Every finding on record at Preference Health Services Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 08/19/2025, 08/20/2025, 08/21/2025 and 08/22/2025 Active Census:30 At this Emergency Preparedness survey, Preference Health Services, was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: 08/19/2025, 08/20/2025, 08/21/2025 and 08/22/2025 CCN: 15K125 Unduplicated 12 month skilled admissions: 60 A partially extended survey was announced to the Clinical Manager and Administrator on 08/20/2025 at 4:15PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations used in the survey include RN for Registered Nurse, POC for Plan of Care

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 patient medications were reviewed in order to identify potential adverse effects, significant side effects and duplicate drug therapy and include frequency of medication in 2 of 2 skilled home visits completed (Patient #1, Patient #2) and in 1 of 1 active clinical records reviewed with insulin prescribed (Patient #6). Findings include: A Plan of Care for Patient #2, for certification period 07/20/2025 to 09/17/2025, lists Tylenol Extra Strength 500mg (2) tabs as needed for pain, but fails to evidence the frequency for which the medication can be taken. 2. During an interview with CM on 08/212025 beginning at 3:23 PM, CM indicated that there should be a frequency for the Tylenol as it is a risk to exceed 4000 mg a day which would only be four doses for Patient #2 and frequency and dose limit was not on the POC. 1. An undated policy, titled, “Comprehensive Assessment,” indicated the comprehensive assessment would include a review of all medications the patient was using in order to identify any potential adverse effects or duplicate drug therapy. 2. An undated policy, titled, “Medication Reconciliation,” indicated medications would be listed on the Medication Profile and include name, dose, route of administrator and frequency, medication review would occur with the Patient on each home visit to determine if other prescriptions or non-prescriptions drugs were being taken. 3. A Comprehensive Assessment Recertification for Patient #1, dated 08/04/2025, indicated medication regimen was reviewed with no new medications. A Patient Medication Record, dated 08/06/2025, indicated RN 1 reviewed all medications for drug interactions and duplicate drug therapy. The Medication Record indicated Patient medications included but not limited to Cardura (blood pressure medication) 4 milligrams (mgs) one tablet every night, start date 08/04/2025, and Doxazosin (generic name of Cardura) 4mgs one tablet every night, start date 08/04/2025; Glyburide (diabetes medication) 5 mgs one tablet daily, start date of 03/05/2020, Potassium 20 milliequivalents one tablet every day, start date of 03/05/2020, and Fluoxetine (antidepressant) 20 mgs one tablet daily, start date of 03/05/2020. During an observation of a home visit on 08/20/2025, beginning at 11:00 AM, during a medication box set up Patient’s Potassium prescription bottle indicated 20 milliequivalents one tablet twice a day and Patient indicated he/she had been on Potassium twice a day for a long time; a prescription bottle, dated 07/01/2025 for Fluoxetine indicated 20 mgs two tablets every day, and Patient indicated had not been on glyburide for six months. The Medication Record failed to indicate the Potassium at two times per day, Fluoxetine 2 tablets every day, and Patient not on glyburide; and indicated duplicate drug therapy for cardura and doxazosin. A Medication Interactions Note, printed on 08/20/2025, indicated duplicate drug therapy of Cardura/Doxazosin. During an interview on 08/20/2025, beginning at 11:00 AM, RN 1 indicated medication reconciliation would be completed and the medication record would be updated at every skilled nurse visit; and include duplicate medication identification. RN 1 indicated if duplicate medications were identified the physician should be notified and indicated she would be notifying the physician of the changed medications and the duplicate Cardura/doxazosin identified during the 08/20/2025 home visit and the medications should have been updated on the medication list. 4. A Comprehensive Assessment Recertification, dated 07/07/2025, for Patient #6 indicated medication regimen was reviewed. A Patient Medication Record indicated Novolin 70/30 (insulin for blood sugar control) per sliding scale blood sugar 60 – 150 no insulin, blood sugar 151 - 200 2 units, blood sugar 201 – 250 4 units, blood sugar 251 - 300 6 units, blood sugar 301 -350 8 units, blood sugar 351 – 400 10 units and blood sugar greater than 400 12 units with physician notification and failed to include frequency of sliding scale. During an interview on 08/20/2025, beginning at 11:00 AM, RN 1 indicated Patient checked blood sugars three times per day for the Novolin 70/30 insulin sliding scale and the frequency should have been included on the medication record. 410 IAC 17-14-1(a)(1)(B) The undated policy titled “Comprehensive Assessment,” indicated the comprehensive assessment would include a review of all medications the patient was using to identify any potential adverse effects or duplicate drug therapy. The undated policy, titled, “Medication Reconciliation,” indicated medications would be listed on the Medication Profile and include name, dose, route of administrator and frequency, medication review would occur with the Patient on each home visit to determine if other prescriptions or non-prescriptions drugs were being taken. The updated comprehensive reassessment for Patient #1, dated 08/04/2025, indicated medication regimen was reviewed with no new medications. A Patient ‘Medication Record,’ dated 08/06/2025, indicated RN 1 reviewed all medications for drug interactions and duplicate drug therapy. The Record indicated Patient’s medications included, but not limited to, Cardura (blood pressure medication) 4 milligrams (mgs) one tablet every night with start date 08/04/2025 and Doxazosin (generic name of Cardura) 4mgs one tablet every night with start date 08/04/2025, Glyburide (diabetes medication) 5 mgs one tablet daily with start date of 03/05/2020, Potassium 20 milliequivalents one tablet every day with start date of 03/05/2020, and Fluoxetine (antidepressant) 20 mgs one tablet daily with start date of 03/05/2020. During an observation of a home visit on 08/20/2025, beginning at 11:00 AM, RN1 preset medications, Patient’s Potassium prescription bottle indicated 20 milliequivalents one tablet twice a day and Patient indicated he/she had been on Potassium twice a day for a long time; a prescription bottle, dated 07/01/2025 for Fluoxetine indicated 20 mgs two tablets every day, and Patient indicated had not been on glyburide for six months. The Medication Record failed to indicate the Potassium at two times per day, Fluoxetine 2 tablets every day, and Patient not on glyburide; and indicated duplicate drug therapy for cardura and doxazosin. A Medication Interactions Note, printed on 08/20/2025, indicated duplicate drug therapy of Cardura/Doxazosin. During an interview on 08/20/2025, beginning at 11:00 AM, RN 1 indicated medication reconciliation would be completed, and the medication record would be updated at every skilled nurse visit; and include duplicate medication identification. RN 1 indicated if duplicate medications were identified the physician should be notified and indicated she would be notifying the physician of the changed medications and the duplicate Cardura/doxazosin identified during the 08/20/2025 home visit and the medications should have been updated on the medication list. *A Comprehensive Assessment Recertification, dated 07/07/2025, for Patient #6 indicated medication regimen was reviewed. A Patient Medication Record indicated Novolin 70/30 (insulin for blood sugar control) per sliding scale blood sugar 60 – 150 no insulin, blood sugar 151 - 200 2 units, blood sugar 201 – 250 4 units, blood sugar 251 - 300 6 units, blood sugar 301 -350 8 units, blood sugar 351 – 400 10 units and blood sugar greater than 400 12 units with physician notification; the record failed to include frequency of testing and use of the sliding scale. During an interview on 08/20/2025, beginning at 11:00 AM, RN 1 indicated Patient checked blood sugars three times per day for the Novolin 70/30 insulin sliding scale and the frequency should have been included on the medication record. 5. The clinical record for Patient #2 included a POC for the recertification period 07/20/20/2025 to 09/17/2025, included Tylenol Extra Strength 500 milligrams [mg] (2) tabs as needed for pain; the POC failed to evidence the frequency for which the medication was to be taken. During an interview with CM on 08/212025 beginning at 3:23 PM, she indicated the frequency for the Tylenol should be on the POC, as there is a risk to exceed 4000 mg a day which would only be four doses for Patient #2. She further relayed the dose limit was not on the POC. 410 IAC 17-14-1(a)(1)(B)

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 home health agency failed to ensure the patient received all services as written and had an individualized plan of care in 3 of 4 active skilled clinical records reviewed (Patient #1, Patient #2, Patient #6) Findings include: 1. Clinical Record for Patient #2, included the recertification period POC dated 07/20/2025 to 09/17/2025, and included the order for SN to refill medication biweekly. The record included two Skilled Nurse Visit notes dated 07/30/2025 and 08/13/2025 which failed to evidence documentation of medications being prefilled from 07/20/2025 thru 08/20/2025 as ordered. 2. A Plan of Care for Patient #5, for recertification period 07/19/2025 to 09/16 /2025, lists the SN to …refill pill box bi weekly. The record included two Skilled Nurse Visit notes dated 07/30/2025 and 08/13/2025 which failed to evidence documentation of medications being prefilled from 07/19/2025 thru 08/20/2025 as ordered. 3. During an interview with CM on 08/212025 beginning at 3:23 PM, CM indicated that documentation for medication refills should be on Skilled Nurse Visit notes and she could not find evidence of documentation. 1. An undated policy, titled, “Plan of Care,” indicated the plan of care would include but not limited to safety measures to protect against injury, treatments/procedures, and type, frequency and duration of all visits/services. 2. A Plan of Care, for Patient #1, for certification period 06/07/2025 to 08/05/2025, indicated skilled nurse visit one time per week for medication education/monitoring and medication box refill. A Plan of Care, for certification period 08/06/2025 to 10/04/2025, indicated skilled nurse visit one time per week for medication education/monitoring and medication box refill. Skilled Nurse Visit Notes dated 06/19/2025, 07/03/2025, and 07/13/2025 failed to evidence documentation of Patient’s medication box refill. A Clinical Record Review indicated skilled nursing visits 06/19/2025, 07/03/2025, 07/13/2025, 08/04/2025, and 08/20/2025 and failed to evidence one time per week skilled nursing visits were completed. During an interview on 08/20/2025, beginning at 11:00 AM, RN 1 indicated she had been providing skilled nursing visits for Patient every 2 weeks for medication box refills for at least 3 months. 3. A Plan of Care, for Patient #6, for certification period 07/10/2025 to 09/07/2025, indicated skilled nurse visit every other week for medication education/monitoring and refill medication box bi-weekly. Skilled Nursing Visit Notes dated 06/08/2025 and 07/25/2025, failed to evidence documentation of Patient’s medication box refill. During an interview on 08/20/2025, beginning at 11:00 AM, RN 1 indicated she does not refill Patient’s medication box and the skilled nursing visits were for assessment of blood pressure. During an interview, on 08/20/2025, beginning at 4:00 PM, the Administrator indicated Patient’s plan of care should not have included the skilled nurse for medication box refill. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care included safety precautions to prevent patient injury in 1 of 1 active clinical records reviewed with oxygen therapy (Patient #5). Findings include: 1. A Plan of Care for Patient #5 with a primary diagnosis of COPD (a lung disorder that makes breathing difficult), for certification period 07/20/2025 to 09/17/2025, indicates under O2 2L via N/C (nasal cannula) as needed for shortness of breath. The Plan of Care fails to evidence how or if patient was receiving their oxygen and any precautions related to oxygen. 2. During an interview with CM on 08/212025 beginning at 3:23 PM, CM indicated that since oxygen was listed on the med list they don’t need to place under DME & supplies, but did further indicate that oxygen precautions should be on the Plan of Care. An undated policy, titled, "Plan of Care," indicated the plan of care was to include but not limited to safety measures to protect against injury. 410 IAC 17-13-1(a)(1)(D)(x)

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the Quality Assurance and Performance Improvement (QAPI) program utilized quality indicator data from the Outcome and Assessment Information Set (OASIS) (a comprehensive assessment data collection tool) in 1 of 1 agency. Findings include: An agency form indicated CMS OASIS information was submitted on 06/27/2024 and failed to indicate further submission after 06/27/2024. An agency Census Form, dated 08/19/2025, indicated the last 12-month skilled patient admission was 16. A QAPI review on 08/22/2025, failed to evidence documentation of OASIS benchmark utilization within their QAPI program. During an interview on 08/22/2025, beginning at 10:40 AM, the Administrator indicated the agency did not utilize quality indicator data from the agency’s OASIS reports for the QAPI program in the last year.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency Administrator failed to ensure the OASIS (Outcome and Assessment Information Set, a comprehensive assessment data collection tool) information was electronically transmitted to CMS (Centers for Medicare and Medicaid Services) system in 1 of 1 agency after 06/27/2024. Findings include: 1. 1. An undated policy, titled, “Comprehensive Client Assessment,” indicated all skilled Medicare and Medicaid patients except pediatric and post-partum patients and patients receiving aide only or homemaking would have comprehensive assessments that included OASIS data set specific to mandated time points. An agency form indicated CMS OASIS information was submitted on 06/27/2024 and failed to evidence submission documentation after 06/27/2024. An agency Census Form, dated 08/19/2025, indicated the last 12 month skilled patient admission was 16. During an interview on 08/20/2025, beginning at 9:30 AM, the Administrator indicated the clinical agency owner was attempting to locate OASIS submission documentation. During an interview on 08/21/2025, beginning at 2:00 PM, the clinical agency owner indicated OASIS data should be submitted through the agency’s electronic medical record system every 30 days and she would need to see why she was unable to locate IQIES (CMS Internet Quality Improvement Evaluation System) OASIS reports for the last year. During a follow up interview on 08/22/2025, at 11:25 AM, the clinical agency owner indicated she had contacted CMS OASIS help desk on 08/22/2025, OASIS had not been submitted for 1 year due to a user role error in the electronic medical records system, she had to have the last year of OASIS data resubmitted, she was informed by the help desk she had to log into the provider OASIS data platform every 60 days and she had not been signing in due to did not have a large number of skilled patients to report in the past.

This visit was for a Federal Recertification and State Re-Licensure survey of a Medicaid Home Health Agency. Survey dates: 09-27, 09-28, 09-29-2022 Census: 17 QR by Area 3 on 10-04-2022

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients were notified in writing of the extent to which payment was expected from Medicaid, any out-of-pocket costs to the patient, or any charges the patient must pay for 1 of 6 active records reviewed. (Patient #5) Findings include: A review of the clinical record for Patient #5, start of care date 8/31/21, evidenced a document dated 8/31/21, titled “Consents, Authorization For Treatment, Financial Authorization & Release of Information.” Patient #5’s printed name was on the signature/authorized representative line followed by the printed name of Individual H, who was identified as a caregiver. The document indicated a home health aide frequency of up to 3 hours for 7 days a week and for 9 weeks. The document failed to indicate the frequency for skilled nursing visits and failed to indicate the insurance liability and out of pocket cost to the client for the skilled nursing and home health aide services. On 9/28/22 at 1:20 PM, the administrator indicated all patients received skilled visits PRN (as needed) by a skilled nurse for physical assessment or to identify problems. The administrator indicated Patient #5’s consent for treatment was blank and did not include notification of expected Medicaid payments, the frequency of skilled nurse visits, or the patient’s liability for skilled nurse and home health aide visits.

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 all patients received a comprehensive assessment that included the patient’s current health status, past medical history, and active health and medical problems, including the patient’s accurate health, psychosocial, functional, and cognitive status at the time of assessment, for 1 of 6 active records reviewed. (Patient #5) Findings include: A review of a comprehensive assessment for Patient #5, dated 8/25/22, 1 day prior to the certification period of 08/26 to 10/24/2022, indicated the patient was hospitalized from 8/18/22 - 8/24/22. An OASIS (Outcome and Assessment Information Set) Question M0032, resumption of care after hospitalization, was marked as not applicable and option #3, resumption of care after inpatient stay, was blank. The patient’s diagnoses included a history of TIA (Transient Ischemic Attack, a temporary period of symptoms similar to those of a stroke that usually disappear within one hour) and cerebral infarction without residual deficits (stroke or damage to tissues in the brain due to loss of oxygen without leftover effects of the damage); cerebral infarction due to unspecified occlusion or stenosis of an artery (damage to tissues in the brain due to loss of oxygen due to blockage of an artery); essential hypertension (high blood pressure that is not the result of a medical condition); non-dominant left-side hemiplegia (paralysis of the patient’s non-dominant left side); and other generalized epilepsy, not intractable, with status epilepticus (abnormal electrical activity occurring in both hemispheres at the same time, not uncontrollable, lasting more than 5 minutes, or more than one seizure within a 5-minute period without returning to a normal level of consciousness between the seizures; indicates a critical situation requiring rapid medical intervention). The comprehensive assessment evidenced Patient #5's symptoms were poorly controlled and needed frequent adjustment in treatment and dose monitoring, the patient was alert, oriented, and attended adult daycare 5 times a week, which would not be possible with status epilepticus because status epilepticus is a seizure or series of seizures which last longer than 5 minutes and are considered a medical emergency. The functional limitations failed to identify paralysis, ambulation/mobility, use of assistive devices, and risk of seizures. The patient's current immunization status was blank. The safety precautions failed to include a seizure plan, assistance with transfer and mobility, COVID-19 precautions, and failed to indicate an emergency plan was developed. A cultural assessment indicated religion was important to the patient but failed to indicate the patient was assessed for religious preference(s), impacts on care, or need for religious accommodations. The patient’s respiratory, endocrine, psychosocial, and cardiac statuses were documented as WNL (Within Normal Limits), failed to indicate what parameters were normal for this patient, and failed to evidence the assessment included auscultation, palpation, and observation including, but not limited to, quality of respirations, lung sounds, capillary refill, pulse quality, heart sounds, presence or absence of edema, presence or absence of carotid bruits, signs/symptoms of elevated blood pressure, and depression. The abdominal assessment failed to evidence auscultation, palpation, and observation of the abdomen including, but not limited to, bowel sounds, appearance, and quality and frequency of bowel movements. The neurological status failed to evidence the patient was assessed for current or residual signs/symptoms of stroke, seizures, and status epilepticus, per the diagnoses including, but not limited to recent/current seizures, type/cause/quality/quantity/duration of seizures, triggers, ability to safely manage seizures, pupil response, grip strength, reflexes, facial droop/smile, and sensory or motor function. The musculoskeletal status failed to indicate the patient had paralysis of the non-dominant side and failed to indicate the extent of hemiplegia and the effect on the patient's inability to use the affected side. The assessment failed to evidence the patient's cognitive status was assessed, including but not limited to, ability to read, write, communicate, and understand their own health and care needs. The patient required assistance for grooming and dressing the upper body, was totally dependent for lower body dressing, was able to bear weight and pivot, was unable to transfer, was chairfast (unable to leave one’s chair without assistance, unable to bear weight), and used a bedside commode with reminder or assistance. The assessment indicated skilled intervention was needed, failed to indicate the type of skilled care needed, and later in the assessment indicated no skilled services were indicated. The assessment failed to evidence information related to the patient's hospital stay, such as new diagnosis, residual deficits, decline, participation in physical or occupational therapy, or the reason for a 6-day hospital stay. The patient required assistance "in the AM" from a home health aide to get ready and meal preparation for adult daycare and failed to indicate specific needs such as hair care, dressing, hygiene, toileting, transfer, oral hygiene, peri care, medication reminders, and grooming. The patient required assistance in the PM for bathing, dressing, grooming, transferring, light house keeping (sic), meal prep/setup and medication reminders and failed to indicate specific needs such as toileting, peri care, hair care, and oral hygiene. The assessment failed to indicate the patient's ability/method of managing meals and self-care needs during the 21 hours the aide was not present, whether or not Patient 5's housing was part of a group home that provided ongoing aide support, the need for specialized transportation to adult daycare, and failed to indicate the patient was assessed for compliance, management, and understanding of oral medications, including dose, route, reason, frequency, and time. The assessment failed to accurately reflect the patient's current health, psychosocial, and functional status and failed to include the patient's past pertinent medical history and accurate medical problems. On 9/28/22 at 1:20 PM, the comprehensive assessment was reviewed with the administrator, who indicated it contained inconsistent documentation and had missing information and she would need to review it. The administrator indicated knowing status epilepticus required emergency medical intervention and the diagnosis was not consistent with a patient that was alert, oriented, received aide services at home and attended adult daycare 5 times a week. When asked for the patient's discharge information from the hospital, the administrator indicated it would be in the electronic medical record if the agency had it. The electronic medical record was reviewed with the administrator and failed to evidence information from the patient's 08/18 to 08/24/2022 hospital stay. 410 IAC 17-14-1(B)

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received an accurate comprehensive assessment that included the patient’s goals and care preferences, for 1 of 6 active records reviewed. (Patient #5), Findings include: A review of the recertification assessment for Patient #5, dated 8/25/22, evidenced the patient had no surrogate or patient representative and rented a room in a home with 3 roommates, one of whom also received Medicaid home health services, and who were "not responsible for assisting patient with daily care.” The assessment failed to indicate if the patient lived in a supervised group home, or had an alternate caregiver or emergency contact for the time period when the agency aide was not present or the patient was not at adult daycare. The cultural assessment indicated religion was important to the patient and failed to indicate the ways in which religion was important, such as religious denomination/preference(s), impact on care, or specific religious accommodations. The assessment failed to evidence the patient was assessed for care preferences and failed to evidence patient stated goals. On 9/28/22 at 1:20 PM, the comprehensive reassessment was reviewed with the administrator, who indicated there were no patient-stated goals or care preferences, including specific religious care preferences.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received an accurate comprehensive assessment that included the patient’s medical, nursing, rehabilitative, and discharge planning needs, for 1 of 6 active records reviewed. Findings include: A review of the comprehensive recertification assessment for Patient #5, dated 8/25/22, indicated the patient was hospitalized from 8/18/22 - 8/24/22, and indicated diagnoses of a personal history of TIA (Transient Ischemic Attack (a temporary period of symptoms similar to those of a stroke that usually disappear within one hour) and cerebral infarction without residual deficits (damage to tissues in the brain due to loss of oxygen without leftover effects of the damage); essential hypertension (high blood pressure that is not the result of a medical condition); non-dominant left-side hemiplegia (paralysis of the patient’s non-dominant left side); and other generalized epilepsy, not intractable, with status epilepticus (abnormal electrical activity occurring in both hemispheres at the same time, not uncontrollable, lasting more than 5 minutes, or having more than one seizure within that 5-minute period without returning to a normal level of consciousness between the two episodes). Symptoms were poorly controlled and needed frequent adjustment in treatment and dose monitoring. The patient was alert, oriented, and forgetful which was inconsistent with a diagnosis of seizures with status epilepticus. The patient was chairfast but able to wheel self, required assistance, reminder, or supervision for transfer on/off the toilet and assistance for grooming and upper body dressing, which was inconsistent with a diagnosis of hemiplegia, and was totally dependent for lower body dressing, which was inconsistent with GG0130C which indicated the patient required only supervision or touch assistance for toileting hygiene. The assessment failed to evidence the patient was assessed by a physical therapist and indicated a therapy threshold of zero. The patient had 2 or more hospitalizations within the last 6 months, 2 or more emergency department visits within the last 6 months, and was at current risk for pressure sores and rehospitalization. The assessment indicated to discharge “when patient is independent in management of medical needs” and failed to evidence how Patient #5, a chairfast, 68-year old with a history of seizures and status epilepticus, stroke, paralysis, incontinence, and dependence for activities of daily living, meals, and transportation, who received no therapy and no skilled nursing follow-up, would achieve independence in management of medical needs. On 9/28/22 at 1:20 PM, the comprehensive reassessment was reviewed with the administrator, who indicated the assessment had inconsistent and conflicting medical information, did not evidence a skilled nursing need, and did not include an assessment for physical therapy. The administrator indicated the agency does not utilize a professional coder or coding company and the agency nurses and clinical manager assign the diagnosis codes when they are completing the assessment and plan of care. the administrator indicated the patient’s diagnosis codes were chosen by the nurse completing the comprehensive assessment and reviewed by the clinical manager before being sent to the patient's physician on the plan of care. 410 IAC 17-14-1 (a)(1)(B)

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 plans of care included the patient’s rehabilitation potential, functional limitations, safety measures, and pertinent interventions and patient-specific, measurable outcomes and goals, for 1 of 6 active records reviewed. (Patient #5) Findings include: A review of the plan of care for Patient #5, for the certification period of 8/26/22 – 10/24/22, indicated the patient’s psychosocial status was WNL (Within Normal Limits) and failed to include any parameters to define what was WNL for this patient. The plan of care failed to evidence a seizure plan including, but not limited to, interventions to monitor and mitigate seizures, when to notify emergency personnel, and interventions for post-seizure management, The functional limitations failed to include ambulation/mobility, paralysis, seizures, specialized transportation, joint stiffness/pain, and transfer assistance. The plan of care indicated orders of “Home health aide duties may include but are not limited to: personal hygiene care, bathing/showering, assisting with ambulation, assisting with transfers, turning/positioning, assistance with wound prevention, incontinent care, checking integumentary status, medication assistance and reminders, meal preparations, and light housekeeping and failed to evidence specific home health aide duties to be provided. Review of the patient's goals indicated the patient would be free of falls during the certification period, patient's skin integrity would remain intact during this episode, and the patient would have no hospitalizations during the certification period and failed to evidence skilled nurse, therapy, or home health aide interventions to facilitate the prevention of falls, hospitalizations, or skin breakdown. The plan of care failed to evidence patient-specific goals and interventions related to personal care, seizure precautions and management, hypertension, medication education and management, signs/symptoms and education related to cerebral infarct and TIA (transient ischemic accident). On 9/28/22 at 1:20 PM, the administrator indicated the plan of care failed to include patient-specific goals and interventions related to personal care, seizure precautions and management, hypertension, medication education and management, signs/symptoms and education related to cerebral infarct and TIA (transient ischemic accident). The administrator indicated the plan of care orders for home health aide services may include the services enumerated on the plan of care, but didn't have to include all services provided because some were on the home health aide plan of care. 410 IAC 17-13-1(a)(1)(D)(v, vi, vii, x, 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 home health aide (HHA 3) failed to wear a mask while providing patient care in 1 of 3 home visits and failed to practice hand hygiene and gloving as part of infection control practices in 2 of 3 home visits. (Patients # 1 and 3) Findings Include: 5. During a home visit with Patient #1, on 9/29/22 at 7 AM, HHA (home health aide) #6 was observed completing hand hygiene with soap and water for less that 10 seconds. The aide donned gloves and assisted Patient #1 to ambulate to the shower, then undressed the patient and provided a full shower that included peri care. Upon completion of the shower, the aide dressed the patient in a brief and towel and assisted the patient to the bedroom. The aide was observed to dress the patient while wearing the same gloves worn throughout the patient's shower and peri care. The aide removed the gloves and donned new gloves without completing hand hygiene, then escorted the patient to the kitchen table. The aide discarded the gloves, completed hand hygiene with soap and water for less than 5 seconds, then donned new gloves and fed the patient oatmeal the aide had cooling in the freezer. The aide failed to perform hand hygiene between gloving and failed to perform standard hand hygiene for 20 - 30 seconds when using soap and water. 1. A review of an agency policy dated 4-3-20, titled “Wearing Mask for the Prevention of COVID -19,” indicated, “Policy: Wearing Face masks is needed to minimize the presence of illness and to prevent the spread of the Covid-19 Coronavirus … 1. Workers/Visitors are required to wear a face covering when working in situations where social distancing cannot be maintained….” 2. A review of an undated agency policy titled “Handwashing/Hand Hygiene” indicated, “Policy: In an effort to reduce the risk for infection in clients and staff members, thorough hand washing/hand antisepsis is required of all employees … 3. Indications for hand washing and hand antisepsis: … c. When there is prolonged or intense contact with the client (bathing the client) … d. Between tasks on the same client… 3. During a home visit on 09-28-22 at 7:05 AM for patient #3, the Certified Nursing Assistant, CNA #3, was observed entering patient #3’s home without wearing a face mask. The CNA performed hand hygiene, donned gloves, and was observed giving the patient a complete bed bath as patient #3 was lying in their hospital bed in the living area. CNA #3 was observed to wash, rinse, dry, and apply lotion to the patient’s face, arms, and back. The CNA removed patient #3’s pajama bottoms and soiled brief. CNA #3 then washed, rinsed, and lotioned patient #3’s legs then buttocks. Patient #3’s family member obtained clean water in the basin, and the CNA received a clean washcloth without removing their gloves and performing hand hygiene. CNA#3 proceeded to wash, rinse and dry patient #3’s perineal area, then applied a new brief and dressed patient #3 without removing their gloves, performing hand hygiene, and donning new gloves. The certified nursing assistant was never observed to have changed their gloves throughout the whole bath, using the same gloves for the entire bath. CNA #3 failed to wear a mask while bathing patient #3. These practices failed to follow infection control guidelines and the agency’s policies. During an interview on 09-28-22 at 7:40 AM, CNA #3 stated, “I know I made a mistake. I should have changed my gloves. I could just kick myself.” 4. During an interview on 09-28-22 at 11:59 AM, the Administrator/Clinical Manager confirmed the employees are to wear masks when they provide patient care per the agency policy. 5. During the daily conference on 09-28-22 at 2:00 PM, the Administrator and Owner of the agency confirmed masks are to be worn by the employees. They further confirmed they were aware that CNA #3 did not change their gloves whiled completing the complete bed bath during the home visit with Patient #3.