and returned to the patient’s clinical record within an appropriate time frame. Agency will implement a tracking system to assure timely response.” 2. Patient #3’s clinical record included an order for home health aide services documented as received from Person H, a physician, by CM on 2/25/25. The record failed to evidence this order was co-signed by Person H until 4/04/25, which was 38 days after the order was received. During an interview on 4/08/25 beginning at 12:00 PM, CM reported she received the 2/25/25 order verbally from Person H. CM reported all verbal orders were to be co-signed by the physician within 30 days. 410 IAC 17-14-1(a)(H)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to document and conduct a performance improvement project(s) approved by the QAPI committee, which had the potential to affect all agency patients and employees. Findings include: 1. The review of the agency’s QAPI meeting minutes for 2024 – 2025 failed to evidence at least one performance improvement project (PIP) had been approved and implemented by the QAPI committee. During an interview on 4/10/25 beginning at 10:30 AM, Administrator reported she oversaw the QAPI committee and activities. Administrator reported the QAPI committee was currently working on reducing patient fall rates and improving the agency’s staffing shortages. Administrator was unable to provide evidence of performance improvement projects revolving these issues, including the goal(s) of the PIPs, interventions or tasks to be implemented, and the projects’ results.

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, record review, and interview, the agency failed to ensure employees followed standards of practice for hand hygiene to reduce the spread of infections for 1 of 1 home visit observation with the HHA (HHA 2). Findings include: 1. The undated agency policy “Handwashing/Hand Hygiene” indicated hand washing and hand antisepsis should be completed before and after each task performed. 2. During a home visit observation conducted with Patient #5 and HHA 2 on 4/09/25 beginning at 8:30 AM, HHA 2 applied gloves and performed peri care to Patient #5. HHA 2 failed to perform hand hygiene prior to putting on the gloves. 3. During an interview on 4/09/25 at 10:08 AM, HHA 2 relayed hand hygiene should have been performed after every activity including bathing, laundry, dishes, peri care, etc. 4. During an interview on 4/09/25 at 12:10 PM, the CM relayed hand hygiene should be performed all the time; before any hands on tasks, food handling, touching soiled laundry and between glove changes. 410 IAC 17-12-1(m)

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the skilled nurse failed to document an assessment of the patient's pain for 1 of 1 records reviewed of a patient diagnosed with dementia (Patient #2) and failed to document their assessment of a wound for 1 of 1 record reviewed of a patient with an active wound (Patient #3). Findings include: 1. The agency policy G-100 “Application of Dry Dressing” indicated documentation of a wound should include the wound’s “appearance, odor … Amount and characteristics of drainage ….” 2. The agency policy C-148 "Pain Assessment/Management" indicated "if the patient has pain that interferes with activity or movement on a daily basis or is determined to be intractable, pain management will be a specific intervention on the plan of care." The policy indicated pain was to be "assessed on every home visit using a standardized agency accepted pain assessment tool … assessment of presence of pain and treatment/response will be incorporated into all agency assessment/reassessment tools." 3. Patient #2’s clinical record included a POC for the recertification period of 3/04/25 – 5/22/25. The POC included a SN intervention to “assess pain including: pain level, frequency, location, quality, precipitating factors, and side effects.” A comprehensive recertification assessment, completed on 3/23/25 by RN 1, indicated the nurse was unable to assess Patient’s pain “due to Patient’s condition.” Patient was noted to be alert and had dementia with “impaired cognition and judgement.” Patient’s medication list included an order for Tylenol Arthritis (a medication used to treat pain) to be taken every eight hours scheduled. A SN visit, completed on 3/24/25 beginning at 7:20 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 3/25/25 beginning at 7:49 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 3/26/25 beginning at 7:12 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 3/27/25 beginning at 7:50 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 3/28/25 beginning at 7:45 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 3/29/25 beginning at 8:14 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 3/30/25 beginning at 8:17 AM by RN 1, indicated the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 3/31/25 beginning at 7:42 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 04/01/25 beginning at 7:36 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 04/02/25 beginning at 7:49 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 04/03/25 beginning at 8:08 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 04/04/25 beginning at 7:53 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 04/05/25 beginning by 7:59 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” A SN visit, completed on 04/06/25 beginning at 7:57 AM by RN 1, indicated Patient was alert however the nurse was unable to assess Patient’s pain “due to Patient’s condition.” During an interview on 4/08/25 beginning at 3:08 PM, RN 1 reported he assessed Patient’s pain at each visit by looking for non-verbal cues, such as grimacing and abnormal breathing. RN 1 stated he would document the assessment as “no pain indicated.” The record failed to evidence RN 1 assessed Patient’s pain using an appropriate pain rating scale, such as the Pain Assessment in Advanced Dementia (PAINAD) scale, during the comprehensive assessment or SN visits. 4. Patient #3’s clinical record included a POC for the recertification period of 2/28/25 – 4/28/25. The POC included a SN intervention to “perform assessment … daily.” A diabetic ulcer (open wound caused by complications of diabetes) to the right foot was first noted on 3/26/25. Patient’s wound care orders indicated the dressing was to be changed every other day. A SN visit, completed on 4/02/25 by LPN 2, indicated wound care was performed but failed to evidence a description of Patient’s wound appearance, including wound bed tissue, surrounding skin appearance, presence or absence of drainage, etc. A SN visit, completed on 4/05/25 by LPN 2, indicated wound care was performed but failed to evidence a description of Patient’s wound appearance, including wound bed tissue, surrounding skin appearance, etc. During an interview on 4/07/25 beginning at 12:31 PM, LPN 2 reported a wound assessment should include observing for signs and symptoms of infection and the presence or absence of drainage, odor, and pain. LPN 2 reported she would document her assessment within the visit note at each visit, however the record failed to evidence a description of the wound appearance, presence or absence of odor, and if any drainage was noted. During an interview on 4/08/25 beginning at 10:15 AM, CM reported an assessment of Patient’s wound should be done at each visit when wound care was performed. The assessment should include the wound bed tissue, presence or absence of drainage, and the appearance of the surrounding skin. CM confirmed LPN 2’s visit notes from 4/02/25 and 4/05/25 failed to evidence a description of Patient’s wound appearance, presence or absence of odor, and if any drainage was noted. 410 IAC 17-14-1(a)(1)(B)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the SN failed to provide services as ordered in the POC for 2 of 2 patient records reviewed with multiple daily SN visits ordered (Patient #1 and 2). 2. Patient #2’s record included a POC for the recertification period of 3/24/25 – 5/22/25. RN 1 completed a recertification comprehensive assessment on 3/23/25 and CM signed the POC on 3/23/25. The POC included orders for SN visits to be done three times a day for nine weeks “for diabetic management and physical assessment.” During a home visit observation conducted on 4/04/25 beginning at 12:00 PM, LPN 2 conducted the second SN visit of the day. The nurse obtained Patient’s vital signs and questioned Patient on their pain, how they slept overnight, and what they had eaten for breakfast. LPN 2 failed to conduct a further physical assessment of Patient during the visit. During an interview on 4/04/25 beginning at 12:17 PM, LPN 2 reported the SN physical assessment of Patient was only conducted during the first visit of the day. During an interview on 4/08/25 beginning at 10:06 AM, CM reported the SN physical assessment was only conducted during the first visit of the day. CM reported the POC failed to clearly identify the frequency the SN interventions were to be completed. Findings include: 1. The undated agency policy “Patients’ Rights & Responsibilities” indicated the client has a right to receive all services outlined in the plan of care. 2. Patient #1’s clinical record included a POC for the certification period 3/09/25 to 5/07/25. The Alternate CM completed a recertification comprehensive assessment on 3/05/25. The POC included orders for SN to obtain blood sugar, administer insulin, perform assessment and obtain vital signs three times a day for nine weeks and medication set up weekly. During a home visit observation conducted with Patient #1 and LPN on 4/04/25 at 11:25 AM, LPN 1 obtained Patient #1’s blood sugar from the glucose monitor device, obtained vital signs and administered insulin. LPN 1 failed to perform an assessment of Patient #1 as ordered on the POC. The POC for Patient #1 failed to clearly identify when the SN assessment should be performed. During an interview on 4/04/25 at 2:45 PM, the CM relayed when a patient has multiple visits a day, the comprehensive assessment is completed during the morning visit and she confirmed the POC orders for Patient #1 should clearly identify when the SN assessment should be performed. During an interview on 4/07/25 at 12:49 PM, LPN 1 confirmed she did not perform an assessment on Patient #1 during the home visit observation and relayed Patient #1 only received a SN assessment during the morning visit. 410 IAC 17-14-1(a)(2)(F)

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all SN visit note documentation was completed accurately for 1 of 1 active patient record reviewed who received SN visits to set up the medications (Patient #1). Findings include: 1. The undated agency policy “Clinical Documentation” indicated all skilled services provided by Nursing will be documented in the clinical record. 2. Patient #1’s clinical record included a POC for the certification period 3/09/25 to 5/07/25 with orders for SN to perform weekly medication set up. The record evidenced SN visits were performed two times a day on 3/11/25 and three times a day on 3/09/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, 3/15/25, 3/16/25, 3/17/25, 3/18/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/26/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, 3/31/25, 4/01/25, 4/02/25, 4/03/25 and 4/04/25. The clinical notes for Patient #1 failed to evidence documentation of when the medications had been set up. 3. During an interview on 4/04/25 at 2:45 PM, the CM relayed LPN 3 was responsible for setting up Patient #1’s medications weekly and the POC should clearly identify when the medication set up should be performed. The CM also relayed the SN should have documented when the medications were set up on the SN visit notes. 4. During an interview on 4/07/25 at 12:49 PM, LPN 1 relayed LPN 3 was responsible for the medication set up for Patient #1. 5. During an interview on 4/08/25 at 1:45 PM, LPN 3 relayed she was responsible for the medication set up for Patient #1 and she relayed this SN task should have been documented in the SN visit notes. 410 IAC 17-14-1(a)(2)(B)

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the HHA performed the required competency skills evaluation tasks with a patient or pseudo patient (See G768); the RN failed to prepare written care instructions for the HHA which clearly delineated when similar tasks were to be performed (See G798); and failed to ensure the HHA provided services according to HHA training safely as ordered in the HHA POC (See G800). Findings include: The cumulative effect of these systemic problems had the potential to impact all 55 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.80 Home health aide services.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the HHA performed the required competency skills evaluation tasks with a patient or pseudo patient (person acting as a patient) for 4 of 4 new hired HHA’s in the past year (HHA 2, 3, 4 and 5). Findings include: 1. The undated agency policy “Employee Orientation” indicated Home Health Aides will complete competency testing prior to providing patient care. 2. The undated agency policy “Personnel Records” indicated the personnel record for an employee will include, but not be limited to: Competency testing for home health aides and/or specific competencies per job title and Skills check if required per job description 3. HHA 2’s personnel file evidenced a hire date of 3/25/25 and included a document titled “Home Health Aide/Hospice Aide Competency Checklist” dated 3/27/25, signed by RN 1. The required skills to be performed on a live patient or pseudo-patient, included communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed, tub and sponge bath, sink, tub and bed shampoo, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation; and normal range of motion and positioning were marked as met via demonstration. During an interview on 4/09/25 at 3:25 PM, RN 1 relayed the HHA skills evaluation for HHA 2 was completed via oral demonstration and not on an actual patient. During an interview on 4/10/25 at 10:46 AM, HHA 2 relayed RN 1 asked her to verbally describe how to perform the skills competencies and she did not perform any hands-on skills competencies with a live patient or pseudo-patient. 4. HHA 3’s personnel file evidenced a hire date of 9/17/24 and included a document titled “Home Health Aide/Hospice Aide Competency Checklist” dated 9/17/24, signed by RN 1. The required skills to be performed on a live patient or pseudo-patient, included communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed, tub and sponge bath, sink, tub and bed shampoo, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation; and normal range of motion and positioning were marked as met via demonstration. During an interview on 4/09/25 beginning at 2:10 PM, HHA 3 reported she had previously worked as a home health aide at another agency but had an approximate three-year gap prior to starting at Able Hands Homecare where she was not providing home health aide services for compensation. HHA 3 reported she did not complete an initial aide skills competency check with an RN prior to providing HHA services. During an interview on 4/09/25 beginning at 3:18 PM, RN 1 reported for HHA 3’s initial HHA skills competency check, he and the aide went to Patient #2’s home. Due to Patient’s minimal needs and lack of equipment in the home, HHA 3 was unable to perform a skills competency check on a patient or pseudo-patient for the tasks of bathing, skin care, oral care, transferring to and from a wheelchair and bedside commode, catheter care, and perineal care. 5. HHA 4’s personnel file evidenced a hire date of 3/25/25 and included a document titled “Home Health Aide/Hospice Aide Competency Checklist” dated 3/27/25, signed by RN 1. The required skills to be performed on a live patient or pseudo-patient, included communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed, tub and sponge bath, sink, tub and bed shampoo, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation; and normal range of motion and positioning were marked as met via demonstration. During an interview on 4/09/25 at 3:25 PM, RN 1 relayed the HHA skills evaluation for HHA 4 was completed via oral demonstration and not with an actual patient. During an interview on 4/10/25 at 11:48 AM, HHA 4 relayed she did not perform any skills competencies on a live patient and she relayed RN 1 verbally explained how to do the task if the HHA was unsure. 6. HHA 5’s personnel file evidenced a hire date of 4/03/24 and included a document titled “Home Health Aide/Hospice Aide Competency Checklist” dated 4/03/24, signed by RN 1. The required skills to be performed on a live patient or pseudo-patient, included communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed, tub and sponge bath, sink, tub and bed shampoo, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation; and normal range of motion and positioning were marked as met via demonstration. During an interview on 4/10/25 at 10:03 AM, HHA 5 relayed she did not perform any skills on a live patient and she was checked off by RN 1 after verbally describing how to perform the required skills. 7. During an interview on 4/09/25 beginning at 3:18 PM, RN 1 reported he performed initial HHA skills competency checks with new aides in one patient’s home. RN 1 stated he would have the aide perform return demonstration on tasks the patient required. For tasks the patient did not require, he would “verbally walk through” how to perform the task with the aide. 410 IAC 17-14-1(1)(A)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the RN failed to prepare written care instructions for the HHA which clearly delineated when similar tasks were to be performed for 1 of 3 active records reviewed of patients receiving HHA services (Patient #4). Findings include: 1. Patient #4’s clinical record included POCs for the recertification periods of 2/02/25 – 4/02/25 and 4/03/25 – 6/01/25. The POCs indicated Patient was to receive HHA services. The record included a home health aide care plan with tasks including “assist with bath … assist with shower.” The aide care plan failed to clearly delineate when the aide was to perform a bath or shower. Visit notes for the HHA visits conducted on 2/11/25, 2/12/25, 2/14/25, 2/17/25, 2/18/25, 2/20/25, 2/24/25, 2/25/25, 2/26/25, 2/27/25, 2/28/25, 3/03/25, 3/04/25, 3/05/25, 3/06/25, 3/13/25, 3/17/25, 3/19/25, 3/20/25, 3/21/25, 3/25/25, 3/26/25, 3/31/25, 4/03/25, and 4/04/25 evidenced HHA 3 documented both a shower and bath was completed. During an interview on 4/09/25 beginning at 2:10 PM, HHA 3 reported she determined how Patient was to bathe by asking Patient each visit. The aide stated if Patient did not feel like showering, the aide would assist Patient with a sponge bath. During an interview on 4/09/25 beginning at 3:45 PM, CM reported the aide care plan should clearly indicate when similar tasks were to be performed. 410 IAC 17-13-2(a)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure the HHA provided services according to HHA training for 1 of 1 home visit observation with HHA (Patient #5) and failed to ensure the HHA followed the aide care plan or notified the agency of a need to alter the aide care plan for 1 of 4 active records reviewed of a patient receiving HHA services (Patient #3). 2. Patient #3's clinical record included a POC for the recertification period of 2/28/25 to 4/28/25 and indicated Patient was to receive HHA services. The aide care plan indicated the aide was to assist with Patient's shower every weekday visit. The record evidenced HHA 10 documented Patient "refused" a shower during the HHA daily visits between 3/17/25 - 3/20/25, 3/24/25 - 3/28/25, and 3/31/25 -4/04/25. During an interview on 4/07/25 beginning at 12:45 PM, Patient #3 reported HHA 10 had been assisting Patient with a shower until a wound developed on the foot. Patient reported she was restricted from showering currently. During an interview on 4/08/25 beginning at 1:40 PM, HHA 10 reported Patient was restricted from showering due to a wound on their foot. The aide reported she had been assisting Patient with a sponge bath during the visits since Patient's wound first developed on 3/26/25. HHA 10 reported she had not notified anyone at the agency of Patient's showering restrictions and the need to alter the aide care plan. Findings include: 1. The undated agency “Home Health Aide Job Description” indicated the Home Health Aide follows a written or digital plan of care, which includes realistic goals and interventions, and is prepared by the RN Case Manager, Performs assigned activities that are taught by a RN and follows safety guidelines. 2. Patient #5’s clinical record included a POC for certification period 3/15/25 to 5/13/25 and indicated Patient #5 was to receive HHA visits 10 hours a day, seven days a week. The aide care plan indicated the patient was to receive a bath every visit. Review of the 3/15/25 SN comprehensive assessment, completed by RN 1, evidenced Patient #5 required total care and was unable to speak. 3. During an interview on 4/04/25 at 12:16 PM, Person A discussed past problems with the home health agency including an incident with HHA 1 and Patient #5 being left unattended in the bathtub. 4. Review of the home health agency complaint log on 4/04/25 at 12:55 PM evidenced a complaint filed on 2/19/25 by HHA 1. HHA 1 reported she was in and out of the bathroom while Patient #5 was in the bathtub. She heard him making noises and checked on him a couple of times. Patient #5’s caregiver became upset and asked HHA 1 to pay attention to Patient #5. HHA 1 failed to remain in the bathroom while Patient #5 was bathing to ensure patient safety. 5. During an interview on 4/09/25 at 12:10 PM, the CM relayed the HHA’s have been trained on bathing safety. 6. During an interview on 4/09/25 at 12:21 PM, the Administrator relayed all HHA’s had been trained on bathing safety. 7. During an interview on 4/09/25 at 1:58 PM, HHA 1 relayed she was educated to never leave a patient in the tub unattended and she never left Patient #5 unattended in the bathroom. During this same interview, she went on to say she sometimes left the bathroom to do laundry tasks, in another room, while Patient #5 was bathing in the bathtub. 8. During an interview on 4/10/25 at 10:03 AM, HHA 5 relayed she performed other assigned housekeeping tasks throughout the house while Patient #5 was bathing in the bathtub. She also relayed she goes in the bathroom every 3 or 4 minutes to check on Patient #5 to make sure he is still ok. HHA 5 failed to remain in the bathroom while Patient #5 was bathing to ensure patient safety.

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 observation, record review and interview, the clinical record failed to include accurate HHA supervisory clinical notes for 1 of 1 patient with a home visit observation with an HHA (Patient #5) and failed to ensure visit documentation was entered accurately for 1 of 1 patient record reviewed with HHA, ATTC and HMK services (Patient #4). 2. Patient #4’s clinical record included POCs for the recertification periods of 2/02/25 – 4/02/25 and 4/03/25 – 6/01/25. The POCs indicated Patient was to receive HHA and attendant care services. A HHA care plan included the tasks “assist with bath … assist with shower” but failed to evidence further direction on when the aide was to perform these tasks. A service plan for Patient’s attendant care services included the task “assist with shower” but failed to evidence further direction on when the attendant was to perform this task. Visit notes for the HHA visits and attendant care visits conducted on 2/11/25, 2/12/25, 2/14/25, 2/17/25, 2/18/25, 2/20/25, 2/24/25, 2/25/25, 2/26/25, 2/27/25, 2/28/25, 3/03/25, 3/04/25, 3/05/25, 3/06/25, 3/13/25, 3/17/25, 3/19/25, 3/20/25, 3/21/25, 3/25/25, 3/26/25, 3/31/25, 4/03/25, and 4/04/25 evidenced HHA 3 documented both a shower and bath was completed during the HHA visit and a shower was completed during the attendant care visit. The attendant care visit was documented as occurring immediately after the HHA visit ended. During an interview on 4/09/25 beginning at 2:10 PM, HHA 3 reported she assisted Patient with bathing as part of both her HHA and attendant care shifts. The aide reported over the past “couple” of months, Patient had requested on “4-5” visits to take a shower over two stages due to fatigue. HHA 3 stated during other visits, if Patient showered or bathed during the HHA visit, she would mark the “assist with shower” task as “not completed” for the attendant care visit. The record failed to evidence the aide accurately documented for which service Patient’s shower and/or bath was completed. During an interview on 4/09/25 beginning at 3:45 PM, CM reported the aide should accurately document which tasks were and were not performed during both the HHA and attendant care visits. Findings include: 1. The undated agency policy “Home Health Aide Supervision” indicated when Home Health Aide services are being furnished to a patient, a Registered Nurse must make a supervisory visit to the patient’s residence at least once every sixty (60) days. Each supervisory visit must occur when the Home Health Aide is providing patient care. 3. Patient #5’s clinical record included a POC for the certification period 3/15/25 to 5/13/25 and included orders for HHA services 10 hours a day seven days a week. The record evidenced documents titled “Supervisory Visit Record” completed on 2/04/25, 3/04/25 and 4/03/25 by RN 1. During a home visit observation on 4/09/25 at 8:30 AM, Person C relayed the RN did not perform HHA supervisory visits and had not discussed HHA performance with them. During an interview on 4/09/25 at 3:25 PM, RN 1 relayed the HHA supervisory visits were usually completed every 14 days and only 1 supervisory visit has to be completed in person annually, all other visits can be done by phone or with the family. RN 1 also relayed he completed the HHA supervisory visit for Patient #5 with HHA 1 on 4/03/24. Clinical record documentation evidenced HHA 1’s last visit with Patient #5 was on 2/19/25. HHA 5 was assigned to Patient #5 after 2/19/25. During an interview on 4/09/25 at 3:55 PM, the CM relayed the HHA supervisory visits should be completed every 30 days in person. During an interview on 4/10/25 at 10:03 AM, HHA 5 relayed RN 1 had not performed a HHA supervisory visit with her and Patient #5 yet.

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 home health agency failed to submit the discharge summary to the physician within 5 days of discharge for 1 of 1 discharge for cause record reviewed (Patient #7). Findings include: 1. Patient #7’s clinical record evidenced a discharge date on 12/16/24. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. 2. During an interview on 4/08/25 at 9:48 AM, the CM relayed she did not fax the discharge summary to the physician until 1/8/25, 23 days after Patient #7 was discharged.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Date: 6/29, 6/30, and 7/1/22 Facility Number: IN011316 Census = 57 At this Emergency Preparedness survey, Able Hands Homecare, was found to be in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Care Agency. Survey Dates: 6/29, 6/30, and 7/01/22 Partially Extended Survey Announced 6/30/2022 at 2:10PM. Extended survey was announced on 7/1/2022 at 10:30AM. Facility Number: IN011316 Census: 57 These deficiencies reflect State findings cited in accordance with 410 IAC 17. QA: A2 7/18/22

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency failed to ensure it provided all patients with the name, address, and telephone number of the QIO (Quality Improvement Organization that manages all beneficiary complaints and quality of care reviews) for 1 of 1 agency, with the potential to affect all patients of the agency. Findings include: Review of an undated agency document titled “Client Orientation to Agency Homecare” included Section III. Your Rights and Responsibilities as a Health Care Client that indicated “… the client has the right to be advised of federally funded … entities that serve the area where the client resides … Quality Improvement Organization ….” During an interview on 6/29/22 at 10:50AM, the director of nursing indicated the agency no longer provided information regarding the QIO because they no longer provided Medicare services.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current psychosocial and functional status for 1 of 2 active records reviewed that received skilled nursing services (Patient #5). Findings include: 1. Review of an undated agency policy C-145, titled, “Comprehensive Patient Assessment,” indicated “… comprehensive and accurate assessment, consistent with the patients’ immediate needs will be completed for all patients ….” 2. Record review for Patient #5, included a plan of care for certification period 5/19/22-7/17/22 with a diagnosis, but not limited to, cerebral palsy (group of disorders that affect movement and muscle tone or posture). The plan of care indicated “… nutritional req [requirement] … DAT (diet as tolerated) ….” A. Review of the comprehensive assessment, dated 5/18/2022, documented “… nutritional status comments … NPO (takes nothing by mouth) g-tube (tube inserted through the abdomen that brings nutrition directly to the stomach) feeding … Assessment Summary … patient is NPO and receives all meds and nutrition via G-tube ….” B. Review of documents titled “Nursing Visit Record,” dated 05/31/2022, 06/04/2022, and 06/14/2022, indicated Patient #5 ate food by mouth for dinner during the visit. 3. During an interview on 7/01/22 at 2:35PM, the director of nursing indicated Patient # 5 has a g-tube and had aspirated (something enters the airway or lungs by accident) and did not know that Patient #5 was eating by mouth.

HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency’s home health aide (HHA) training program failed to include training regarding adequate nutrition intake, with the potential to harm all patients receiving HHA services, for 1 of 1 agency. Findings include: An agency document titled, “Certified Home Health/Hospice Aide Checklist,” undated and reviewed on 7/1/22, failed to evidence evaluation of knowledge of adequate nutrition intake. During an interview on 7/1/22 starting at 2:35 p.m., the director of nursing relayed they could not produce evidence of the agency’s HHA training program included education and testing regarding adequate nutrition and intake.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA) care plan was specific to the needs of the patient for 3 of 4 active record reviews with orders for HHA services (Patient #3, 6, and 7). Findings include: 1. Review of an undated agency job description C-140, copyright Briggs Corporation titled “Position: Home Health Aide” indicated “… provides personal care services under the direction of the Registered Nurse ….” 2. Record review for Patient #3, contained a plan of care for certification period 5/22/22 - 7/20/22, included patient diagnosis of cognitive impairment and orders for HHA services for 1-2 hours, 4-5 days a week with HHA interventions that included to “assist [patient] with personal care and ADL’s (daily self-care activities); bathing, skin care … and other tasks as outlined in HHA care plan ….” Review of a document titled “HHA Agency Homecare Care plan”, dated 7/21/21, with review date of 5/17/22, indicated “… sponge / bed bath … bath tub / shower … assist bath / shower … skin care / peri care ….” Each task was marked for completion 7 days of the week. The document failed to provide specific directions to the HHA regarding the frequency to provide the tasks and failed to specify the task to be completed. 3. Record review for Patient #6, contained a plan of care for certification period 5/30/22 - 7/28/22 with order for HHA services 1-2 hours, 3-5 days a week with HHA interventions that indicated “assist with personal care, ADL’s, bathing, skin care and other tasks as outlined in the HHA care plan ….” Review of a document titled “HHA Agency Homecare Care plan” dated 11/30/2021, with review date of 05/27/2022, indicated “… sponge / bed bath … bath tub / shower … assist bath / shower … skin care / peri care ….” Each task was marked to be completed 7 days of the week. The document failed to provide specific directions to the HHA regarding the frequency to provide the tasks and failed to specify the task to be completed. 4. Record review for Patient #7, contained a plan of care for certification period 6/09/22 - 8/07/22 with diagnoses that included, but not limited to, post polio syndrome, anxiety disorder, functional limitations included paralysis, endurance, and ambulation, dyspnea on exertion, wheelchair for mobility, orders for HHA services for 4 hours a day, 7 days a week with HHA interventions that indicated (sic) “… assist with ADLs / personal care and other tasks as outlined in in the Home Health Aide care plan ….” Review of a document titled “HHA Agency Homecare Care plan” dated 6/09/22, indicated “… sponge / bed bath … bath tub / shower … assist bath / shower … skin care / peri care ….” The document failed to provide specific directions to the HHA regarding the specific task to be completed. 5. During an interview on 06/30/2022 at 3:30PM, the director of nursing [DON] relayed that multiple bathing tasks were on the aide care plans and as to be completed daily because the patients directed the care and were to relay to their aide which task was to be completed, each day. When asked, the DON relayed that a tub bath and shower were different tasks.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA) followed the plan of care for 1 of 2 non-skilled active records reviewed with orders for home health aide services only (Patient #7). Findings include: 1. Review of an undated agency job description C-140, copyright Briggs Corporation titled “Position: Home Health Aide” indicated “… provides personal care services under the direction of the Registered Nurse … Documents care provided ….” 2. A home visit was conducted on 06/30/2022 at 9:45AM, with Patient #7 who relayed HHA #2 applied an ace wrap (elastic bandage) to their left leg, every morning. Record review for Patient #7, contained a document titled “HHA Agency Homecare Care plan”, dated 06/09/2022. The HHA care plan failed to evidence an intervention for the application of an ace wrap to patient's leg. 3. During an interview on 06/30/2022 at 3:30PM, the director of nursing indicated the HHA was not to perform tasks that were not on the aide care plan and should notify the office if patient / caregiver requests tasks that are not on the care plan.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient’s clinical records would be made available to the patient, free of charge, upon request, at the next home visit or within 4 business days (whichever came first) for 1 of 1 agency. Findings include: Review of an undated agency document titled “Client Orientation to Agency Homecare” included a section titled “Privacy Notice”, dated 10/04/2006, that indicated “… right to inspect and copy … the fee for making and providing copies of medical records is a fifteen dollar ($15) retrieval fee for the first ten pages and twenty-five cents … page thereafter and any postage costs … we will act on your request within thirty (30) calendar days after we receive your request ….” During an interview on 6/29/22 at 10:50AM, the director of nursing indicated that when a patient or patient representative request a copy of the clinical record, the agency provided copies within a few days and charged a fee per page.