Every finding on record at Precious Pearl Home Health Care Agency LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 11/17, 11/18, and 11/19/2025. Active Census: 10 At this Emergency Preparedness survey, Precious Pearl Home Health Care Agency LLC. was found to be in compliance with Emergency Preparedness Requirements for a Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 11/21/2025.

This visit was for an Initial Federal Medicaid and Initial State Licensure survey for a Home Health provider. Survey Dates: 11/17, 11/18, and 11/19/2025. 12 Month Unduplicated Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide ADLs Activities of Daily Living RN Registered Nurse SOC Start of care CM Clinical Manager SN Skilled Nursing POC Plan of Care DME Durable Medical Equipment QR completed by Area 3 on 11/21/2025.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC was individualized and included all necessary elements, including: services being provided, frequency and duration of visits, nutrition, caregiver status, advance directives, activities, onset dates of diagnoses, and hospitalization risk for 10 of 10 active clinical records reviewed. (Patients: #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings Include: 1. A review of an agency policy, effective date of 08/27/2024, titled “Plan of Care,” indicated but was not limited to, “ … The Plan of Care is based on a comprehensive assessment …2. The Plan of Care shall be completed in full to include: a. All pertinent diagnosis (es), principal and secondary, including dates of onset. E. Need for/presence of home medical equipment and assistive devices … k. Activities Permitted or restrictions. L. Specific dietary or nutritional requirements or restrictions … n. Medical supplies and equipment required … u. Other appropriate items … ” 2. A review of the clinical record for Patient #1, SOC date of 11/01/2025, contained a physician-signed POC for the initial certification period of 11/01/2025 through 12/31/2025. The POC listed principal diagnosis of Acute Stroke (a condition when blood flow to the brain is interrupted leading to brain damage), with onset date12/13/2024, other pertinent diagnoses listed Obesity, but failed to list the onset date, Dyslipidemia (a condition of abnormal fats in the blood), but failed to list onset date, Debility/Generalized Weakness, but failed to list onset date. The section titled “Activities Permitted” had checked cane and wheelchair, but failed to list the activities permitted. The POC failed to list Patient #1’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 11:45 AM, upon review of the clinical record for Patient #1, the Administrator/CM confirmed they did not sign the POC or date it and communicated they were unaware they needed to. When questioned about the POC containing activities permitted, advance directives, and hospital risk factors and interventions addressing those underlying risk factors, the Administrator/CM stated, after reviewing Patient #1’s POC, “I didn’t have it all on it.” 3. A review of the clinical record for Patient #2, SOC date of 11/01/2025, contained a physician-signed POC for the initial certification period of 11/01/2025 through 12/31/2025. The POC listed principal diagnosis of Dementia (a condition describing a group of symptoms affecting memory, thinking, and social abilities), other pertinent diagnoses listed Hypertension (a condition of high blood pressure), Unsteady Gait (a pattern of walking that is unstable), Gout (a condition of elevated urate crystals accumulated in a joint causing inflammation and intense pain), but failed to list onset dates of all the diagnoses listed. The section titled “Activities Permitted” had check cane, walker, and wheelchair, but failed to list the activities permitted. The POC failed to list Patient #2’s advanced directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. A review of a document dated 08/08/2025, titled “Durable Power of Attorney,” indicated Patient #2 designated Admin 4, the agency’s Secretary, and the daughter of Patient #3 as their Attorney-In-Fact, signed on 08/08/2025. During an interview on 11/18/2025, at 9:40 AM, Admin 2, the agency’s Secretary, confirmed they were the family member and the Durable Power of Attorney for Patient #2. Admin 2 signed the consent for a home visit at Patient #2’s residence. 4. During an interview on 11/18/2025 at 9:41 AM, the Administrator/CM confirmed they had completed the POC for Patient #2 and did not know they needed to sign the POC. The Administrator/CM further indicated they had not documented the advanced directives, activities permitted, or hospital risk for Patient #2’s POC. 5. A review of the clinical record for Patient #3, SOC date of 10/10/2025, contained a physician-signed POC for the initial certification period of 10/10/2025 through 12/09/2025. The POC listed principal diagnosis of Pressure Ulcer (a condition of localized damage to the skin and/or underlying tissue that occurs due to sustained pressure over a bony prominence), with onset date 08/20/2025, other pertinent diagnoses listed Cellulitis of Lower Extremities (a condition of bacterial infection of the skin and the tissues beneath it), Morbid Obesity, Peri Area Maceration (a condition of softening and breakdown of the skin that occurs due to prolonged exposure to moisture), but failed to list onset dates for the listed other pertinent diagnoses. The section titled Nutritional Requirements” listed Not Applicable (N/A). The section titled “Activities Permitted” had checked cane and wheelchair, but failed to list the activities permitted. The POC failed to list Patient #3’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 2:20 PM, when asked regarding Patient #3’s nutritional requirements, advance directives, and hospital risk, upon review of the POC for Patient #3, the Administrator/CM stated, “Oh, why did I do that N/A in the nutrition?” 6. A review of the clinical record for Patient #4, SOC date of 10/13/2025, contained a physician-signed POC for the initial certification period of 10/13/2025 through 12/12/2025. The POC listed principal diagnosis of Myocardial Infarction (a condition when blood flow to a part of the heart muscle is blocked or restricted, leading to tissue damage or death), with onset date 09/26/2020, other pertinent diagnoses listed Essential Hypertension (a condition of high blood pressure), with onset date 11/05/2020, Patient Noncompliance with Medication or Self-Monitoring, but failed to list an onset date, Long Term use of Multiple Medications/Polypharmacy, but failed to list onset date. The section titled “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration) indicated a frequency of 1 or 2 times a week based on cardiovascular compliance and condition, with weekly medication set up for a duration of 6 to 8 weeks. The POC failed to list the discipline and failed to provide a specific frequency and duration for the visit. The POC failed to list Patient #4’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 2:11 PM, when questioned about the discipline providing services on the POC for Patient #4, the Administrator communicated Skilled Nursing isn’t on the POC and should be. The Administrator/CM further confirmed they had completed the unsigned and undated POC, and hospital risk, advance directives were missing, and when to notify the physician. 7. A review of the clinical record for Patient #5, SOC date of 10/13/2025, contained a physician-signed POC for the initial certification period of 10/13/2025 through 12/12/2025. The POC listed principal diagnosis of Pulmonary Arterial Hypertension (a serious condition characterized by high blood pressure in the arteries that supply blood to the lungs, increasing strain on the heart), other pertinent diagnoses listed, Obstructive Sleep Apnea (a condition of a sleeping disorder occurring when the muscles in the back of the throat relax too much causing temporary blockage of the airway), Obesity, and Chronic Pain, but failed to list onset dates of all diagnoses. The section titled “DME and Supplies” listed cane, shower chair, wheelchair, Continuous Positive Airway Pressure (CPAP) (a therapy device that delivers air in a mask worn to keep the airways open during sleep), and oxygen, but failed to list nasal cannula, tubing, oxygen concentrator, and portable oxygen tanks. The section titled “Activities Permitted” listed cane and wheelchair, but failed to list Patient #5’s activities permitted. The section titled “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration) indicated a frequency of 1 or 2 times a week based on respiratory stability and oxygen saturation levels for 8 weeks, but failed to list the discipline. The POC failed to list Patient #5’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 2:11 PM, when questioned about the discipline providing services on the POC for Patient #5, the Administrator/CM reviewed the POC for Patient #5 and communicated Skilled Nursing isn’t on the POC and should be. The Administrator/CM further confirmed that they had completed the unsigned, undated POC and that Patient #5 used nasal cannulas for their continuous oxygen. Upon further review of the POC, the Administrator/CM indicated hospital risk, advanced directives, oxygen nasal cannulas, tubing were missing, and call parameters for notifying the physician. 8. A review of the clinical record for Patient #6, SOC date of 10/24/2025, contained a physician-signed POC for the initial certification period of 10/24/2025 through 12/23/2025. The POC listed principal diagnosis of Paraplegia (a condition of paralysis of the lower half of the body caused by injury or disease of the spinal cord or nerves ), other pertinent diagnoses listed, Neuromuscular Dysfunction of Bladder (a condition which damage to the brain and nerves cause an abnormal function of bladder), Chronic Back Pain, and Depression, but failed to list onset dates of all diagnoses. The section titled “Activities Permitted” wheelchair but failed to list Patient #6’s activities permitted. The POC failed to list Patient #6’s advanced directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 2:07 PM, when asked about the POC for Patient #6, the dates of onset for diagnoses, activities permitted, call parameters, and hospital risk, the Administrator/CM reviewed the POC and communicated they had completed the POC and had not signed and dated it on completion. The Administrator/CM further indicated that they were unaware of the required dates for diagnoses. 9. A review of the clinical record for Patient #7, SOC date of 10/29/2025, contained a physician-signed POC for the initial certification period of 10/29/2025 through 12/28/2025. The POC listed the principal diagnosis of Multiple Myeloma (a cancer that forms in the white blood cells called plasma, affecting the ability to fight against infections), other pertinent diagnoses listed Other Reduced Mobility, Fatigue, and Chronic Back Pain, but failed to list the onset dates of all diagnoses. The section titled “Activities Permitted” listed cane but failed to list activities permitted for Patient #7. The POC failed to list Patient #7’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 11:45 AM, when asked who had completed the POC and the location of the diagnoses’ onset dates, advance directives, activities permitted, hospital risk, and call parameters, the Administrator/CM communicated they had completed the POC and were not aware they needed to sign and date it. The Administrator/CM, upon review, noted Patient #7’s POC further indicated call parameters, advanced directives, hospital risk, and onset dates were not listed on the POC. 10. A review of the clinical record for Patient #8, SOC date of 11/01/2025, contained a physician-signed POC for the initial certification period of 11/01/2025 through 12/30/2025. The POC listed principal diagnosis of Acute Ischemic Right Internal Carotid Artery (ICA) Stroke (a condition caused by decreased blood flow to the brain due to blood clotting, bleeding, or both), other pertinent diagnoses listed Degenerative Cervical Intervertebral Disc(a condition of breakdown of the disc in the cervical spine causing pain and discomfort in the neck), Degenerative Lumbar Intervertebral Disc (a condition of breakdown of the discs in the lumbar region leading to pain and dysfunction in the lower back), and Carotid Artery Stenosis (a condition of narrowing of the carotid arteries by a build of fatty deposits which leads to reduced blood flow to the brain and increased risk of stroke), but failed to list an onset date for all diagnoses. The section titled “Activities Permitted” listed wheelchair and walker, but failed to list activities permitted. The POC failed to list Patient #8’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 2:11 PM, when questioned about who completed the POC, and the location of activities permitted, advanced directives, hospital risk, and parameters on the POC for Patient #8, the Administrator/CM communicated they had completed the POC for Patient #8 and had not signed and dated the POC. The Administrator/CM further reviewed the POC for Patient #8 and indicated that the onset dates, advance directives, hospital risk, and parameters for notifying the physician were not listed. 11. A review of the clinical record for Patient #9, SOC date of 10/29/2025, contained a physician-signed POC for the initial certification period of 10/29/2025 through 12/28/2025. The POC listed principal diagnosis of Asthma with Exacerbation (a condition progressive increase in symptoms of airway constriction and inflammation in the airways of the lungs), other pertinent diagnoses listed Allergic Rhinitis (an allergic reaction that causes symptoms such as sneezing, congestion, itchy nose, when exposed to allergens), Childhood Emotional Disorder, and Sickle Cell Trait (a condition of carrying an abnormal genetic blood disorder), but failed to list an onset date for all diagnoses. The section titled “Activities Permitted” were left blank. The POC failed to list Patient #9’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 11:45 AM, when asked who had completed the POC and the location of the diagnoses’ onset dates, advance directives, activities permitted, hospital risk, and call parameters, the Administrator/CM communicated they had completed the POC and were not aware they needed to sign and date it. The Administrator/CM, upon review, noted Patient #9’s POC further indicated that call parameters, advanced directives, hospital risk, and onset dates were not listed on the POC. 12. A review of the clinical record for Patient #10, SOC date of 10/27/2025, contained a physician-signed POC for the initial certification period of 10/27/2025 through 12/26/2025. The POC listed the principal diagnosis of Sciatica (a condition of underlying symptoms caused by injury or pressure to the sciatic nerve in the lower back, causing sharp shooting pain, tingling, or numbness radiating down one side of the lower extremities), other pertinent diagnoses listed Anxiety and Depression, but failed to list an onset date for all diagnoses. The POC failed to list Patient #9’s advance directives, call parameters for blood pressure, pulse, respirations, oxygen saturation, and temperature, and failed to list a description of the patient's risk for emergency department visits and hospital readmission, as well as all necessary interventions to address the underlying risk factors. The POC section titled “Nurse’s Signature and Date” had been left blank. During an interview on 11/19/2025 at 11:45 AM, when asked who had completed the POC and the location of the diagnoses’ onset dates, advance directives, activities permitted, hospital risk, and call parameters, the Administrator/CM communicated they had completed the POC and were not aware they needed to sign and date it. The Administrator/CM, upon review, noted Patient #10’s POC further indicated that call parameters, advanced directives, hospital risk, and onset dates were not listed on the POC. 410 IAC 17-13-1(a)(1)(C)(D)(ii, iii, vii, vii, viii, and xiii)

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 the RN adhered to standard precautions to prevent the transmission of infections and communicable diseases through proper hand hygiene, gloving, and bag technique during 2 of 2 RN home visit observations. (Employee: Administrator/CM) Findings Include: 1. A review of an agency policy effective date 08/27/2025, titled “Handwashing/Hand Hygiene” indicated, but was not limited to, “ … In an effort to reduce the risk for Infection In clients and staff members … 3. Indications for handwashing and hand antisepsis include the following: … d. between tasks on the same client … f. After removing gloves … q. Decontaminate hands after contact with inanimate objects, including equipment in the immediate vicinity of the client … ” 2. A review of an agency policy effective date 08/27/2025, titled “Bag Technique” indicated but was not limited to, “ … The Precious Pearl Home Healthcare Agency mandates the use of proper bag technique during all home healthcare visits to reduce the risk of contamination and transmission of infections … 1. Use hand hygiene between contact with each item or piece of equipment, especially before and after using gloves … ” 3. During a home visit at Patient #2’s residence on 11/18/2025 at 11:45 AM, observed the Administrator/CM perform an assessment to Patient #2. The Administrator/CM performed hand hygiene, donned gloves, and obtained Patient #2’s blood pressure. Afterwards, the Administrator/CM observed and then reached into their bag after touching Patient #2 with their gloved hand to obtain their pen, without discarding their gloves, performing hand hygiene, and reaching into their clean bag. 4. During a home visit at Patient #3’s residence on 11/18/2025 at 3:00 PM, observed the Administrator/CM applying a blood pressure cuff on Patient #3’s left wrist. Afterwards, the Administrator/CM reached into their bag and obtained the thermometer, without discarding their gloves, and performing hand hygiene after touching Patient #3. During an interview on 11/18/2025 at 2:15 PM, when asked regarding glove changes, hand hygiene, and prior to them reaching into their clean bag process, the Administrator/CM stated, “No, I should have discarded my gloves, performed hand hygiene, donned new gloves prior to getting into my bag.” 5. During an interview on 11/19/2025 at 10:44 AM, when reviewing the visit observations with the Administrator/CM, asked about when gloves are to be changed and hand hygiene performed with the bag technique. The Administrator/CM communicated they knew they had reached into their bag to obtain the pen with their gloves after touching Patient #2. The Administrator/CM further indicated that their thermometer had fallen out of the bag they keep their equipment in, and that they had reached into their bag to retrieve it after touching Patient #3. 410 IAC 17-12-1(m)