Every finding on record at Purpose Home Health LLC

Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a "qualified home health aide" as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA's patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA's patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the HHA training/competency was independent of the agency, as agency staff had scored/graded written competency exams and placed home health aides on the State Aide Registry, despite being precluded from doing so, for 4 of 4 newly licensed HHA personnel files reviewed. (HHAs 12, 13, 14, and 15) Findings include: 1. A review of an agency policy titled 'Competency Evaluation of Home Care Staff' stated, "… A Home Health Aide training and/or competency evaluation program may be offered by any organization except an Agency that has been determined to be out of compliance with one or more requirements of the Home Health Aide Services Condition of Participation within any one of the twenty-four (24) months before the training and/or competency evaluation program is to begin …" 2. Review of the personnel record for HHA 12 with a hire date of 07/30/2025, had completed HHA a training and competency program on 09/02/2025 and 09/03/2025, and evidenced a home health aide license issued 09/09/2025. The record evidenced a completed 160-question written competency exam which had been graded and not signed. 3. Review of the personnel record for HHA 13 with a hire date of 08/06/2025, had completed HHA a training and competency program on 09/02/2025 and 09/03/2025, and evidenced a home health aide license issued 09/09/2025. The record evidenced a 160-question 'scoring sheet' for a written competency exam, which had been scored, was not dated, and was not signed. 4. A review of the personnel record for HHA 14 with a hire date of 08/08/2025, had completed HHA a training and competency program on 09/02/2025 and 09/03/2025, and evidenced a home health aide license issued 09/09/2025. The record evidenced a 160-question written competency exam had been taken twice, was not dated, had been graded twice, and was not signed. 5. A review of the personnel record for HHA 15 with a hire date of 08/12/2025, had completed HHA a training and competency program on 09/02/2025 and 09/03/2025, evidenced a home health aide license issued 09/09/2025. The record evidenced a completed 160-question written competency exam which was dated 09/03/2025 which had been graded and was not signed. 6. On 09/08/2025 at 11:36 AM, in an interview, the Administrator/Clinical Manager indicated due to previous survey findings, and the resulting preclusion from providing their own home health aide training, the agency had hired two (2) third party contracted nurses to provide the home health aide skills training and competency testing. Person 8, a contracted RN, was hired 09/02/2025 and had started the previous week. Person 9, a contracted RN, was hired 09/04/2025 and started today. 7. On 09/09/2025 at 1:38 PM, in an interview, Person 8, an RN contracted to provide HHA training and competency, indicated they had started with the agency the previous week, and had completed the first set of training classes for HHA's last week. Person 8 stated HHA's had completed 60 hours of online education and training before coming to class, where hands-on training was provided. Person 8 stated they had completed all required training, skills competency and checks-offs with the aides, and the aides individually completed a 160-question written competency exam. Person 8 stated they had not graded or signed off on the written competency exams, had not personally provided or uploaded the aides' training and competency documents to the State Aide Registry, and believed the documents had been scanned in by Administrative Staff 8, an RN of the home health agency, and an office staff member. Person 8 stated, "I don't have access, I'm a 1099 contractor". 8. On 09/09/2025 at 3:14 PM, in an interview with Person 9, an RN contracted to provide HHA training and competency, indicated they had started with the agency the previous day and had completed training and competency for home health aide trainees 09/09/2025. Person 9 stated they had not signed off on the trainees' written competency exams, but Administrative Staff 6 had signed off and graded the exams. Person 9 stated it was their understanding that all the trainees had passed. Person 9 stated they understood Administrative Staff 6 had the documents from today and would get the trainees on the registry. Person 9 indicated did not know how to place someone on the registry. 9. On 09/09/2025 at 3:34 PM, in an interview, Administrative Staff 6 indicated was not clinical themselves, and they understand now that it was incorrect to have agency staff grade/score, sign off on the HHA written competency exams, and place trainees on the aide registry. Administrative Staff 6 indicated they would be bringing all the aides back to office to ensure the documents were completed properly. 10. On 09/10/2025 at 9:39 AM, in an interview, when queried as to the HHA written competency exams being graded and signed off, and sent to the aide registry by agency staff, the Administrator/Clinical Director stated the agency would have to ensure the aides "go back and retake" the exams. When queried as to the agency's process for placing aides on the registry, indicated would not be utilizing their own staff going forward, and would need to figure out how Person 8 and Person 9 would do so.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for Home Health Agencies. Survey Dates: 07/24/2025, 7/25/2025, 07/28/2025, 07/29/2025, 07/30/25 and 08/04/2025 Census: 2,718 At this Emergency Preparedness Survey, PurposeCare of Indiana was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 3 on 8/6/2025.

This visit was for a Federal and State licensure complaint of a home health provider. Complaint # IN002563644 Survey Dates: 07/24/2025, 07/25/2025, 07/28/2025, 07/29/2025, 07/30/2025 and 08/04/2025. Unduplicated 12-month Skilled Admissions: 37 An Immediate Jeopardy, identified at §484.80 began on 06/20/2025, when it was identified the agency failed to ensure a home health aide was properly trained on the safe use of a Hoyer. On 06/20/2025 HHA #3 was transferring Patient #1 fell out of their Hoyer lift (medical device designed to safely lift and transfer individuals who are unable to bear weight or have limited mobility, utilizing a sling and a mechanical lifting mechanism, either manual or electric, to move patients between surfaces like beds, chairs, or wheelchairs), HHA 3 stated the patient was already in the air and they hadn't checked all the straps, the patient fell to the floor and hit their head, as a strap was not secured. Patient #1 declined a transfer to the hospital following an RN assessment. An RN did not conduct a direct observation of the HHA providing care, after the concern had been identified. HHA 3 indicated they did not know what Patient #1's care needs were when they arrived, indicated an aide in the home showed HHA 3 how to use the patient's Hoyer, and the agency provided no training on using a Hoyer lift, was unsure who their orientation was conducted by, and "did the application, went over skills, we did not demonstrate anything, and they just talked". The patient's plan of care failed to evidence the Hoyer lift among the Durable Medical Equipment orders, and failed to evidence orders for the home health aide to transfer the patient, or to utilize a Hoyer lift to do so. The Administrator/Director of Nursing was notified of the Immediate Jeopardy on 07/29/2025 at 10:39 AM. The provider submitted a removal plan on 07/29/2025, which was found to be acceptable. The Immediate Jeopardy remained unremoved at Exit on 07/30/2025. The Immediate Jeopardy was removed on 08/04/2025 at 4:25 PM. Purposecare of Indiana is precluded from providing its own home health aide training and competency evaluation program for a period of 2 years beginning 07/30/2025 through 07/29/2027 for being found out of compliance with the Condition of Participation 42 CFR 484.80 Home Health Aide Services. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. See the State Form for State only deficiencies. Abbreviations used: RN - Registered Nurse POC - Plan of Care SOC - Start of Care HHA - Home Health Aide QR by Area 3 on 8/6/2025.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (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 represented patients functional status, in 1 of 5 active clinical records reviewed. (Patient #1) Findings include: 1. A review of an agency policy titled 'Client Admission Process' stated, "… The admission professional will: … Complete a comprehensive assessment, including OASIS data elements if required …" 2. A review of the clinical record for Patient #1 with a start of care date of 05/02/2025, and a recertification period of 07/01/2025 to 08/29/2025 with diagnoses which included but were not limited to Cerebral Palsy (a group of neurological disorders that affect movement, balance, and posture, primarily due to brain damage that occurs during early development) contained a comprehensive reassessment dated 06/27/2025 and evidenced a section titled 'Functional Status' which indicated the patient was 'able to get to and from the toilet and transfer independently with or without a device', 'was able to transfer independently', 'was able to independently walk on even and uneven surfaces and negotiate stairs with or without railings, (specifically; needs no human assistance or assistive devices, then listed 'Functional Limitations' as: contracture and ambulation, with 'Activities Permitted' being use of wheelchair and a motorized chair. The comprehensive assessment failed to evidence the patient required an assistive device to transfer from surface to surface, and failed to evidence the patient had a Hoyer lift (medical device designed to safely lift and transfer individuals who are unable to bear weight or have limited mobility, utilizing a sling and a mechanical lifting mechanism, either manual or electric, to move patients between surfaces like beds, chairs, or wheelchairs) in the home. 3. On 07/28/2025 at 1:57 PM, in an interview, the Administrator/Clinical Director confirmed after review, the record for Patient #1 failed to include information the patient had a Hoyer in the home, and stated best practice would have been to include it. 4. On 07/30/2025 at 1:55 PM, in an interview with the Administrator/Clinical Director, when queried as to inaccurate or incomplete comprehensive assessments, indicated the expectation would be the clinician documenting would complete the forms accurately and in their entirety. 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 patient plans of care included required elements, including but not limited to: Durable Medical Equipment (DME, a category of medical devices designed to assist individuals with disabilities, injuries, or chronic health conditions, prescribed by healthcare professionals and intended for repeated use over an extended period), and orders for specific home health aide services/tasks, in 1 of 5 active clinical records reviewed. (Patient #1) Findings include: 1. A review of agency policy titled 'Plan of Care' stated, "… The Plan of Care shall be completed in full to include the following: … d. The types of services, supplies, and equipment required … I. Safety measures to protect against injury …" A review of agency policy titled 'Physician Orders' stated, "… The patient's physician orders for treatments and services are the foundation of the plan of care. All medications, treatments, and services provided to clients must be ordered by a physician …" 2. A review of the clinical record for Patient #1 with a start of care date of 05/02/2025, and a recertification period of 07/01/2025 to 08/29/2025 with diagnoses which included but were not limited to Cerebral Palsy (a group of neurological disorders that affect movement, balance, and posture, primarily due to brain damage that occurs during early development), contained a Plan of Care dated 06/27/2025 orders for home health aides services 1-2 hours per visit, 5-7 times per week for 9 weeks to assist with bathing, dressing, hygiene, grooming, and light housekeeping task related to physical deficits and chronic health conditions. The Plan of Care failed to evidence hoyer lift as DME, failed to include Transfer Precautions as a safety measure, and failed to evidence home health aide orders to transfer the patient, or to utilize an assistive device/hoyer lift to do so. 3. On 07/25/2025 at 3:14 PM, in an interview, HHA 3 indicated they had been caring for Patient #1 since April of this year. Indicated the day the patient fell out of the Hoyer (medical device designed to safely lift and transfer individuals who are unable to bear weight or have limited mobility, utilizing a sling and a mechanical lifting mechanism, either manual or electric, to move patients between surfaces like beds, chairs, or wheelchairs) (06/20/2025), HHA 3 was transferring patient from a shower chair to bed, and they had put on the patient's "strap thing" with the Hoyer lift. HHA 3 stated the patient was already in the air and they hadn't checked all the straps, then the patient fell to the floor, as the strap was not secured. HHA 3 indicated they did not know what Patient #1's care needs were when they arrived, indicated an aide in the home showed them how to use the patient's hoyer. 4. On 07/28/2025 at 1:57 PM, in an interview, the Administrator/Clinical Director verified there were no orders in Patient #1's POC/485 nor the Aide Care Plan for the home health aide to transfer Patient #1 or to use a hoyer lift to do so. A Hoyer lift was also not mentioned in the POC/485, and the Administrator/Clinical Director stated best practice was to include the information. 410 IAC 17-13-1(a)(1)(D)(ii)

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 home health aides performed hand hygiene at appropriate intervals while providing care to patients, in 3 of 3 home visit observations. (Patient's #3, #4, and #8) Findings include: 1. A review of an agency policy titled 'Handwashing/Hand Hygiene' stated, "… Indications for hand washing and hand antisepsis: … Before and after client care … When there is prolonged or intense contact with the client (bathing the client) … Between tasks on the same client … Before putting on and after removing gloves … After touching objects that are potentially contaminated … Before eating, drinking, handling and/or serving food … Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the client … Decontaminate hands after removing gloves …" 2. On 07/28/2025 at 9:30 AM, during a home visit for Patient #3, HHA #4 was observed providing care to the patient. HHA #4 gathered up patient's trash in bag and went outside to dispose of it in a garbage can, doffed their gloves and threw them in the can as well, grabbed the handle to the door to re-enter the home, entered the kitchen and grabbed the handle to the freezer to open it, grabbed a package of frozen waffles to prepare for the patient, HHA 4 failed to perform hand hygiene, after doffing gloves and before preparing food. When queried, HHA 4 indicated they should have washed their hands after taking out the trash and removing their gloves. 3. During an observation of HHA 6 at Patient #8’s residence on 07/30/2025 at 7:47 AM, HHA 6 was observed transferring the patient from their electric wheelchair to the bed using the track system with a Hoyer lift. The HHA transferred the patient back into their electric wheelchair. For the entirety of the visit, the HHA wore the same gloves after touching the patient and failed to doff the gloves and perform hand hygiene after they were finished working with the patient. 4. On 07/30/2025 at 7:45 AM, during a home visit for Patient #4, HHA #5 was observed providing a bed bath, and failed to change gloves and perform hand hygiene after cleaning the peri area. When queried, HHA 5 indicated they could have washed their hands, or used hand sanitizer and motioned to the standing dresser where the sanitizer was located. 5. On 07/30/2025 at 2:08 PM, in an interview, while discussing infection control breaches observed during the home visits for Patient #3, Patient #4, and Patient #8 the Administrator/Clinical Director indicated hand hygiene was important and would expect aides to perform hand hygiene.

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 agency failed to ensure home health aides were appropriately trained prior to providing aide services to patients; failed to ensure trainees had been adequately trained and competencied before placing on the Indiana State Aide Registry (see G0754), failed to ensure home health training was of an adequate duration, the agency indicating; orientation, skills training and competency, a written competency test, 6-hours of dementia training, and 12-hours of home health aide in-services were completed in one (1) business day (see G0762), failed to ensure home health aides were assigned to specific patients by an RN (see G0798), failed to ensure home health aide care/services provided to patients were physician ordered and included in the Plan of Care (see G0800), and failed to conduct direct observation of a home health aide after concerns were identified related to Patient #1's fall due to improper use of a mechanical lift (G0812). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services. These practices had the potential to impact all 37 active skilled patients serviced by the agency. An Immediate Jeopardy, identified at §484.80 Home Health Aide Services, began on 06/20/2025. The Administrator/Director of Nursing was notified of the Immediate Jeopardy on 07/29/2025 at 10:39 AM. The provider submitted a removal plan on 07/29/2025, which was found to be acceptable. The Immediate Jeopardy was removed on 08/04/2025 at 4:25 PM. In regard to G0750: Based on record review and interview the agency failed to ensure trainees met requirements for home health aides, to proficiently and safely provide care to patients, including the safe use of transfer devices such as a hoyer lift (medical device designed to safely lift and transfer individuals who are unable to bear weight or have limited mobility, utilizing a sling and a mechanical lifting mechanism), failed to ensure HHAs were assigned to patients by an RN, failed to ensure orders for the HHA were included in the plan of care to transfer a patient via hoyer, failed to conduct direct observation of aide after a concern was identified when Patient #1 had a fall while being transferred via hoyer, in 1 of 5 active patients with hoyers reviewed. (Patient #1) Findings include: 1. A review of the clinical record for Patient #1 with a start of care date of 05/02/2025, and a recertification period of 07/01/2025 to 08/29/2025 with diagnoses which included but were not limited to: Cerebral Palsy (a group of neurological disorders that affect movement, balance, and posture, primarily due to brain damage that occurs during early development), contained orders for home health aides services 1-2 hours per visit, 5-7 times per week for 9 weeks to assist with bathing, dressing, hygiene, grooming, and light housekeeping task related to physical deficits and chronic health conditions. The record failed to evidence HHA orders to transfer the patient, or orders to utilize an assistive device/hoyer lift to do so. 2. A review of the agency's Complaint/grievance Log evidenced a document titled 'Patient/Family Grievance Form' dated 06/20/2025 which indicated Patient #1 had fallen and hit their head when HHA 3 was transferring the patient from a showerchair to their bed, a strap of their hoyer lift had not been secured and the patient fell 5 feet to the floor, hitting their head. An agency RN assessed the patient later that day, no injury or sequela were noted. 3. On 07/25/2025 at 3:14 PM, in an interview, HHA 3 indicated had been caring for Patient #1 since April of this year. Indicated the day the patient fell out of the hoyer (06/20/2025), HHA 3 was transferring patient from a showerchair to bed, and they had put on the patient's "strap thing" with the hoyer lift. HHA 3 stated the patient was already in the air and they hadn't checked all the straps, then the patient fell to the floor since the strap was not secured, and a nurse came out to check on the patient later the same day. When queried regarding orientation and training, HHA 3 indicated they did not know what Patient #1's care needs were when they arrived for their first visit, indicated an aide in the home showed them how to use the patient's hoyer and stated the agency had provided no training on using a hoyer and indicated was unsure who their orientation was conducted by, and "did the application, went over skills, we did not demonstrate anything, and they just talked". 4. On 07/25/25 at 12:08 PM, in an interview, HHA 1 indicated had been with the agency for one month, was a new aide and had received their aide certification from the agency and had not done this kind of work previously. Stated in one instance, they had been given, "no heads up" about a patient, their status or their care needs. HHA 2 indicated they knew the RN is supposed to get in touch with them and tell them about the patient, but received no such response. Upon arrival to the home, HHA 1 discovered the patient was a bedbound paraplegic with a hoyer. When queried if HHA 1 had transferred the patient, HHA 1 inquired what 'transfer' meant, and indicated the patient required some kind of equipment to be moved, and could not recall what the equipment was called, but did not transfer them stating, "I didn't want to hurt anybody". HHA 1 stated the previous aide had already left, "so the patient walked me through what to do" for the visit. When queried about home health aide training, stated they did not get training on 'paralyzed patients'. Indicated use of a hoyer lift was discussed, the trainer had let them do it, and showed them how, stated they had to transfer a dummy, and the trainees also transferred each other. When queried as to whether there was support available after the training, indicated there had been no support for follow up questions like hoyer use questions, and further had not received responses to calls or texts placed to the agency. 5. On 07/25/2025 at 12:29 PM, in an interview, HHA 2 indicated was a new aide, and been asked by unknown agency staff via text to see a patient and was given only an address and time, no information about the patient was provided. HHA 3 indicated in one instance they were not told about a patient being paralyzed from the waist down and was a total care patient. HHA 2 indicated they had "never changed a diaper" before, "it was my first time ever" and stated, "there was no way one person should be assigned to a patient like this", citing needed to roll the patient to their side, while stabilizing them, and cleaning the peri-area (the area of skin located between the anus and the external genitalia) during a disposable brief change. HHA 2 stated, "the last worker threw a fit" because they had not been informed of the care needs of the patient. HHA 2 indicated had been an HHA for one month and had received their training and certification from the agency. Indicated RN 1, had provided the training/orientation. HHA 2 indicated orientation and training was completed in one day, stated information and paperwork were completed along with a written competency exam, which was taken as a group. Indicated there had been, "little hands on training with the hoyer" and was not shown how to give a bed bath or how to change a disposable brief. Indicated after this one day of training, they received their aide certification. HHA 2 stated, "I learned on my own, no one showed me". HHA 2 informed they never had to use the hoyer with the patient, as they had let the patient know it would be their first time. 6. On 07/28/2025 at 9:30 AM, in an interview, HHA 4 indicated had not been aide before this job and had received their HHA license from the agency. Training was "Quick! From 9AM to 3-4PM". Indicated the written competency test had been completed as group, "and we graded as a group". HHA 4 shared they did not know the severity of a patient's condition before accepting an assignment from a "front desk person" at the agency. HHA 3 explained they were not oriented to the patient, what their needs were, or what care was to be provided, "I had no idea [patient] had a stroke, [patient] can’t move their left side", and indicated the spouse had to, "show me everything". When asked to demonstrate hoyer use, the aide indicated they appropriately prepared the sling and lifted the patient, and stated was unaware the hoyer legs/base needed to be in an open or wide position while the patient was suspended from the hoyer, to maintain a balanced state, and said, "they never told me that". 7. On 07/25/2025 at 1:30 PM, in an interview, the Administrator/DON was queried regarding home health training and competency being completed in one (1) day and whether they thought this was adequate, stated, "yes". 8. On 07/25/2025 at 2:21 PM, in an interview, RN 1 indicated part of their previous responsibilities included aide training and certifying home health aides. RN 1 stated "we run off of State Guidelines" and had a hands-on skills course. RN 1 stated the training included rolling patient safely, turning every 2 hours, safe transfers, use of gait belt, hoyer … what the aides can and cannot do, skilled vs. non-skilled, every situation …" then stated, "the entire training is from 10:00 AM to 3:30 PM", and the skills portion took about one to 1 1/2 hours of that, the class size was usually 2-3 trainees, occasionally more. Indicated the written competency testing was completed as a group. When queried regarding hoyer education and training, RN 1 indicated they demonstrated and talked through each part of the hoyer, and told the trainees the hoyer they were training on may be different than the hoyer in a patient's home and an RN Case Manager has to walk them through the patient's specific hoyer. RN 1 stated they demonstrated hoyer lift transfer to a wheelchair, transfer to a bed, then had each person demonstrate the technique, and indicated there a was a 'dummy' used. When queried as to how or whether retention of the training was assessed, RN 1 indicated the aides received 3 to 4 in-services yearly, and supervisory visits every 6 months to observe the HHA perform care. When queried as to aides being sent into a home without being oriented to a patient and their needs, RN 1 stated it was possible this was occurring. 9. On 07/29/2025 at 2:05 PM, in an interview, the Administrator/Clinical Director confirmed home health aide orientation, skills training and check-offs, a 65-question written competency exam, 6 hours of dementia training, and 12 hours of home health aide general in-services were all completed in one (1) day, from 8:00 AM - 4:30 PM, for home health aide trainees who were then placed on the Indiana State Aide Registry. 10. On 07/30/2025 at 11:24 AM, in an interview, the Administrator/Clinical Director when queried as to how the competency exam should be taken, indicated the exam should be taken "by the person [trainee]" and indicated this should be individualized. When queried if the exam should be scored together as a group, indicated again this should be individualized. 11. On 07/30/2025 at 1:12 PM, in an interview the Administrator/Clinical Director indicated there was not a documented policy, process, or procedure in place for RN's who provided home health aide training and competency. 12. On 07/25/2025 at 1:38 PM, in an interview, when queried regarding who orients an aide to a patient and their needs, the Administrator/Clinical Director indicated the Branch Manager or RN Case Manager. When queried further as to whether this was happening, the Administrator stated, "I hope it's happening". 13. On 07/25/25 at 4:18 PM, in an interview with the Administrator/Clinical Director, when queried as to who was responsible for assigning the home health aides to patients, answered, "the scheduler". 14. On 07/28/2025 at 1:32 PM, in an interview with RN 2, indicated had been an RN Case Manager with the agency for 2 1/2 to 3 years, indicated had not historically oriented aides to patients, sometimes old aides will help, or the group home will orient the aides to patients. When queried if they had ever been asked to provide information about patients to aides, stated yes they had been asked to call aides and give them a heads up, but had not oriented aides to patient's specific hoyers. 15. On 07/28/2025 at 3:22 PM, in an interview with RN 3, when queried as to whether they ever orient aides to patients stated, "no, I do not" and had not been asked to orient aides. When queried whether they had ever observed or oriented an aide to a patients specific hoyer, stated "no, I've not done that". 16. On 07/29/2025 at 4:08 PM, in an interview with RN 4, when queried, indicated RNs do not go out and orient new aides to patients, or orient aides to new patients. 17. On 07/28/2025 at 1:57 PM, in an interview, the Administrator/Clinical Director confirmed after review, Patient #1 did not have orders for the HHA to transfer or for use of hoyer lift in the chart, the record failed to include information that the patient had a hoyer in the home, and stated best practice would have been to include them. 18. On 07/28/2025 at 4:08 PM, in an interview, RN 4 indicated was aware of the incident on 06/20/2025 and had a conversation afterwards with HHA 3 and discussed the appropriate use of hoyer and an RN did not go out and orient or re-educate, and stated, "we rely on the training". When queried as to why an RN did not provide direct observation after a concern had been identified, RN 4 stated, "we probably should have observed the aide, in retrospect".

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure home health aides had been adequately trained and competencied before placing them on the Indiana State Aide Registry, for 4 of 6 home health aides reviewed, hired in the last 12 months. (HHA's 1, 2, 3, and 4) Findings include: 1. A review of an undated agency policy titled 'Competency Evaluation of Home Care Staff' stated, "… Skills competency is evaluated by observing the aide with client or "pseudo" client (not a manikin). The Home Health Aide Applicant may be placed on the State of Indiana Home Health Registry in two (2) ways. 1. Home Health Aide Applicants with No Past Training: Successful completion of a training program totaling at least seventy-five (75) hours. At least sixteen (16) of those hours must have been devoted to supervised practical training. The individual must complete at least sixteen (16) hours of classroom training before beginning the supervised practical training. At the completion of training, the applicant must successfully complete a competency program which includes completion of a written exam with a score of 80% or higher and successful completion of a skills demonstration which includes all state and federal required mandatory topics. OR 2. Home Health Aide Applicants with Past Training: Successfully completion of a competency program which includes completion of a written exam with a score of 80% or higher and successful completion of a skills demonstration which includes all state and federal required mandatory topics. Any Home Health Aide who is already on the State of Indiana Home Health Registry must still successfully complete the written and skills competency evaluation program. 2. On 07/29/2025 at 9:30 AM, during a home visit observation for Patient #3, HHA 4, when asked to demonstrate Hoyer use (without patient), the aide explained how to appropriately prepare the sling and lift the patient, and stated was unaware the Hoyer base legs needed to be in an open or wide position while the patient was suspended from the Hoyer, to maintain a balanced state, and said, "they never told me that". 3. On 07/30/2025 at 8:00 AM, during a home visit, HHA 5 was observed transferring Patient #4 from their bed to their motorized wheelchair, and failed to widen the base legs of the Hoyer to maintain balance while transferring patient. When queried, HHA 5 indicated they did not know the base legs of the Hoyer needed to be widened to maintain balance/stability, but thought the base was adjustable so as to fit both Hoyer legs under the patient's motorized wheelchair during transfers. 4. Review of the Personnel file for HHA 1 evidenced a hire date of 06/04/2025, a home health aide license had been issued 06/05/2025. A document dated 06/04/2025 titled 'Home Health Aide/Hospice Aide Competency Checklist' identified the 'Type of Competency Evaluation', 'initial' had been conducted, and the HHA had successfully completed the agency's aide training and competency program. . 5. Review of the Personnel file for HHA 2 evidenced a hire date of 06/11/2025, and a home health aide license had been issued 06/12/2025. A document dated 06/11/2025 titled 'Home Health Aide/Hospice Aide Competency Checklist' identified the 'Type of Competency Evaluation', 'initial' had been conducted, and the HHA had successfully completed the agency's aide training and competency program. 6. Review of the Personnel file for HHA 3 evidenced a hire date of 03/26/2025, and a home health aide license had been issued 03/27/2025. A document dated 03/26/2025 titled 'Home Health Aide/Hospice Aide Competency Checklist' failed to identify the 'Type of Competency Evaluation' conducted, and the HHA had successfully completed the agency's aide training and competency program. 7. Review of the Personnel file for HHA 4 evidenced a hire date of 11/27/2024, and a home health aide license had been issued 12/03/2024. A document dated 11/27/2025 titled 'Home Health Aide/Hospice Aide Competency Checklist' failed to identify the 'Type of Competency Evaluation' conducted. A section titled 'Home Health Aide Section' requested the trainee to sign and date if they, "had provided the services of a home health with a patient for Agency compensation within the last 24 months" was blank, and indicated the HHA had successfully completed the agency's aide training and competency program. 8. On 07/25/25 at 12:08 PM, in an interview, HHA 1 indicated they had been with the agency for one month, was a new aide, and had received their aide certification from the agency. When queried about home health aide training, stated they did not get training on 'paralyzed patients'. Indicated use of a Hoyer lift was discussed, the trainer had let them do it, and showed them how, stated they had to transfer a 'dummy', and trainees also transferred each other. When queried as to whether there was support available after the training, indicated there had been no support for follow up questions like Hoyer use questions. HHA 1 indicated because they had been "nervous", they had not used the Hoyer with Patient #2, and stated "I didn't want to hurt anybody". HHA 1 indicated they did not feel they had been adequately prepared to care for Patient #2. 9. On 07/25/2025 at 12:29 PM, in an interview, HHA 2 indicated they had been an HHA for one month and had received their training and certification from the agency. Indicated RN 1, had provided the training/orientation. HHA 2 indicated orientation and training was completed in one day. HHA 2 stated information and paperwork were completed along with a written competency exam which was completed as a group. Indicated there had been "little hands on training with the Hoyer" and was not shown how to give a bed bath or how to change a disposable brief. Indicated after this one day of training, they received their aide certification. HHA 1 indicated they felt unprepared to care for Patient #2 as the patient was paralyzed from the waist down and was a total care patient. HHA 2 indicated they had never changed a disposable brief for a patient before, "it was my first time ever" and stated, "there was no way one person should be assigned to a patient like this", as they needed to roll the patient to their side while stabilizing them and cleaning the peri-area during a disposable brief change. 10. On 07/25/2025 at 3:14 PM, in an interview with HHA 3, when queried regarding orientation and training, HHA 3 indicated, for Patient #1, they did not know what the patient care needs were when they arrived, indicated a non-agency aide in the home showed them how to use the patient's Hoyer. Indicated the agency provided no training on using a Hoyer. Indicated was unsure who their orientation was conducted by, and "did the application, went over skills, we did not demonstrate anything, and they just talked". 11. On 07/28/2025 at 9:30 AM, in an interview, HHA 4 indicated had not been aide before this job and had received their HHA license from the agency. Training was "Quick! From 9AM to 3:00 or 4:00 PM." Indicated the written competency test had been completed as group, "and we graded as a group". HHA 4 indicated they had not been prepared to care for Patient #3, a bedbound patient. HHA 4 explained they were not oriented to the patient, what their needs were, or what care was to be provided, "I had no idea [patient] had a stroke, [patient] can’t move their left side", and indicated the spouse had to, "show me everything". 12. On 07/25/2025 at 2:21 PM, in an interview, RN 1 indicated part of their responsibilities had included aide training and certifying home health aides. RN 1 stated "we run off of State Guidelines" and had a hands-on skills course. RN stated the training included rolling patient safely, turning every 2 hours, safe transfers, use of gait belt, Hoyer … what the aides can and cannot do, skilled vs. non-skilled, every situation …" then stated, "the entire training is from 10:00 AM to 3:30 PM", and the skills portion took about one to 1 1/2 hours of that, the class size was usually 2-3 trainees, occasionally more. Indicated the written competency testing was completed as a group. When queried regarding Hoyer education and training, RN 1 indicated they demonstrated and talked through each part of the Hoyer, and told the trainees the Hoyer they were training on may be different than the Hoyer in a patient's home and an RN Case Manager has to walk them through the patient's specific Hoyer. RN 1 stated they demonstrated Hoyer lift transfer to a wheelchair, transfer to a bed, then had each trainee demonstrate the technique, and indicated there a was a 'dummy' used. When queried as to how or whether retention of the training was assessed, RN 1 indicated the aides received 3 to 4 in-services yearly, and supervisory visits every 6 months to observe the HHA perform care. 13. On 07/25/2025 at 1:30 PM, in an interview, the Administrator/Clinical Director was queried regarding home health training and competency being completed in one (1) day and whether they thought this was adequate, stated, "yes". 14. On 07/29/2025 at 9:00 AM, in an interview with the Administrator/Clinical Director, when discussing home visit observations and HHA 4 and HHA 5 were not aware of the need to widen the Hoyer base legs to maintain balance while transferring patient, indicated HHA's need retraining across the board. 15. On 07/29/2025 at 2:05 PM, in an interview, the Administrator/Clinical Director confirmed home health aide orientation, skills training and check-offs, a 65-question written competency exam, 6 hours of dementia training, and 12 hours of home health aide general in-services were completed in one (1) day, from 8:00 AM - 4:30 PM, for home health aide trainees, who were then placed on the Indiana State Aide Registry. 16. On 07/30/2025 at 11:24 AM, in an interview, the Administrator/Clinical Director when queried as to how the competency exam should be taken, indicated the exam should be taken "by the person [trainee]" and indicated this should be individualized. When queried if the exam should be scored together as a group, indicated again this should be individualized. 410 IAC 17-14-1(l)(1)(A)

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure home health training was of an adequate duration, before placing trainees on the Indiana State Aide Registry, for 1 of 1 agency. Findings include: 1. A review of an undated agency policy titled '4-220 Competency Evaluation of Home Care Staff' stated, "… Skills competency is evaluated by observing the aide with client or "pseudo" client (not a manikin). The Home Health Aide Applicant may be placed on the State of Indiana Home Health Registry in two (2) ways. 1. Home Health Aide Applicants with No Past Training: Successful completion of a training program totaling at least seventy-five (75) hours. At least sixteen (16) of those hours must have been devoted to supervised practical training. The individual must complete at least sixteen (16) hours of classroom training before beginning the supervised practical training. At the completion of training, the applicant must successfully complete a competency program which includes completion of a written exam with a score of 80% or higher and successful completion of a skills demonstration which includes all state and federal required mandatory topics. OR 2. Home Health Aide Applicants with Past Training: Successfully completion of a competency program which includes completion of a written exam with a score of 80% or higher and successful completion of a skills demonstration which includes all state and federal required mandatory topics. Any Home Health Aide who is already on the State of Indiana Home Health Registry must still successfully complete the written and skills competency evaluation program. 2. On 07/29/2025 at 9:30 AM, during a home visit observation for Patient #3, HHA 4 indicated had not been aide before this job and had received their HHA license from the agency, training was, "Quick! From 9AM to 3:00 or 4:00 PM." Indicated the written competency test had been completed as group, "and we graded as a group". When asked to demonstrate hoyer use (without patient), the aide indicated they appropriately prepared the sling and lifted the patient, and stated was unaware the hoyer base legs needed to be in an open or widened position while the patient was suspended from the hoyer, to maintain a balanced state, and said, "they never told me that". 3. On 07/30/2025 at 8:00 AM, during a home visit observation, HHA 5 was observed transferring Patient #4 from their bed to their motorized wheelchair, and failed to widen base of the hoyer to maintain balance while transferring the patient. When queried, HHA 5 indicated did not know the base legs of the hoyer needed to be widened to maintain balance/stability, but thought the base was adjustable so as to fit both base legs under the motorized wheelchair during transfer. 4. On 07/25/2025 at 12:29 PM, in an interview, HHA 2 indicated had been an HHA for one month and had received their training and certification from the agency. Indicated RN 1, had provided the training/orientation. HHA 2 indicated orientation and training was completed in one (1) day. HHA 2 stated information and paperwork were completed along with a written competency exam, which was completed as a group. Indicated there had been "little hands on training with the hoyer" and was not shown how to give a bed bath or how to change a disposable brief. Indicated after this one day of training, they received their aide certification. HHA 1 indicated they felt unprepared to care for Patient #2 as the patient was paralyzed from the waist down and was a total care patient. HHA 2 indicated they had never changed a disposable brief for a patient before, "it was my first time ever" and stated, "there was no way one person should be assigned to a patient like this", as they needed to roll the patient to their side while stabilizing them and cleaning the peri-area during a disposable brief change. 5. On 07/25/2025 at 2:21 PM, in an interview, RN 1 indicated part of their responsibilities include, "making sure HHA's are doing what they should" and had provided Home Health Aide Training. Confirmed they had certified home health aides, and "we run off of State Guidelines". Indicated the entire training was conducted in one (1) day, between "10:00 AM and 3:30 PM" and "skills took one to one and a half hours to complete". Indicated class size was usually 2-3 people. Confirmed the written competency was completed as a group. Stated peri-care and brief changes were covered during the training, including how often. Hoyer training was included and they demonstrated and talked through each part of the hoyer. Aide training also included demonstrating transfer to wheelchair, transfer to bed, then each trainee demonstrated the technique. When queried whether there was anything in place to ensure the retention of the training and education, RN 1 indicated in-services are done quarterly and supervisory visits are made every 6 months to ensure we witness the aides, and indicated they had instructed the aides to call RN 1 for support, "but no one has taken me up on the offer". 6. On 07/29/2025 at 9:00 AM, in an interview with the Administrator/Clinical Director, when discussing home visit observations and HHA 4 and HHA 5 not being aware of the need to widen hoyer base legs to maintain balance while transferring patient, the Administrator/Clinical Director stated HHA's needed retrained across the board. 7. On 07/29/2025 at 2:05 PM, in an interview, the Administrator/Clinical Director confirmed orientation, skills training and check-offs, a 65 question written competency exam, 6 hours of dementia training, and 12 hours of home health aide general in-services all occurred in one (1) day, from 8:00 AM - 4:30 PM, for home health aide trainees who are then placed on the Indiana State Aide Registry.

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 home health aides were assigned to patients by an RN with written patient care instructions prepared by the same RN, in 3 of 5 home health aides reviewed. (HHA's 1, 2, and 4) Findings include: A review of an undated agency policy titled 'Home Health Aide Assignment' started, "… the designated Registered Nurse will assign and orient the aide to the care plan … When changes in assignment occur, the new Home Health Aide is oriented to his/her responsibilities and the client's needs. If necessary, this orientation occurs on site …" On 07/25/25 at 12:08 PM, in an interview, HHA 1 indicated they had been with the agency for one month, was a new aide and had received their aide certification from the agency. Stated on their first visit (07/15/2025) with Patient #2, they had been given, "no heads up" about the patient and their status or their care needs. When queried as to how patients are assigned to them, stated the office sends text messages and, for example, would state only days needed and location, no other information was provided. HHA 2 indicated they knew an RN is supposed to get in touch with them and tell them about the patient, but received no such response. On 07/25/2025 at 12:29 PM, in an interview, HHA 2 indicated had cared for Patient #2 one time. Indicated was not assigned to patient but was sent a text from Admin 3, a scheduler, asking if they would take a patient and was given only an address and time, no information about the patient was provided. Indicated Admin 3, a scheduler, had told them nothing about the fact Patient #2 was paralyzed from the waist down and was a total care patient. On 07/28/2025 at 09:50 AM, in an interview, HHA 4 indicated they did not know the severity of the patient's condition before accepting the assignment from a "front desk person" at the agency. HHA 4 explained they were not oriented to the patient, what their needs were, or what care was to be provided, "I had no idea [patient] had a stroke, [patient] can’t move their left side", and indicated the spouse had, "showed me everything". On 07/28/2025 at 1:32 PM, in an interview with RN 2, indicated had been an RN Case Manager with the agency for 2 1/2 to 3 years, indicated had not historically oriented aides to patients, sometimes old aides will help, or the group home will orient the aides to patients. When queried if they had ever been asked to provide information about patients to aides, stated yes they had been asked to call aides and give them a heads up, but had not oriented aides to patients. On 07/28/2025 at 3:22 PM, in an interview with RN 3, when queried as to whether they ever orient aides to patients stated, "no, I do not" and had not been asked to orient aides. When queried whether they had ever observed or oriented an aide to a patients specific hoyer, stated "no, I've not done that". On 07/29/2025 at 4:08 PM, in an interview with RN 4, when queried, indicated RNs do not go out and orient new aides to patients, or aides to new patients. On 07/25/2025 at 2:21 PM, in an interview with RN 1, when queried as to who assigns aides to patients, RN 1 indicated the staffing scheduler, ADMIN 3 was assigning aides to patients, unless they are 'hire-on' (aides that came with the patient, often a family member). 07/25/25 at 4:18 PM, in an interview with the Administrator/Clinical Director, when queried as to who was responsible for assigning the home health aides to patients, answered, "the scheduler". 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 record review and interview the agency failed to ensure home health aide care/services provided to patients were physician ordered and included in the Plan of Care, in 1 of 1 active clinical record reviewed. (Patient #1) Findings include: 1. A review of an undated agency policy titled 'Home Health Aide Care Plan' stated, "… A complete and appropriate Care Plan, identifying duties to be performed by the Home Health Aide, shall be developed by a Registered Nurse. All home health aide staff will follow the identified plan … A home health aide provides services that are: Ordered by the physician; Included in the plan of care; … and Consistent with the home health aide training …" 2. A review of the clinical record for Patient #1 with a start of care date of 05/02/2025, and a recertification period of 07/01/2025 to 08/29/2025 with diagnoses which included but were not limited to Cerebral Palsy (a group of neurological disorders that affect movement, balance, and posture, primarily due to brain damage that occurs during early development), contained orders for home health aides services 1-2 hours per visit, 5-7 times per week for 9 weeks to assist with bathing, dressing, hygiene, grooming, and light housekeeping task related to physical deficits and chronic health conditions. The record failed to evidence HHA orders to transfer the patient, or orders to utilize an assistive device/hoyer lift to do so. 3. A review of the agency's complaint/grievance log evidenced a document titled 'Patient/Family Grievance Form' dated 06/20/2025 which indicated Patient #1 had fallen and hit their head when HHA 3 was transferring the patient from a shower chair to their bed, as a strap of their Hoyer lift was not secured and the patient fell 5 feet to the floor, hitting their head. An agency RN assessed the patient later that day, no injury or sequela were noted. 4. On 07/25/2025 at 3:14 PM, in an interview, HHA 3 indicated they had been caring for Patient #1 since April of this year. Indicated the day the patient fell out of the Hoyer (06/20/2025), HHA 3 was transferring patient from a shower chair to bed, and they had put on the patient's "strap thing" with the Hoyer lift. HHA 3 stated the patient was already in the air and they hadn't checked all the straps, then the patient fell to the floor, as the strap was not secured. HHA 3 indicated a nurse came out to check on the patient later the same day, no injuries were found, and the patient refused to seek further evaluation at the hospital. HHA 3 indicated they did not know what Patient #1's care needs were when they arrived, indicated a non-agency aide in the group home showed them how to use the patient's Hoyer. 5. On 07/28/2025 at 1:57 PM, in an interview, the Administrator/Clinical Director verified there were no orders in Patient #1's POC/485 nor the Aide Care Plan for the home health aide to transfer the patient or use a Hoyer lift to do so. The patient's Hoyer lift was also not evidenced on the POC/485, and the Administrator/DON stated best practice is to include the information.

If area of concern is noted CFR(s): 484.80(h)(1)(iii) If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a supervising RN conducted a direct observation of a home health aide, after concerns were identified related to Patient #1's fall, due to improper use of a mechanical lift, in 1 of 1 active clinical record reviewed with reported fall. (Patient #1) Findings include: 1. A review of an agency policy effective 08/01/2023, titled 'Home Health Aide Supervision' stated, "… If a deficiency in aide services is verified by the Registered Nurse or other appropriate skilled professional during an onsite visit, then the agency must conduct, and the home health aide must complete, retraining and a competency evaluation related to the deficient skill(s) …" 2. A review of the agency's Complaint/grievance Log evidenced a document titled 'Patient/Family Grievance Form' dated 06/20/2025 which indicated Patient #1 had fallen and hit their head when HHA 3 was transferring the patient from a showerchair to their bed, a strap of their hoyer lift was not secured and the patient fell, 5 feet to the floor, hitting their head. An agency RN assessed the patient later that day, no injury or sequela were noted. 3. On 07/25/2025 at 3:14 PM, in an interview, HHA 3 indicated they had been caring for Patient #1 since April of this year. Indicated the day the patient fell out of the Hoyer (06/20/2025), HHA 3 was transferring patient from a shower chair to bed, and they had put on the patient's "strap thing" with the Hoyer lift. HHA 3 stated the patient was already in the air and they hadn't checked all the straps, then the patient fell to the floor, as the strap was not secured. HHA 3 indicated they had given the agency a statement as requested, and a nurse came out to check on the patient later the same day. When queried as to whether a nurse had also come out to re-train or re-educate HHA 3 on safe use of the Hoyer lift, stated "no one came out, they called me" and indicated an agency RN had re-educated them about ensuring all the straps were secure. 4. On 07/28/2025 at 4:08 PM, in an interview, RN 4 indicated was aware of the incident on 06/20/2025 and had a conversation afterwards with HHA 3 and discussed the appropriate use of Hoyer. RN 4 stated a nurse did not go out and orient or re-educate HHA 3, and stated, "we rely on the training". When queried as to why an RN did not provide direct observation after a concern had been identified, RN 4 stated, "we probably should have observed the aide, in retrospect".

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview the Administrator failed to ensure they were responsible for day to day operations including HHA training and competencies before being placed on the Indiana State Aide Registry, ensuring home health aides and nursing staff had up to date and complete personnel files, for 1 of 1 agency. Findings include: 1. A review of an undated agency policy titled 'Competency Evaluation of Home Care Staff' stated, "… Skills competency is evaluated by observing the aide with client or "pseudo" client (not a manikin). The Home Health Aide Applicant may be placed on the State of Indiana Home Health Registry in two (2) ways. 1. Home Health Aide Applicants with No Past Training: Successful completion of a training program totaling at least seventy-five (75) hours. At least sixteen (16) of those hours must have been devoted to supervised practical training. The individual must complete at least sixteen (16) hours of classroom training before beginning the supervised practical training … Any Home Health Aide who is already on the State of Indiana Home Health Registry must still successfully complete the written and skills competency evaluation program …" 2. A review of an agency document dated 07/22/2024 titled 'Orientation - Administrator/Alternate Administrator/DON/ADON' stated, "… Overview of Home Care & Day to Day Operations … 9. Competency Evaluations (HHA … ) … Roles/responsibilities of the Administrator … Assumes responsibility of day-to-day operations of the agency … 4. Ensures adequate staff education … 5. Maintains agency reports, records … documentation … files required to show compliance during state surveys …" 3. On 07/29/2025 at 3:14 PM, when asked to provide their job description for the role of Administrator, a document titled 'Orientation - Administrator/Alternate Administrator/DON/ADON' was submitted, and the Administrator explained the document was considered their job description as well as their orientation. 4. On 07/25/2025 at 1:30 PM, in an interview, the Administrator/Clinical Director was queried regarding home health training and competency being completed in one (1) day and whether this was adequate, stated, "yes". 5. On 07/29/2025 at 9:00 AM, in an interview with the Administrator/Clinical Director, when discussing home visit observations where HHA 4 and HHA 5 were not aware of the need to widen Hoyer base legs to maintain balance while transferring patient, indicated HHA's need retrained across the board. 6. On 07/29/2025 at 2:05 PM, in an interview, the Administrator/Clinical Director confirmed home health aide orientation, skills training and check-offs, a 65-question written competency exam, 6 hours of dementia training, and 12 hours of home health aide general in-services were completed in one (1) day, from 8:00 AM - 4:30 PM, for home health aide trainees, who were then placed on the Indiana State Aide Registry. 7. On 07/29/2025 at 8:53 AM, in an interview, the Administrator/Clinical Director indicated the agency was unable to locate missing documents requested from the agency's personnel files, suspected they were completed but not uploaded, and stated RN 1 who was responsible, had resigned during the survey, and the agency would continue to search for the documents. When discussing missing components of personnel records, and certain items not having been uploaded or maintained by RN 1, the Administrator stated, " I need to have that oversight to make sure things are followed through." 8. On 07/29/2025 at 9:08 AM, in an interview during Personnel Records review, the Administrator/Clinical Director indicated they did not have full access to all components of personnel records, needed to be granted certain permissions, and assured that records could be requested from human resource staff, and was usually available within a few hours. 410 IAC 17-12-1(c)(1)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for Home Health Agencies. Survey Dates: 10/08/2024, 10/09/2024, and 10/10/2024 Census: 2,197 At this Emergency Preparedness Survey, PurposeCare of Indiana was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR completed by Area 3 on 10-15-2024.

This visit was for a Federal Recertification and State Re-Licensure survey for a Home Health provider. Partially extended survey on: 10/10/2024 at 8:43 AM. Survey Dates: 10/08/2024, 10/09/2024, and 10/10/2024 12 Month Unduplicated Admissions: 18 Active Census: 2,197 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse HHA Home Health Aide QR completed by Area 3 on 10/15/2024.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN coordinated the delivery of care to meet the patient's needs for 2 of 2 active records reviewed with patients receiving outside services. (Patients: #1 and 5) Findings Include: Review of Patient #1's clinical record contained a document titled "Recertification / Resumption of Care" signed by RN 1, and dated 10/09/2024. The document failed to evidence Patient #1 was receiving services from Entity 2. Review of Patient #1's clinical record failed to evidence care coordination notes with Entity 2 for the certification period of 08/11/2024 through 10/09/2024. During an interview on 10/09/2024 at 12:24 PM, RN 1 failed to indicate that care coordination is completed during a recertification. During an interview on 10/10/2024 at 9:44 AM, Person 3 confirmed that the agency was not in contact with Entity 2 to coordinate care. 410 IAC 17-14-1(a)(1)(F) 1. A review of an agency policy titled "3-360 Coordination of Client Services" indicated but was not limited to" … Care conferences will be held as often as necessary to establish interchange, reporting, and coordinated evaluation between all disciplines and Providers involved in the client's care … Care conference will be documented in the patient record … " 2. A review of the clinical record for Patient #5 contained a recertification comprehensive assessment signed by RN 3 dated 09/10/2024. The comprehensive assessment failed to evidence Patient #5 was receiving outpatient therapy services at Entity 1. A review of the agency documents titled "Care Coordination Form" dated 09-09-2024 through 10-09-2024 failed to evidence documentation of care coordination between Purpose Home Health and Entity 1. During a home visit on 10/09/2024 at 9:40 AM, Patient #5 and Home Health Aide (HHA) 2 were interviewed. HHA 2 indicated that for the past 28 weeks, HHA 2 had been transporting Patient #5 to outpatient therapy at Entity 1 for physical therapy to increase Patient #5’s strength related to right-sided weakness. 3. During an interview on 10/09/2024 at 12:39 PM, the case manager for Patient #5, RN 3, confirmed they do not coordinate care with other providers for Patient #5. RN 3 further stated, " The office scheduler handles that." 4. During an interview on 10/09/2024 at 1:04 PM, the Administrator indicated that the RN case manager is expected to complete a care coordination note if their patient is receiving care from any other providers. 1. Review of an agency policy titled "3-360 Coordination of Client Services" indicated but was not limited to" … Care conferences will be held as often as necessary to establish interchange, reporting, and coordinated evaluation between all disciplines and Providers involved in the client's care … Care conference will be documented in the patient record … " 2. Review of the clinical record for Patient #5 contained a recertification comprehensive assessment signed by RN 3 dated 09/10/2024. The comprehensive assessment failed to evidence Patient #5 had been receiving physical therapy, at Entity 1, an outpatient therapy facility. Review of the agency documents titled "Care Coordination Form" dated 09-09-2024 through 10-09-2024 failed to evidence documentation of care coordination between Purpose Care of Indiana and Entity 1. During a home visit on 10/09/2024 at 9:40 AM, Patient #5 and HHA 2 were interviewed. HHA 2 indicated for the past 28 weeks, HHA 2 transported Patient #5 to outpatient therapy at Entity 1 for physical therapy to increase Patient #5’s strength related to right-sided weakness. 3. During an interview on 10/09/2024 at 12:39 PM, the case manager for Patient #5, RN 3, confirmed they had not coordinated care with other providers for Patient #5. RN 3 further stated, " The office scheduler handles that." 4. During an interview on 10/09/2024 at 1:04 PM, the Administrator indicated the RN case manager is expected to complete a care coordination note if their patient is receiving care from any other providers. 5. Review of Patient #1's clinical record contained a document titled "Recertification / Resumption of Care" signed by RN 1, and dated 10/09/2024 for the certification period of 08/11/2024 through 10/09/2024. The document failed to evidence Patient #1 was receiving services from Entity 2, a home health agency with care coordination notes. During an interview on 10/09/2024 at 12:24 PM, RN 1 failed to indicate that care coordination is completed during a recertification. 6. During an interview on 10/10/2024 at 9:44 AM, Person 3, the office staff for Entity 2, confirmed that the agency was not in contact with Entity 2 to coordinate care. 410 IAC 17-14-1(a)(1)(F)

This survey was for a Federal and State complaint investigation of a Home Health Provider. Survey Dates: 01/30/24 - 01/31/24 Complaint: #104327 with related deficiencies cited. 12-month unduplicated skilled admissions: 30 This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body failed to assume responsibility for the agency's overall management and operation, including but not limited to appointment of the administrator and ensuring the provision of correct demographic and agency information such as the physical address, provider number, and scope of services for 1 of 1 Home Health Agency and accompanying 11 branches. Findings include: A review of undated agency policy 2-100 "Governing Body" indicated "A governing body ... must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services ... The duties and responsibilities of the Governing Body shall include: Appoint a qualified Administrator ... Delegate to that individual the authority and responsibility for the provision of home care services in accordance with state and federal regulations, accreditation standards, and Agency mission ... " On 01/30/24 at 12:48 PM the Administrator, Regional Vice President, and Alternate Administrator participated in the entrance conference. The Administrator indicated she was hired on 01/11/23 as Director of Nursing and she became the Administrator in January 2024. The Administrator was given a Home Health Agencies Report, a geographic locations form, a facility census form, and a Centers for Medicare and Medicaid (CMS) 2567 to complete and was encouraged to ask questions if necessary. The Administrator was asked for an active patient list specifying patients who received skilled care, the start of care (SOC) dates for all patients, and the patient's admitting diagnosis. The Administrator indicated they were unable to provide a report with the requested diagnosis but could check with corporate for further instructions. The Administrator, Alternate Administrator, and Regional Vice President referred to the agency as "the unskilled side," or PurposeCare Home Care" and indicated patients were transferred to the "skilled or Home Health side" should a skilled need develop. When asked what skill the agency provided according to regulatory requirements the Administrator indicated they provided home health aide visits. When asked if the agency provided skilled nursing, such as wound care, the Administrator indicated all patients who developed a nursing need other than medication set-up were transferred to the skilled side. On 01/30/24 at 3:40 PM, the Administrator submitted completed forms and began reviewing them out loud. When asked for the active and discharged lists as previously requested at 12:48 PM, the Administrator indicated they were not printed yet. At 3:45 PM, the Administrator submitted the active patient list for all branches. The report failed to evidence a patient diagnosis and had a column labeled "Visit MIN start date." The Administrator, Regional Vice President, and Alternate Administrator were unable to indicate the meaning of "MIN." The Administrator indicated the visit dates were either the patient's SOC date or the most recent recertification date. When asked why all the dates occurred on or after 05/2023 the Administrator called the Regional Vice President, who indicated they started a new medical record system around May 2023, and they couldn't retrieve dates before 05/23/23. When asked if they had printed a separate list to show patients receiving skilled nursing the Administrator indicated they were having trouble generating that information but had submitted it to corporate and were awaiting a response. A review of the completed CMS 2567 Survey Report and the Home Health Agencies Report that were provided by the state agency, revealed missing, inaccurate, and/or incomplete information on all forms, such as an incorrect facility identification number of 15K8083 vs 15K083, unduplicated skilled admissions left blank, skilled nursing services left blank, Suite D and not Suite B, and inaccurate demographic information. The Administrator and Regional Vice President indicated the medical record system didn't capture unduplicated census and they would not be able to provide that information. When asked why readmissions were blank, they indicated they didn't readmit patients who were hospitalized because they were placed on hold. When asked what happens if a patient was hospitalized past their recertification period but wanted to come back for services, they indicated the patient is a new admission, not a readmission. When asked what they considered as "unduplicated" they were unsure. On 01/31/24 at 9:23 AM, the Administrator submitted the geographic area form, CMS 2567 Survey Report, and the Home Health Agencies Report and indicated they were corrected. A review of the Home Health Agencies Report evidenced the Facility CCN continued to show 15K8083 instead of 15K083, Ste D remained uncorrected to Ste B, and counties listed on the geographic report didn't match the typed list provided by the agency or the counties listed with the Indiana Department of Health. On 01/31/24 at 9:23 AM, the Administrator submitted a letter from the Indiana Department of Health which indicated [Name of Administrator] was listed as the agency Administrator effective 01/15/24. The Administrator submitted a document titled "Governing Body Minutes - 2023. Review," dated 01/31/24. The document evidenced the names of Persons #1, 2, 3, and 4 as governing body members and indicated " ... [Name of Regional Vice President] appointed as Administrator November 2023 ... [Name of Administrator] started on 12/4/23. Fulfilled Administrator role and DON [Director of Nursing] January 2024" and failed to indicate the date the Administrator was appointed and the Governing Body members present for the appointment meeting. On 01/31/24 at 11:25 AM, the Administrator and Regional Vice President were asked why there were minutes, or notes taken during a meeting, for a meeting that hadn't occurred, yet she indicated it was going to occur that day and the minutes were more of an agenda. The Administrator indicated she was "verbally confirmed." When asked for the date of the verbal confirmation and the names of the Governing Body members who participated in the verbal vote, no further information was available. A review of the orientation verification document for the Administrator, dated 01/04/24, indicated the Administrator received orientation including, but not limited to, State/Federal regulations and policy manual, Medicaid Prior Authorization, organizational chart, and reporting structure, role of the Governing Body, and appointment of a qualified Administrator. The administrator indicated she completed orientation on 01/04/24 but was still on a significant learning curve. The Administrator indicated the Regional Vice President was her direct support and was always available to assist her but was not necessarily located on site. The Governing Body failed to ensure oversight and responsibility of the agency by failing to appoint the current Administrator, failing to ensure the Administrator had a working knowledge of the agency and branches, including but not limited to correct addresses and correct identification numbers; and failing to ensure the Administrator and leadership support of a newly hired Administrator were knowledgeable concerning the agency's scope of practice and related regulatory requirements. 410 IAC 17 -12 - 1(b)

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview the governing body failed to appoint an administrator for 1 of 1 home health agencies. Findings include: A policy received on 01/31/2024 at 12:01 PM from the Administrator titled “2-100 Governing Body Policy” indicated but was not limited to “. . . assume full legal authority and responsibility for the agency’s overall management and operation . . . appoint a qualified administrator . . . .” A review of a document received from the Agency on 01/31/2024 at 9:49 AM from the Indiana Department of Health indicated as of January 16th, 2024 the Agency’s Administrator on file was the individual in the entrance conference stating they were the Administrator. A review of a document received 01/31/2024 at 9:32 AM, titled “Governing Body Minutes – 2023 Review” dated 01/31/2024 at 2:00 PM evidenced but was not limited to a section titled “Topics discussed: “ . . . “ {Name of Administrator} started on 12/4/23 . . . Fulfilled Administrator role and DON January 2024. “ A review of a revised document received on 01/31/2024 at 10:35 AM titled “ Governing Body Minutes - 2023 Review evidenced the start date of the Administrator as being 12/11/2023. The Administrator indicated the revised version contained the correct date she “started” at the Agency. During an interview on 01/31/2024 at 10:10 AM, the Administrator indicated the meeting "is occurring today at 2:00 PM " and reported the Governing Body "will appoint me as the administrator today." The Director of Compliance reported the administrator was verbally confirmed but could not confirm a date or what Governing Body Members appointed the position and indicated 01/31/2024 at 2:00 PM they would officially appoint the Administrator. During an interview on 01/31/2024 at 11:25 AM, the Regional Vice President indicated the document titled “Governing Body Minutes - 2023 Review” was an agenda for the meeting, not the actual meeting minutes. During an interview on 01/31/2023 at 12:01 PM with the Administrator when queried if there were any other Governing Body Minutes to present, they reported the last meeting was in February of 2023. 410 IAC 17-12-1(b)(1)

This visit was for the investigation of a Federal and State complaint/intake of a Medicaid Home Health provider. Survey Dates: 03-06-2023, 03-07-2023, and 03-08-2023 Complaint # 96546 Substantiated; with deficiencies cited. Purpose Home Health was found out of compliance with Condition of Participation 42 CFR 484.50, Patient Rights, in relation to the complaint allegations. An Immediate Jeopardy was identified which began on 02-28-2023. The Immediate Jeopardy was announced on 03-08-2023, at 8:28 AM for 42 CFR 484.50, Patient Rights. The agency failed to perform a complete investigation to ensure Patient #1's safety when Patient #1 indicated to their home health aide (HHA) #1 they had been hit by their spouse, who had guardianship over the patient, and indicated the spouse had stolen property items from them. The agency failed to perform a comprehensive assessment, failed to notify the physician, failed to notify Entity H (the assisted living facility where Patient #1 resided) failed to notify Adult Protective Services or law enforcement regarding Patient #1's allegations of abuse, and failed to provide for Patient #1's safety while the allegations were investigated. The failure to perform these actions created a likelihood of the risk of serious harm, impairment, disability, or death, and resulted in Immediate Jeopardy to 251 (patients with a diagnosis of dementia) of the current census of 801 patients. The Administrator was notified of the Immediate Jeopardy (IJ) on 03-08-2023 at 08:28 AM. The agency submitted a 2nd revised removal plan for the immediacy component of the IJ for 42 CFR 484.50, Patient Rights on 03-08-2023 at 3:36 PM. The agency's revised removal plan was found to be acceptable. The Immediate Jeopardy was not abated by the end of the exit conference on 03-08-2023 at 03:58 PM, because on-site verification could not occur with a completion date of 3-17-2023 (9 days future.) QR by Area 3 on 3-13-2023

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the protection and promotion of a patient's rights (Patient #1) upon having received a report of physical abuse for a patient with a cognitive deficit (diagnosis of dementia) by having failed to conduct/document an investigation that included a physical assessment and an interview with the patient and a witness identified in the abuse report (G478) in relation to their allegation of abuse and misappropriation of property by their spouse. The failure to take action to protect the affected patient (G486) and failure to report allegations of abuse and misappropriation of property to the appropriate authorities (G488) created the likelihood of risk of serious injury, harm, impairment, or death for all of its cognitively impaired patients (251 of 801 patients on census). The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.50, Patients Rights. The Findings include: 1. A policy received 03-06-2023 at 10:58 AM, from the Agency's Administrator, “3-540 IDENTIFYING AND REPORTING ABUSE/NEGLECT/EXPLOITATION OF CLIENTS,” approved by the Governing Body on 11-03-2022, indicated but was not limited to, “Clients have the right to be free from mental physical sexual and verbal abuse, neglect, and exploitation … Employee/Agency Responsibilities … The Director of Clinical Supervision/designee will review the information presented and investigate if this is a reportable incident. If so, the information will be reported to the appropriate county social service Agency or Adult/Child Protection agency by the Administrator or an appropriate designee ... “ 2. A policy received on 03-06-2023 at 10:58 AM, from the Agency’s Administrator, “3-560 ABUSE PREVENTION PLAN,” indicated but was not limited to, “All clients admitted to the agency will be assessed for vulnerability. An individual abuse prevention plan for individuals suspected or determined to be vulnerable will be documented in the Care Plan … Client Assessment: The following situations need to be addressed: Physically frail or severe functional limitations ... decreased mental functioning ... Client/family behaviors that may pose safety risks … the comprehensive assessments and modifications to the plan of care will be documented in the clinical record. Effectiveness of the plan will also be documented and if client safety is not achieved appropriate disciplines will be notified and care conference set up to address possible alternatives … ” 3. A review of a document “Grievances 2023,” received from the Alternate Administrator on 03-06-2023 at 11:55 AM, evidenced on 2/28/2023, Patient #1 had reported to home health aide #1 (HHA) their spouse hit them 2 times and takes things. The description of the resolution of the grievance evidenced Entity B, an agency that is responsible for the management of care for disabled adults was updated and Entity H (assisted living facility of Patient #1) was notified. The document evidenced a State reportable had been entered. 4. A review of the clinical record for Patient #1, start of care date of 12-13-2022, indicated, but was not limited to, diagnoses of Hemiplegia and Hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke), unspecified dementia with behavioral disturbances, major depressive disorder, anxiety…” The record evidenced Patient #1 resided in an assisted living facility (ALF). The clinical record failed to evidence a vulnerability assessment was completed for Patient #1 at admission, recertification, or at the time of the reported physical abuse allegation. The clinical record failed to evidence documentation of any home health agency case conferences. 5. A review of Case communication notes evidenced: On 2-28-23, an untimed entry by RN #5/ Clinical Manager for Patient #1, indicated HHA #1 called to report Patient #1 had made allegations that their spouse was abusive to them, and Patient #1 had a witness. Patient #1 reported to the HHA that their spouse had hit them and would take their items and money. Patient #1 indicated recently having a cellphone but now the phone was gone because Patient #1’s spouse took it. On 2-28-23, an untimed entry indicated RN #5/ Clinical Manager for Patient #1 spoke with RN #2, and updated Patient #1's allegations. RN #2 was scheduled for a supervisory visit (a visit to supervise the HHA for Patient #1) today if RN #2 has any concerns (Employee #2) would contact the office. On 2-28-23, an untimed entry indicated the Director of Nursing (DON) documented “If (sic witness) can state … saw (sic Patient # 1) being hit by [sic] spouse or (Patient #1) says … has been hit by … spouse we must complete a State Reportable and complete an investigation.” On 2-28-23, an untimed entry indicated the DON called and spoke with HHA #1 again and confirmed Patient #1 told HHA #1 they had been hit by their spouse twice, once before they moved into the ALF (Entity H) and once while living in their current ALF apartment (Entity H.) On 2-28-23 an untimed entry indicated RN #5/ Clinical Manager for Patient #1 updated the communication notes that this was a state reportable. 6. A review of a 03-01-23, untimed case communication note indicated the agency called the ALF's DON, Person A, and left a voicemail that the home health agency was completing a state reportable because of Patient #1's allegation their spouse was abusive, to include having hit them. The note indicated the DON of the ALF, Person A, did not believe the spouse had hit Patient #1. 7. A review of Patient #1’s care visits evidenced RN #2 had made a visit on 02-28-2023 that was time-stamped with a beginning time of 2:44 PM and an end time of 2:45 PM, and documented a supervisory visit of the home health aide was completed. No other documentation was recorded to evidence an assessment for the presence or absence of injuries/injuries of unknown origin or a specific abuse-focused interview with Patient #1 regarding their allegation of physical abuse and their safety concerns. 8. Interviews: On 03-06-23 at 11:37 AM, HHA#1 confirmed having received an allegation from Patient #1 that their spouse had physically abused them and taken pr#operty without permission (to include their cell phone.) HHA #1 reported they saw the patient with the cell phone one day and it was gone the next day. HHA #1 indicated Patient #1 told them their spouse had stolen it. HHA #1 reported Patient #1 had expressed they were scared. HHA #1 indicated he had observed Patient #1 hiding personal items and keeping the apartment door locked, blocking it with their wheelchair, and allowing entry only after seeing who was at the door. On 03-07-23 at 8:44 AM, during an interview with the Agency’s Administrator, she reported that Clinical Manager, RN #5, did an interview over the phone with Patient #1 after the allegation was received. The administrator further reported a RN #2 went to visit Patient #1 the day after the allegation was reported. The administrator was unable to show documentation that a physical, risk, or psychosocial assessment was completed and reported, “we typically don’t.” The administrator indicated RN #2 reported the physical abuse had happened on previous dates. When asked what had been put in place for Patient #1’s protection she reported, “we are not there with [sic Patient #1] so we notified everyone we could.” The administrator indicated the ALF (entity H) did not believe Patient #1's allegations. The administrator indicated having submitted reports to the state, the ALF, and Entity B (an agency responsible to manage elderly and disabled patients' care.) She confirmed the agency had not reported Patient #1's allegations to Adult Protect Services, the Police, or Patient #1’s physician. The administrator stated, “If we felt [sic Patient #1] was in immediate danger we would have called APS." During an interview on 03-07-23 at 11:32 AM, Patient #1 reported last Friday (03-03-23) their spouse tried to get into the apartment, and Patient #1 had held the door closed with their foot and right hand. Patient #1 reported they did not want the spouse in their apartment. When queried if they were fearful of the spouse, Patient #1 answered, “ I am fearful of (spouse) physically, just don’t want (spouse) to visit.” During an interview on 03-07-23 at 12:33 PM, with the Director of Nursing of Entity H (ALF), Person A, where Patient #1 resided, reported the ALF (Entity H) they had done an investigation and assessment and had contacted APS and had provided resources to Patient #1. The Director of Entity H, Person A, was unable to confirm that Purpose Home Health agency was aware of the ALF's actions.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to implement their abuse and neglect policies in 1 of 8 records reviewed (Patient #1). The findings include: 1. A policy received 03-06-2023 at 10:58 AM, from the Agency's Administrator, “3-540 IDENTIFYING AND REPORTING ABUSE/NEGLECT/EXPLOITATION OF CLIENTS,” approved by the Governing Body on 11-03-2022, indicated but was not limited to, “Clients have the right to be free from mental physical sexual and verbal abuse, neglect, and exploitation … Employee/Agency Responsibilities … The Director of Clinical Supervision/designee will review the information presented and investigate if this is a reportable incident. If so, the information will be reported to the appropriate county social service Agency or Adult/Child Protection agency by the Administrator or an appropriate designee. “ A policy received on 03-06-2023 at 10:58 AM, from the Agency’s Administrator, “3-560 ABUSE PREVENTION PLAN,” indicated but was not limited to, “All clients admitted to the agency will be assessed for vulnerability. An individual abuse prevention plan for individuals suspected or determined to be vulnerable will be documented in the Care Plan … Client Assessment: The following situations need to be addressed: Physically frail or severe functional limitations decreased mental functioning Client/family behaviors that may pose safety risks … the comprehensive assessments and modifications to the plan of care will be documented in the clinical record. Effectiveness of the plan will also be documented and if client safety is not achieved appropriate disciplines will be notified and care conference set up to address possible alternatives …” 2. A review of the clinical record for Patient #1 admitted on 12-13-2022, indicated but was not limited to diagnoses of Hemiplegia and Hemiparesis (paralysis of one side of the body)following cerebral infarction (stroke), unspecified dementia with behavioral disturbances, major depressive disorder, anxiety …” The record reported Patient #1 resided in an assisted living facility (ALF). The document failed to evidence a vulnerability assessment completed on admission, recertification, or at the time of the reported allegation. 3. A review of a document “Grievances 2023,” received from the Alternate Administrator on 03-06-2023 at 11:55 AM, contained but was not limited to, “2/28/2023 (Name of Patient #1) Person Reporting, Employee #1, HHA (SIC Home Health Aide) … HHA reported the client stated … (spouse) hit [them] 2 times and takes … things … DESCRIPTION OF RESOLUTION (Entity B, agency managing older disabled adults) updated, Entity H, (assisted living facility of Patient #1) notified. State reportable entered." 4. A review of Patient #1’s care visit notes completed by an RN #2 evidenced a visit on 02-28-2023 that was time-stamped enter at 2:44 PM, exit at 02:45 PM, and was completed by RN #2. The visit note indicated a supervisory visit of the home health aide was completed. No other documentation evidenced the RN interviewed or conducted a physical assessment of Patient #1 for evidence of injury/harm. 5. A case communication note dated 03-02-2023 by Employee #5, a Clinical Manager, included an interview over the phone with Patient #5 where Patient #5 reported their spouse had hit them and the patient provided specific dates in 2021 and 2022. Patient # 5 continued to report items stolen by their spouse and requested a no-contact order. 6. On 03-07-23 at 8:44 AM, during an interview with the Agency’s Administrator, she reported that a clinical manager in the office did an interview over the phone with Patient #1 after the allegation was received. She further reported a nurse went to visit Patient #1 the day after the allegation was reported. The administrator reviewed the visit note and verified there was no documentation of an abuse-focused interview or of a physical assessment, vulnerability assessment, or psychosocial assessment, and indicated “we typically don’t.” She reported the physical abuse happened on previous dates. When asked what has been put in place for Patient #1’s protection she reported, “we are not there with him, so we notified everyone we could.” The administrator indicated the ALF had shared they did not believe Patient #1's allegations. The administrator indicated we reported to the state, ALF, and Entity B. She confirmed the agency had not reported Patient #1's allegations to Adult Protect Services, the Police, or Patient #1’s physician. She stated, “If we felt [sic Patient #1] was in immediate danger we would have called APS.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to take action to prevent further potential risk of physical abuse and misappropriation of the patient’s property in 1 of 7 (Patient #1) records reviewed. The Findings Include: A policy received on 03-06-2023 at 10:58 AM from the Agency’s Administrator titled, “3-560 ABUSE PREVENTION PLAN” indicated but not limited to, “All clients admitted to the agency will be assessed for vulnerability. An individual abuse prevention plan for individuals suspected or determined to be vulnerable will be documented in the Care Plan… Client Assessment: The following situations need to be addressed: Physically frail or severe functional limitations decreased mental functioning Client/family behaviors that may pose safety risks…the comprehensive assessments and modifications to the plan of care will be documented in the clinical record. Effectiveness of the plan will also be documented and if client safety is not achieved appropriated disciplines will be notified and care conference set up to address possible alternatives…” A review of the clinical record for Patient #1 admitted on 12-13-2022, indicated but not limited to diagnoses including Hemiplegia and Hemiparesis (paralysis of one side of the body)following cerebral infarction. (stroke), unspecified dementia with behavioral disturbances, major depressive disorder, anxiety…”. The record reported Patient #1 resided in an assisted living facility. The document failed to evidence a vulnerability assessment completed on admission, recertification, or time of the reported allegation. A review of a document titled “Grievances 2023” received from the Alternate Administrator on 03-06-2023 at 11:55 AM, contained but not limited to, “2/28/2023 (Name of Patient #1) Person Reporting, Employee #1, HHA (SIC Home Health Aide) …HHA reported the client stated … (spouse) hit him 2 times and takes… things…DESCRIPTION OF RESOLUTION (Entity B, agency managing older disabled adults) updated, Entity H, (assisted living facility of Patient #1)notified. State reportable entered A review of Patient #1’s calendar of visits completed by an Agency Nurse evidenced a visit on 02-28-2023 that was time-stamped “ 02:44 PM-02:45 PM” completed by RN #2 with notes indicating a supervisory visit of the home health aide was completed. No other entry evidencing an assessment of Patient #1 was completed. A case communication note dated 03-02-2023 by Employee #5, Clinical Manager, included an interview over the phone with Patient #5 where Patient #5 reported his spouse had hit them and provided specific dates in 2021 and 2022. Patient # 5 continued to report items stolen by their spouse and requested a no-contact order. On 03-07-23 at 8:44 Am during an interview with the Agency’s Administrator, she reported that a clinical manager in the office did an interview over the phone with Patient #1 after the allegation was received. She further reported a nurse went to visit Patient #1 the day after (the allegation was reported). She could not confirm a physical, risk, or psychosocial assessment was completed and reported, “we typically don’t”. She reported the physical abuse happened on previous dates. When asked what has been put in place for Patient #1’s protection she reported, “we are not there with him, so we notified everyone we could”. The ALF did not believe him. We reported to the state, ALF, and Entity B. She confirmed no report was made to Adult Protect Services, the Police, or Patient #1’s physician by this agency. She stated, “If we felt he was in immediate danger we would have called APS. During an interview on 03-07-23 at 11:32 AM Patient #1 reported that last Friday the spouse tried to get into the apartment and Patient #1 held the door closed with their foot and right hand. Patient #1 reported they did not want the spouse in their apartment. When queried if they were fearful of the spouse, they answered, “ I am fearful of her physically, just don’t want (spouse) to visit.”

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review the agency failed to report allegations of abuse and misappropriation of property to all of the appropriate authorities in 1 of 8 records reviewed. 1. A policy received 03-06-2023 at 10:58 AM, from the Agency's Administrator, titled “3-540 IDENTIFYING AND REPORTING ABUSE/NEGLECT/EXPLOITATION OF CLIENTS” approved by the Governing Body 11-03-2022, indicated but not limited to, “Clients have the right to be free from mental physical sexual and verbal abuse, neglect, and exploitation…Employee/Agency Responsibilities…The Director of Clinical Supervision/designee will review the information presented and investigate if this is a reportable incident. If so, the information will be reported to the appropriate county social service Agency or Adult/Child Protection agency by the Administrator or an appropriate designee. “ 2. A review of the clinical record for Patient #1 admitted on 12-13-2022, indicated but not limited to diagnoses including Hemiplegia and Hemiparesis (paralysis of one side of the body)following cerebral infarction. (stroke), unspecified dementia with behavioral disturbances, major depressive disorder, anxiety…”. The record reported Patient #1 resided in an assisted living facility. The document failed to evidence a vulnerability assessment completed on admission, recertification, or time of the reported allegation. 3. A review of a document titled “Grievances 2023” received from the Alternate Administrator on 03-06-2023 at 11:55 AM, contained but not limited to, “2/28/2023 (Name of Patient #1) Person Reporting, Employee #1, HHA (SIC Home Health Aide) …HHA reported the client stated … (spouse) hit him 2 times and takes… things…DESCRIPTION OF RESOLUTION (Entity B, agency managing older disabled adults) updated, Entity H, (assisted living facility of Patient #1)notified. State reportable entered. 4. A review of Patient #1’s calendar of visits completed by an Agency Nurse evidenced a visit on 02-28-2023 that was time-stamped “ 02:44 PM-02:45 PM” completed by RN #2 with notes indicating a supervisory visit of the home health aide was completed. No other entry evidencing an assessment of Patient #1 was completed. 5. A case communication note dated 03-02-2023 by Employee #5, Clinical Manager, included an interview over the phone with Patient #5 where Patient #5 reported his spouse had hit them and provided specific dates in 2021 and 2022. Patient # 5 continued to report items stolen by their spouse and requested a no-contact order. 6. On 03-07-23 at 8:44 Am during an interview with the Agency’s Administrator, she reported that a clinical manager in the office did an interview over the phone with Patient #1 after the allegation was received. She further reported a nurse went to visit Patient #1 the day after (the allegation was reported). She could not confirm a physical, risk, or psychosocial assessment was completed and reported, “we typically don’t”. She reported the physical abuse happened on previous dates. When asked what has been put in place for Patient #1’s protection she reported, “we are not there with him, so we notified everyone we could”. The ALF did not believe him. We reported to the state, ALF, and Entity B. She confirmed no report was made to Adult Protect Services, the Police, or Patient #1’s physician by this agency. She stated, “If we felt he was in immediate danger we would have called APS (Adult Protect Services). The agency failed to contact APS or the Police.

This survey was for a Recertification, State Re-licensure, and Complaint survey of Purpose Home Health. The complaint investigation was initiated by the Indiana Department of Health. Complaint #62359: Substantiated; with findings Survey dates were 3/14/22 - 3/18/22. This report also reflects State findings in accordance with 410 IAC 17-12 et seq. QR by Area 3 on 3-31-2022

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 record review, observation, and interview, the agency failed to implement their policy which required all patients received a complete and accurate medication review/reconciliation at admission, recertification; and with skilled visits for 6 of 12 active records reviewed. (Patient #2, 4, 6, 7, 8, 17) Findings include: 410 IAC 17-14-1(a)(1)(B) 8. The clinical record of Patient #2 was reviewed on 3-15-2022, with a start of care date of 1-18-22, and an initial certification period of 1-18-2022 to 3-18-2022. The record contained an agency document titled “Start of Care Assessment” dated 1-18-2022, and electronically signed by the RN, employee O. The initial comprehensive assessment contained a section subtitled “Respiratory” that indicated, “…Oxygen Flow Settings Nasal Cannula: 2 liters (l)…” The agency document titled “Medication Profile” failed to list Oxygen 2 liters per nasal cannula continuously. During a home visit on 3-17-2022 at 12:30 PM, Patient #2 was observed sitting upright in a recliner. The patient was observed with a nasal cannula in their nose with oxygen infusing. Patient #2 confirmed they were always on oxygen due to their lung issues. 9. The clinical record of Patient #17 was reviewed on 3-16-2022 with a start of care date of 12-22-20. The record contained a plan of care for the recertification period of 2-15-2022 to 4-15-2022. The record contained an agency document titled “Home Health Certification and Plan of Care” dated 2-10-2022, and electronically signed by the RN, employee Z. The plan of care contained a section subtitled “60 Day Summary” that indicated but was not limited to, “… Patient continues to wear supplemental oxygen at 2 liters per minute intermittently to keep saturations above 90 percent…” The agency document titled “Medication Profile” failed to list Oxygen 2 liters per nasal cannula intermittently. During an interview on 3-17-2022 at 4:02 PM, patient #17 confirmed being on oxygen. 10. During an interview on 3-16-2022 at 11:30 AM, the administrator, and director of clinical services, when queried about Patient #4's insulin dose and sliding scale on the plan of care or medication profile, confirmed it was not listed on the plan of care or medication profile. 11. During a daily conference on 3-18-2022 at 12:20 PM, the administrator and clinical director confirmed that the RN should list all the medications the patient is taking on the medication profile. 1. A review of agency policy 3-145, titled Comprehensive Assessment," indicated the agency comprehensive assessment included "Medications, adverse events/reaction, reconciliation and follow up." 2. A review of agency policy #3-709, titled "Medication Reconciliation," indicated "Purpose Home Health will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission, before and after inpatient facility stays, and at the time of discharge." Further review of the policy indicated "Medications will be reviewed with the client on each home visit to determine if other prescriptions or non-prescription drugs are being taken." 3. A review of the plan of care for Patient #4, for the certification period of 3/8/22 - 5/6/22, indicated the patient received "Humalog KwikPen Subcutaneous Solution Pen-injector, 100 unit/ml (milliliter)/100 unit/ml/sliding scale/subcutaneous/three times a day." The plan of care failed to include the patient's sliding scale doses for Humalog and failed to evidence the patient's physician was contacted to review medications. A review of the recertification comprehensive assessment, dated 3/3/22, failed to evidence the clinician completed a full medication review that included screening for new, discontinued, or changed medications; failed to evidence a review of all medications to determine concerns, including but not limited to, compliance, effectiveness, side effects, duplication, and knowledge of all medications ordered; failed to indicate the patient's sliding scale for insulin; and failed to indicate the patient's physician was contacted to review medications. 4. A review of the plan of care for Patient #6, for the certification period of 1/16/22 - 3/16/22, indicated orders for Antifungal External Cream 1%, 1 application/external/4 times every 1 day(s), apply to bilateral buttocks and posterior bilateral knees [for] redness and irritation, but failed to indicate the correct amount/dose for "1 application" of cream, and identify all sites, including but not limited to, under the breasts, sternum, and arm folds; azithromycin oral tablet 500mg (milligram), take 500mg once/day but failed to include duration of delivery, or when the mediation was discontinued; topiramate oral tablet 100mg, take 200mg orally twice a day; and nystatin powder, 1 application, topical, PRN (as needed) 1 time every 12 hours but failed to include the correct amount/dose for "1 application", the specified topical sites to apply the medication, and any PRN qualifier(s) such as "for yeast rash" or "for redness and itching. The plan of care failed to evidence the patient received a complete review of all medications, including but not limited to, compliance, significant side effects, ineffective drug therapy, and addition/discontinuation/change of medications, and failed to indicate the physician was contacted to review medications. 5. A review of the plan of care for patient #7, for the certification period of 2/7/22 - 4/7/22, failed to evidence the patient received a review of all medications taken and failed to evidence the physician was contacted to review medications. A review of a skilled nurse visit note completed by employee BB, RN (Registered Nurse), dated 2/8/22, indicated the RN changed the site of the patient's Libre sensor (a small sensor for measuring blood sugar, applied externally to the skin), and "set up meds (medications) and insulin x2 weeks as ordered." The visit note failed to evidence the patient received a review of all medications that included determining new, discontinued, or changed medications; failed to evidence a review of all medications to determine concerns, including but not limited to, compliance, effectiveness, and side effects; and failed to evidence the patient's physician was contacted to review medications. A review of a skilled nurse visit note completed by employee CC, registered nurse (RN), dated 2/22/22, indicated the RN gave the patient an insulin injection, "set up medications and insulin x2 weeks," and applied a new Libre sensor to the patient's arm. The visit note failed to evidence the patient received a review of all medications as indicated in agency policy #3-70; and failed to evidence the patient's physician was contacted to review medications. A review of a skilled nurse visit note completed by employee CC, dated 3/8/22, indicated the RN provided "medications and insulin set up x2 weeks as ordered," gave an insulin injection, and changed the patient's Libre sensor. The visit note failed to evidence the patient received a review of all medications taken as indicated in agency policy #3-709; and failed to evidence the patient's physician was contacted to review medications. 6. A review of the plan of care for Patient #8, for the certification period of 2/11/22 - 4/11/22, failed to evidence the patient received a review of all medications that included new/discontinued/changed medications and failed to evidence a review of all medications to determine concerns, including but not limited to, compliance, effectiveness, side effects, duplication, and interactions; and failed to evidence the patient's physician was contacted to review medications. On 3/17/22 at 9:30 AM, the patient's facility medication record was reviewed and indicated active medication orders for hydrocortisone cream, fluconazole, vitamin D3, and vitamin B12. The agency plan of care for the certification period 2/11/22 - 4/11/22 was compared to the patient's electronic medication profile provided by entity V (assisted living facility/ALF) and failed to include hydrocortisone, fluconazole, Vitamin D3, and Vitamin B12 included on the ALF electronic medical record as active medications. 7. On 3/17/22 at 12:10 PM employee A (administrator in training) and person A ,employee of entity DD [a consulting company] who was responsible for training employee A as administrator) were interviewed concerning the agency's policy and process for medication reviews. Person A indicated that medication reviews are done on admission, recertification, discharge/transfer, and any time a nurse makes a home visit. Person A stated the nurse calls the physician after the comprehensive assessment is completed, at which time all medications are reviewed for accuracy, changes, additions, and discontinuations. At this time the clinician was supposed to discuss any concerns, including but not limited to effectiveness, side effects, interactions, compliance, and any discrepancies identified, and document the contact.

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 services were furnished as ordered for 6 (Patients 1, 2, 3, 14, 15, 16, and 17) of 12 patients whose clinical records were reviewed. 1. The clinical record of Patient #1 was reviewed on 3-15-2022, with a start of care date of 10-28-20. The record contained a plan of care for the recertification period of 2-20-2022 to 4-20-2022. The plan of care included, but was not limited to, orders to provide home health aide (HHA) services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 2-20-22, for up to 1-hour visit 5-7 times per week for 9 weeks. 2. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee O, on 2-19-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: ambulation “stand by assist,” shower, partial bath, skincare, hair care, shaving-electric razor, dressing, foot care, assist with making bed/changing bed linens, removing clutter from pathways, empty trash, cleaning up soiled linens, clean up after any care is preformed, oral care, observe safety/seizure precautions, and fall risk precautions. Review of untitled documents for Patient #1, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee J, provided a partial bath and shaved with the electric razor on the following dates: 2-21, 2-22, 2-23, 2-24, 2-25, 2-28, 3-2, 3-3, 3-4, 3-7, 3-8, 3-9, 3-10, and 3-14-22. The HHA failed to provide services as directed in the aide care plan. During a home visit on 3-17-2022 at 9:00 AM, Patient #1 confirmed that they always receive showers never partial baths. Patient #1 further confirmed they will not allow the HHA to shave them. During an interview on 3-17-2022 at 9:05 AM, the HHA, employee J, when queried about Patient #1 refusing shave and partial bath confirmed that Patient #1 always refuses those tasks. When queried about care plan tasks and changes in a patient's condition confirmed the HHA is to let the RN case manager know. 3. The clinical record of Patient #2 was reviewed on 3-15-2022 with a start of care date of 1-18-22. The record contained a plan of care for the initial certification period of 1-18-2022 to 3-18-2022. The plan of care included but was not limited to orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 1-18-22, for up to 1 hour a visit for 3-5 times per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee O, on 2-4-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: a shower, partial bath, skincare, hair care, dressing, foot care, and light housekeeping. Review of untitled documents for Patient #2, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee L, provided a partial bath, shower, or hair care on the following dates: 1-18, 1-21, 1-24, 1-25, 1-26, 1-27, 1-28, 2-3, 2-4, 2-7, 2-8, 2-9, 2-10, 2-11, 2-14, 2-15, 2-16, 2-18, 2-21, 2-22, 2-23, 2-25, 2-28, 3-1, 3-2, 3-4, 3-7, 3-8, 3-9, 3-10, 3-11, 3-14, 3-15, 3-16, and 3-17-22. The HHA failed to provide services as directed in the aide care plan. 4. The clinical record of Patient #3 was reviewed on 3-15-2022 with a start of care date of 11-11-20. The record contained a plan of care for the recertification period of 3-6-2022 to 5-4-2022. The plan of care included but was not limited to orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 3-6-22, for up to 1 hour a visit for 1-2 times per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee O, on 3-2-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: ambulation, shower, partial bath, skincare, hair care, catheter care, dressing, fall risk precaution “report falls or injury,” foot care, light housekeeping, and oral care “denture care.” Review of untitled documents for Patient #3, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee K, provided a partial bath, catheter care, oral care on the following dates: 3-8, 3-10, 3-15, and 3-17-22. The HHA failed to provide services as directed in the aide care plan. During an interview on 3-17-2022 at 10:15 AM, Patient #3 confirmed they complete their own oral care and catheter care. 5. The clinical record of Patient #14 was reviewed on 3-16-2022 with a start of care date of 9-28-20. The record contained a plan of care for the recertification period of 1-21-2022 to 3-21-2022. The plan of care included but was not limited to orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 1-21-22, for up to 1 hour a visit for 3-5 times per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee X, on 1-20-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: transfer assist “bed to chair, walker,” a shower, partial bath, peri care, oral care, ambulation “walker, touching assist,” fall risk precautions, skin care, hair care, dressing, foot care, and light housekeeping. Review of untitled documents for Patient #14, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee K, provided a shower, or oral care on the following dates:1-24, 1-25, 1-26, 1-27, 1-28, 1-31, 2-1, 2-2, 2-7, 2-8, 2-10, 2-11, 2-14, 2-15, 2-16, 2-17, 2-22, 2-23, 2-24, 2-28, 3-1, 3-2, 3-3, 3-4, 3-8, 3-9, 3-10, 3-11, 3-14, 3-15, 3-16, and 3-17-22. The HHA failed to provide services as directed on the aide care plan. During an interview on 3-17-22 at 3:41 PM, patient #14 confirmed they would never take a shower due to vertigo and completed their denture care. Patient #14 further confirmed the HHA gives the patient a bed bath and then washes the patient’s hair at the sink. 6. The clinical record of Patient #15 was reviewed on 3-16-2022 with a start of care date of 11-15-21. The record contained a plan of care for the recertification period of 1-14-2022 to 3-14-2022. The plan of care included but was not limited to orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 1-14-22, for up to 1 hour a visit for 5-7 times per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee U, on 1-10-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: transfer assist “bed to chair, walker,” a shower, partial bath, peri care, oral care, ambulation “walker, touching assist,” fall risk precautions, skin care, hair care, dressing, foot care, and light housekeeping. Review of untitled documents for Patient #15, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that employees Q, provided a shower on 1-19, failed to provide a shower or partial bath, and assist with feeding on 3-7-2022. The HHA, employee R, failed to provide to provide a shower or partial bath on the following dates: 1-20, 1-23, 1-27, 1-28, 2-5, 2-8, 2-14, 2-17, 2-19, 2-22, 2-23, 2-24, 3-3, 3-6, and 3-10-2022. The HHA, employee S, failed to provide a shower or partial bath on 1-21 and 2-20-2022. The HHA, employee T, failed to provide a shower or partial bath on the following dates: 1-22, 1-24, 1-25, 1-26, 1-29, 1-31, 2-1, 2-4, 2-7, 2-9, 2-10, 2-11, 2-12, 2-18, 2-21, 2-25, 2-26, 2-27, 2-28, 3-1, and 3-2-2022. The HHA, employee AA, failed to provide a shower or partial bath on 1-30-2022. The HHA, employee BB, failed to provide a shower or partial bath on 2-15, and 2-16-2022. The HHA, employee CC, failed to provide a shower or partial bath on 3-8, and 3-13, and failed to provide a shower on 3-9-2022. The HHA, employee DD, failed to provide a shower or partial bath on 3-11-2022. The HHA, employee EE, failed to provide a shower or partial bath on 3-14, and 3-15-2022. The HHAs failed to provide services as directed in the aide care plan. 7. The clinical record of Patient #16 was reviewed on 3-16-2022 with a start of care date of 10-19-21. The record contained a plan of care for the recertification period of 2-16-2022 to 4-16-2022. The plan of care included but was not limited to orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 2-16-22, for up to 1 hour a visit 1time per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee V, on 2-23-22, the HHA care plan indicated the tasks the HHA was to perform 5-7 days a week at every visit and tasks to perform as patient requests. The care plan included: transfer assist “uses an electric wheelchair cannot ambulate,” a shower, partial bath, peri care, oral care, ambulation “walker, touching assist,” fall risk precautions, skincare, hair care, dressing “help the patient put in hearing aid,” foot care, and light housekeeping. Review of untitled documents for Patient #16, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee W, provided a shower on the following dates: 2-15, 2-16, 2-17, 2-18, 2-19, 2-20, 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-27, 2-28, 3-1, 3-2, 3-4, 3-5, 3-6, 3-7, 3-8, 3-9, 3-10, 3-11, 3-12, 3-13, 3-14, and 3-15-2022. The HHA failed to provide services as directed on the aide care plan. 8. The clinical record of Patient #17 was reviewed on 3-16-2022 with a start of care date of 12-22-20. The record contained a plan of care for the recertification period of 2-15-2022 to 4-15-2022. The plan of care included but was not limited to orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 2-15-22, for up to 1 hour a visit 3-5 times per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee Z, on 2-11-22, the HHA care plan indicated the tasks the HHA was to perform at every visit and tasks to perform as patient requests. The care plan included: fall risk precaution, transfer assist, repositioning, oral care, housekeeping, dressing, shaving electric razor, hair care, skin care, partial bath, peri care, shower, and assist with ambulation. Review of untitled documents for Patient #17, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee Y, provided a shave on the following dates: 2-15, 2-17, 2-21, 2-22, 2-23, 2-24, 2-25, 2-28, 3-2, 3-3, 3-4, 3-7, 3-8, 3-9, 3-10, 3-11, 3-14, and 3-15-2022. The documents failed evidence documentation the employee Y provided a shower on the following dates: 2-15, 2-17, 2-21, 2-23, 2-24, 2-28, 3-1, 3-2, 3-3, 3-7, 3-8, 3-10, and 3-15-2022. The documents failed to evidence employee Y provided a partial bath on the following dates: 2-22, 2-25, 3-1, 3-4, 3-8, 3-11, and 3-14-2022. The HHA failed to provide services as directed in the aide care plan. During an interview on 3-17-2022 at 4:02 PM, Patient #17 confirmed he/he takes showers three times a week and is never to be shaved. The patient further confirmed showers are three times a week due to fear of falling and fainting when they stand up. 9. During an interview on 3-18-2022 at 12:20 PM, the administrator and clinical director confirmed aides are to report changes to the RN case managers for changes/updates to the care plan to individualize the plan to address the patients' needs.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received a complete and accurate plan of care that included all pertinent diagnoses, an accurate psychosocial status, the supplies and equipment required, rehabilitation potential, functional limitations, nutritional requirements, all medications/treatments, all safety measures, hospitalization risk, patient/caregiver education and training, individualized, patient-specific, and measurable goals, and additional items, such as discharge plans for 7 of 12 active records reviewed. (Patients #2, 4, 5, 6, 7, 8, 17) Findings include: 410 IAC 17-13-1(a)(1)(B) 410 IAC 17-13-1(a)(1)(C) 410 IAC 17-13-1(a)(1)(D)(i-xiii) 8. The clinical record of Patient #2 was reviewed on 3-15-2022, with a start of care date of 1-18-22, and an initial certification period of 1-18-2022 to 3-18-2022. The plan of care included, but was not limited to, the following diagnosis: chronic obstructive pulmonary disease, unspecified asthma, and rheumatoid arthritis with rheumatoid factor. Review on an agency document titled “Start of Care Assessment” dated 1-18-2022, was electronically signed by the registered nurse (RN,) employee O. The initial comprehensive assessment contained a section subtitled “Respiratory” that indicated, “…Oxygen Flow Settings Nasal Cannula: 2 liters (l)…” The plan of care failed to list Oxygen 2 liters per nasal cannula continuously on the medication list. During a home visit on 3-17-2022 at 12:30 PM, Patient #2 was observed sitting upright in a recliner. The patient was observed with a nasal cannula in their nose with oxygen infusing. Patient #2 confirmed they were always on oxygen due to their lung issues. 9. The clinical record of Patient #17 was reviewed on 3-16-2022, with a start of care date of 12-22-20. The record contained a plan of care for the recertification period of 2-15-2022 to 4-15-2022. The record contained an agency document titled “Home Health Certification and Plan of Care” dated 2-10-2022 and electronically signed by the RN, employee Z. The plan of care contained a section subtitled “60 Day Summary” that indicated but was not limited to, “… Patient continues to wear supplemental oxygen at 2 liters per minute intermittently to keep saturations above 90 percent…” The plan of care failed to evidence on the medication list Oxygen 2 liters per nasal cannula intermittently. 10. During an interview on 3-14-2022 at 4:20 PM, the administrator, confirmed medication review was at every start of care and every recertification and should be listed on the plan of care. 1. A review of agency policy #3-660, titled “Care Plans” indicated “The Care Plan shall include, but not be limited to: Nursing diagnosis(es)/problems and needs identified. Reasonable, measurable, and realistic goals as determined by the assessment and client expectations. A list of specific interventions with plans for implementation. Indicators for measuring goal achievement and identified time frames. The physician Plan of Care may be used as a care plan if specific interventions are clearly identified for home care staff to address client needs." 2. A review of the plan of care for Patient #4, for the certification period of 3/8/22 - 5/6/22, failed to include the patient's sliding scale for Humalog (a short acting injectable insulin); failed to indicate that Humalog is injected 15 minutes before meals or immediately after eating; failed to include PRN (as needed) qualifiers/indicators for interventions and medications ordered as needed; failed to include all DME (durable medical equipment) and supplies including lancets, glucometer strips, alcohol wipes, weekly medication box, and briefs/pads; failed to include all safety measures, functional limitations, and nutritional requirements including diabetic precautions, type of diet, and dyspnea with minimal exertion; failed to indicate all medications were reviewed; failed to include patient specific blood pressure and blood sugar parameter; failed to include patient specific, individualized, and measurable goals; failed to indicate the patient’s progress toward goals; failed to include the patient’s knowledge level and understanding of diabetes and self-care; failed to include the patient’s rehabilitation potential; and failed to include any discharge plans. On 3/17/22 at 4:30 PM, Patient #4 was interviewed during a home visit. The patient was an unreliable historian due to cognitive delays and verbally indicated being unable to identify or set up their own medications and injectables. During the home visit, the nurse was observed using the patient's glucometer, strips, and lancets. A weekly medication box belonging to the patient was observed on the kitchen table. 3. A review of the plan of care for Patient #5, for certification period 2/17/22 – 4/17/22, failed to indicate all medications included the reason prescribed; failed to indicate the patient’s complete health status including pain level and response to pain medication; failed to include all functional limitations including the suprapubic catheter and bilateral foot drop; failed to include all pertinent diagnoses, including but not limited to, chronic pain, bladder dysfunction, presence of a suprapubic catheter, and heart disease; failed to indicate all nutritional requirements and type of diet, related to the absence of all teeth or dentures; failed to include realistic, individualized, and patient-specific goals which were measurable; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC (skilled nursing facility/long term care)" but failed to include patient-specific and individualized discharge plans. On 3/17/22 at 8:30 AM, Patient #5 was interviewed during a home visit. When queried as to whether the patient needed help with oral care, the patient denied wearing dentures and stated not having teeth at all. 4. A review of the clinical record for Patient #6, for the certification period of 1/16/22 – 3/16/22, failed to include accurate and pertinent diagnoses including candida skin infection, seizure disorder, and short term memory impairment; failed to indicate all medications included the correct dose, frequency, the reason for use; failed to include the discontinued date for azithromycin; failed to include a comprehensive seizure plan that included how to position the patient and how to protect the airway; failed to include individualized, patient-specific goals that are measurable; failed to include the patient’s progress toward goals; failed to include the patient’s psychosocial status, including effects of memory loss, ability to accurately use judgment to direct self-care needs; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC " but failed to include patient-specific and individualized discharge plans. 5. On 3/17/22 at 9:30 AM, person U (representative for Patient #6) was interviewed concerning Patient #6. Person U stated the patient currently had a dormant glioblastoma (a type of brain tumor). The patient had a history of 2 surgical resections, chemotherapy, and radiation therapy which caused significant personality changes and affected the patient’s social awareness, judgment, and memory, which rendered Patient 6 incapable of living independently. Person U stated the patient had not fallen in over a year and never had a history of falling. Person U stated Patient #6 had a history of frequent candida (yeast) skin infections due to obesity, particularly under the breasts, abdominal folds, and behind the knees, and was to receive a full shower 3x/week from the agency and 2x/week from entity V (assisted living facility), for a total of 5 full showers/week. Individual U indicated becoming aware approximately 2 months ago that the patient was refusing baths and had a rash, and requested an immediate phone call any time the patient refused a shower because person U could redirect the patient without causing distress. Person U stated the agency agreed to call if the patient refused bathing, but person U had received no calls since November 2021. On 3/8/22, individual U entered the patient’s room and smelled a foul odor, specifically of yeast, and noted drainage had seeped through the patient’s shirt over the sternum and under the breasts. The patient was having difficulty walking due to the irritation caused by the rash and excoriation behind the patient's knees. Person U also noted the patient had a rash from below the sternum to the top of the sternum and under both breasts. Person U stated the drainage was puss-like and bleeding. Person U contacted a nurse from entity V, who assisted the patient with a shower. Person U stated the nurse indicated the rash and signs of infection were significant enough to consider calling 911, but ultimately decided not to call. Patient #6 saw their Primary Care Physician on 3/9/22, and was prescribed antifungal cream 2x/day and nystatin powder 4x/day, to be applied by entity V employees. 6. A review of the clinical record for Patient #7, for the certification period of 2/7/22 – 4/7/22, failed to include that the patient was profoundly hard of hearing bilaterally and required the aide to shout directly into the patient’s ear from very close range; failed to include the hearing impairment in safety measures; failed to include goals that were patient-specific, individualized, and measurable; failed to indicate the patient’s progress toward goals; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC " but failed to include patient-specific and individualized discharge plans. 7. A review of the clinical record for Patient #8, for the certification period of 2/11/22 – 4/11/22, indicated medications were reviewed and reconciled, with no changes, but failed to evidence the patient was receiving hydrocortisone cream 1%, fluconazole cream 5%, vitamin D3, and Vitamin B12 per the patient’s active medical record provided by the facility. The plan of care also failed to include individualized, patient-specific goals that were measurable; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC " but failed to include patient-specific and individualized discharge plans.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure integration of services with all disciplines involved in 8 of 12 active records reviewed. (Patients #1, 2, 3, 6, 14, 15, 16, 17) Findings include: 410 IAC 17-12-2(g) 410 IAC 17-12-2(h) 3. The clinical record of Patient #1 was reviewed on 3-15-2022, with a start of care date of 10-28-20. The record contained a plan of care for the recertification period of 2-20-2022 to 4-20-2022. The plan of care included but was not limited to orders to provide home health aide (HHA) services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 2-20-22, for up to 1 hour, visit 5-7 times per week, for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee O, on 2-19-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: ambulation “stand by assist,” shower, partial bath, skincare, hair care, shaving-electric razor, dressing, foot care, assist with making bed/changing bed linens, removing clutter from pathways, empty trash, cleaning up soiled linens, clean up after any care is preformed, oral care, observe safety/seizure precautions, and fall risk precautions. Review of untitled documents for Patient #1, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation the HHA, employee J, provided a partial bath and shaved with the electric razor on the following dates: 2-21, 2-22, 2-23, 2-24, 2-25, 2-28, 3-2, 3-3, 3-4, 3-7, 3-8, 3-9, 3-10, and 3-14-22. The HHA failed to document communication with the RN case manager that tasks were not completed, and changes needed to be made to the care plan. During a home visit on 3-17-2022 at 9:00 AM, Patient #1 confirmed they always receive showers never partial baths. Patient #1 further confirmed they will not allow the HHA to shave them. During an interview on 3-17-2022 at 9:05 AM, the HHA, employee J, when queried about patient #1 refusing shave and partial bath confirmed that patient #1 always refuses those tasks. When queried about care plan tasks and changes in a patient's condition confirmed the HHA is to let the RN case manager know. 4. The clinical record of Patient #2 was reviewed on 3-15-2022, with a start of care date of 1-18-22. The record contained a plan of care for the initial certification period of 1-18-2022 to 3-18-2022. The plan of care included but was not limited to orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 1-18-22, for up to 1 hour a visit, for 3-5 times per week, for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee O, on 2-4-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks the HHA was to perform as the patient requested. The care plan included: a shower, partial bath, skincare, hair care, dressing, foot care, and light housekeeping. Review of untitled documents for Patient #2, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee L, provided a partial bath, shower, or hair care on the following dates: 1-18, 1-21, 1-24, 1-25, 1-26, 1-27, 1-28, 2-3, 2-4, 2-7, 2-8, 2-9, 2-10, 2-11, 2-14, 2-15, 2-16, 2-18, 2-21, 2-22, 2-23, 2-25, 2-28, 3-1, 3-2, 3-4, 3-7, 3-8, 3-9, 3-10, 3-11, 3-14, 3-15, 3-16, and 3-17-22. The HHA failed to document communication with the RN case manager the tasks were not completed and changes needed to be made to the care plan. 5. The clinical record of Patient #3 was reviewed on 3-15-2022 with a start of care date of 11-11-20. The record contained a plan of care for the recertification period of 3-6-2022 to 5-4-2022. The plan of care included, but was not limited to, orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 3-6-22, for up to 1 hour a visit for 1-2 times per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee O, on 3-2-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: ambulation, shower, partial bath, skincare, hair care, catheter care, dressing, fall risk precaution “report falls or injury,” foot care, light housekeeping, and oral care “denture care.” Review of untitled documents for Patient #3, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee K, provided a partial bath, catheter care, oral care on the following dates: 3-8, 3-10, 3-15, and 3-17-22. The HHA failed to document communication with the RN case manager that tasks were not completed, and changes needed to be made to the care plan. During a home visit on 3-17-22 at 10:00 AM, observed patient #3 showing the HHA, employee K, a rash covering her abdominal and upper thighs. HHA, employee K was discussing with the patient discoloration on left should from fall earlier that am. During an interview on 3-18-2022 at 10:01 AM, the RN case manager for Patient #3, employee O, confirmed the HHA did not inform them of the rash or fall. Employee O confirmed the director of clinical informed the RN of the fall, the HHA called the office and reported the fall. 6. The clinical record of Patient #14 was reviewed on 3-16-2022, with a start of care date of 9-28-20. The record contained a plan of care for the recertification period of 1-21-2022 to 3-21-2022. The plan of care included, but was not limited to, orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 1-21-22, for up to 1 hour a visit for 3-5 times per week for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee X, on 1-20-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requests. The care plan included: transfer assist “bed to chair, walker,” a shower, partial bath, peri care, oral care, ambulation “walker, touching assist,” fall risk precautions, skin care, hair care, dressing, foot care, and light housekeeping. Review of untitled documents for patient #14, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee K, provided a shower, or oral care on the following dates:1-24, 1-25, 1-26, 1-27, 1-28, 1-31, 2-1, 2-2, 2-7, 2-8, 2-10, 2-11, 2-14, 2-15, 2-16, 2-17, 2-22, 2-23, 2-24, 2-28, 3-1, 3-2, 3-3, 3-4, 3-8, 3-9, 3-10, 3-11, 3-14, 3-15, 3-16, and 3-17-22. The HHA failed to document communication with the RN case manager that tasks were not completed, and changes needed to be made to the care plan. During an interview on 3-17-22 at 3:41 PM, Patient #14 confirmed they would never take a shower due to vertigo and completed their denture care. Patient #14 further confirmed the HHA gives the patient a bed bath and then washes the patient’s hair at the sink. 7. The clinical record of Patient #15 was reviewed on 3-16-2022, with a start of care date of 11-15-21. The record contained a plan of care for the recertification period of 1-14-2022 to 3-14-2022. The plan of care included, but was not limited to, orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 1-14-22, for up to 1 hour a visit, for 5-7 times per week, for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee U, on 1-10-22, the HHA care plan indicated the tasks the HHA was to perform every visit and tasks to perform as patient requested. The care plan included: transfer assist “bed to chair, walker,” a shower, partial bath, peri care, oral care, ambulation “walker, touching assist,” fall risk precautions, skincare, hair care, dressing, foot care, and light housekeeping. Review of untitled documents for Patient #15, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that employee Q, provided a shower on 1-19, failed to provide a shower or partial bath, and assist with feeding on 3-7-2022. The HHA, employee R, failed to provide to provide a shower or partial bath on the following dates: 1-20, 1-23, 1-27, 1-28, 2-5, 2-8, 2-14, 2-17, 2-19, 2-22, 2-23, 2-24, 3-3, 3-6, and 3-10-2022. The HHA, employee S, failed to provide a shower or partial bath on 1-21 and 2-20-2022. The HHA, employee T, failed to provide a shower or partial bath on the following dates: 1-22, 1-24, 1-25, 1-26, 1-29, 1-31, 2-1, 2-4, 2-7, 2-9, 2-10, 2-11, 2-12, 2-18, 2-21, 2-25, 2-26, 2-27, 2-28, 3-1, and 3-2-2022. The HHA, employee AA, failed to provide a shower or partial bath on 1-30-2022. The HHA, employee BB, failed to provide a shower or partial bath on 2-15, and 2-16-2022. The HHA, employee CC, failed to provide a shower or partial bath on 3-8, and 3-13, and failed to provide a shower on 3-9-2022. The HHA, employee DD, failed to provide a shower or partial bath on 3-11-2022. The HHA, employee EE, failed to provide a shower or partial bath on 3-14, and 3-15-2022. The HHA failed to document communication with the RN case manager that tasks were not completed, and changes needed to be made to the care plan. 8. The clinical record of Patient #16 was reviewed on 3-16-2022, with a start of care date of 10-19-21. The record contained a plan of care for the recertification period of 2-16-2022 to 4-16-2022. The plan of care included, but was not limited to, orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 2-16-22, for up to 1 hour a visit, 1time per week, for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee V, on 2-23-22, the HHA care plan indicated the tasks the HHA was to perform 5-7 days a week at every visit and tasks to perform as patient requests. The care plan included: transfer assist “uses an electric wheelchair cannot ambulate,” a shower, partial bath, peri care, oral care, ambulation “walker, touching assist,” fall risk precautions, skincare, hair care, dressing “help the patient put in hearing aid,” foot care, and light housekeeping. Review of untitled documents for Patient #16, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee W, provided a shower on the following dates: 2-15, 2-16, 2-17, 2-18, 2-19, 2-20, 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-27, 2-28, 3-1, 3-2, 3-4, 3-5, 3-6, 3-7, 3-8, 3-9, 3-10, 3-11, 3-12, 3-13, 3-14, and 3-15-2022. The HHA failed to document communication with the RN case manager that tasks were not completed, and changes needed to be made to the care plan. 9. The clinical record of Patient #17 was reviewed on 3-16-2022, with a start of care date of 12-22-20. The record contained a plan of care for the recertification period of 2-15-2022 to 4-15-2022. The plan of care included, but was not limited to, orders to provide HHA services to assist with bathing, grooming, hygiene, mobility, and housekeeping needs starting 2-15-22, for up to 1 hour a visit, 3-5 times per week, for 9 weeks. A review of an agency document titled “Paraprofessional Assignment Sheet” electronically signed by the RN, employee Z, on 2-11-22, the HHA care plan indicated the tasks the HHA was to perform at every visit and tasks to perform as the patient requested. The care plan included: fall risk precaution, transfer assist, repositioning, oral care, housekeeping, dressing, shaving electric razor, hair care, skincare, partial bath, peri care, shower, and assist with ambulation. Review of untitled documents for patient #17, included HHA tasks completed each visit by the HHA and any communication of comments regarding changes in condition, COVID questions screening and comments, and any changes needed to the care plan. The documents failed to evidence documentation that the HHA, employee Y, provided a shave on the following dates: 2-15, 2-17, 2-21, 2-22, 2-23, 2-24, 2-25, 2-28, 3-2, 3-3, 3-4, 3-7, 3-8, 3-9, 3-10, 3-11, 3-14, and 3-15-2022. The documents failed evidence documentation the employee Y provided a shower on the following dates: 2-15, 2-17, 2-21, 2-23, 2-24, 2-28, 3-1, 3-2, 3-3, 3-7, 3-8, 3-10, and 3-15-2022. The documents failed to evidence employee Y provided a partial bath on the following dates: 2-22, 2-25, 3-1, 3-4, 3-8, 3-11, and 3-14-2022. The HHA failed to document communication with the RN case manager that tasks were not completed, and changes needed to be made to the care plan. During an interview on 3-17-2022 at 4:02 PM, Patient #17 confirmed took showers three times a week and is never to be shaved. The patient further confirmed showers are three times a week due to fear of falling and fainting when standing up. 10. During an interview on 3-18-2022 at 12:20 PM, the administrator and clinical director confirmed aides are to report changes to the RN case managers. 1. A review of agency policy 3-360, titled "Coordination of Client Services", indicated "All personnel furnishing services shall maintain a liaison to assure their efforts are coordinated effectively and support the objective outlined in the Plan of Care. This may be done through formal care conferences, maintaining complete, current Care Plans and written and verbal interaction." The purpose of care coordination included ensuring services were coordinated between all Providers; ensuring services were appropriate and quality care was provided; ensuring continuity of care. Further review of the policy evidenced "Ongoing care conferences shall be conducted to evaluate the client's status and progress ... All caregivers ... shall have access to the Client Plan of Care and will be expected to participate in ... coordination activities, as appropriate." The policy indicated the primary care nurse assumed responsibility for updating or changing the care plan, and communicating changes to caregivers within 24 hours following the care conference of changes. 2. A review of the clinical record for Patient #6, for the certification period of 1/16/22 - 3/16/22 indicated "Orders for Discipline and Treatment" of a home health aide (hha) up to 1 hour/visit, with 3 - 5 visits/week x 9 weeks, to assist with bathing, grooming, hygiene, mobility, IADL (Instrumental Activities of Daily Living), and housekeeping needs in accordance with patient-specific, written instructions provided by a Registered Nurse. Further review of Patient 6's medical plan of care evidenced a section labeled "Problems and Interventions" which indicated "HHA (home health aide) to assist with ADLs (Activities of Daily Living), Personal Care, and Housekeeping needs. Patient/Family is cognitively able to make the choice regarding bathing and ADL/IADL (Instrumental Activities of Daily Living) needs. A review of an untimed case communication note, created on 3/9/22, by employee B (alternate director of nursing), indicated "HHA (home health aide) called and said [Name of Patient #6] has a rash on his/her bottom and is red under his/her breasts. [HHA] let [name of entity V] nurses know and they are ordering her some cream." A review of an untimed case communication note, dated 3/10/22, indicated "Per Team Lead follow up: I wasn't clear on what the concern was. I did speak with [name of employee N] ... looks like facility is now using Nystatin powder under breast, and has been using a barrier cream to bottom. HHA (home health aide) reported it was looking better. HHA didn't seem to have any concerns at this time. Reported that the client sometimes will refuse an actual shower at times. But will allow a partial in place of a shower." A review of the aide visit notes for 1/18/22, 1/19/22, 1/20/22. 1/21/22, 1/25/22, 1/26/22, 1/28/22, 2/1/22, 2/2/22, 2/3/22, 2/4/22, 2/7/22, 2/8/22, 2/9/22, 2/11/22, 2/14/22, 2/15/22, 2/16/22, 2/17/22, 2/18/22, 2/19/22, 2/22/22, 2/23/22, 2/25/22, 2/28/22, 3/1/22, 3/2/22, 3/3/22, 3/7/22, 3/8/22, 3/9/22, and 3/11/22, indicated the patient refused a full shower and accepted a partial bath and skincare. The notes failed to evidence what was included in the partial bath; failed to indicate what type of skincare was provided; failed to evidence the aide notified the supervisory nurse that the patient was not bathing for days at a time; and failed to evidence the aide inspected the patient's skin to identify and report concerns. A review of the plan of care, for the certification period of 1/16/22 - 3/16/22, failed to evidence Patient 6's representative/POA (power of attorney) had been contacted when Patient #6 refused a full shower, as the POA had requested.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure care coordination with other home care agencies and assisted living facilities, failed to coordinate care between the clinician and home health aide, failed to coordinate care with the patient's physician, and failed to include the patient's representative in care coordination in 5 of 12 clinical records reviewed. (Patients #1, 3, 4, 6, 7) Findings Include: 410 IAC 17-14-1(a)(1)(F) 410 IAC 17-12-2(g) 5. The clinical record of patient #1 was reviewed on 3-15-2022, with a start of care date of 10-28-20. The record contained a plan of care for the recertification period of 2-20-2022 to 4-20-2022. The patient’s diagnosis included, but was not limited to: Type 2 diabetes mellitus, Other seizures, Other polyosteoarthritis, Chronic kidney disease stage 3, Abscess of the lung without pneumonia, Myelodysplastic syndrome, mild intellectual disabilities, and Other psoriasis. The plan of care further contained a section titled, “60 Day Summary” which indicated patient #1 resided in a group home, Entity J. Review of an agency document Titled, “Care Conference” dated 2-19-2022, was electronically signed by the registered nurse (RN), employee O. The RN indicated that patient #1 remained appropriate for services. Employee O further indicated care coordinated between all interdisciplinary team members. The document failed to evidence care coordination with Entity J and review the medications, blood sugars, and what care Entity J employees were completing. During a home visit with patient #1 on 3-17-2022 at 8:55 AM, observed patient #1 receiving an injection with an insulin pen in the right upper arm by direct care staff, for Entity J, person K. During an interview on 3-17-2022 at 9:02 AM, direct care staff for Entity J, person K confirmed that they cared for patient #1 and give insulin injections. Person K, further indicated they care for one other person who lives in the home. 6. The clinical record of patient #3 was reviewed on 3-15-2022, with a start of care date of 11-11-20. The record contained a plan of care for the recertification period of 3-6-2022 to 5-4-2022. The plan of care included but was not limited to the following diagnosis: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, Type 2 diabetes mellitus with diabetic nephropathy, Atherosclerotic heart disease, Essential hypertension, Major depressive disorder, Neuromuscular dysfunction of the bladder, Chronic kidney disease stage 3, and Generalized anxiety disorder. The plan of care further contained a section titled, “60 Day Summary” that indicated patient #3 is at risk for falls, and an increased risk for infection due to suprapubic catheter. Review of an agency document Titled, “Care Conference” dated 3-2-2022, was electronically signed by the RN, employee O. The RN indicated that patient #3 remained appropriate for services. Employee O further indicated care coordinated between all interdisciplinary team members. The document failed to evidence care coordination with Entity Z. The document failed to evidence review of the services being provided by a skilled nurse of the catheter changes, and therapy progress by Entity Z. During a home visit observation on 3-17-2022 at 10:02 AM, observed patient #3 telling the home health aide, employee K that she fell at 4:30 AM that morning. The patient pointed out her glasses made an abrasion above her left eyebrow. Observed patient number #3 had a purple-blue discoloration around her lower left and left upper arm. Patient #3 had a suprapubic catheter located under her abdominal fold that patient #3 lifted to show the red discharge and 2 pieces of skin protruding out of the suprapubic insertion site that caused bleeding. During an interview on 3-17-2022 at 10:15 AM, patient #3 confirmed Entity Z, a home care agency, was to send a nurse and therapist to change the catheter and to help prevent all the falls. During an interview on 3-18-2022 at 10:01 AM, the RN for patient #3, employee O, when queried about when the catheter was changed, and about the therapy could not name staff or when. Employee O named Entity Z was the name of the agency only. 7. During an interview on 3-18-2022 at 12:05 PM, when reviewed record reviews and home visits findings, the owner, person F confirmed the agency could do a better job coordinating care. 1. A review of agency policy 3-360, titled "Coordination of Client Services", indicated "All personnel furnishing services shall maintain a liaison to assure their efforts are coordinated effectively and support the objective outlined in the Plan of Care. This may be done through formal care conferences, maintaining complete, current Care Plans and written and verbal interaction." The purpose of care coordination included ensuring services were coordinated between all Providers; ensuring services were appropriate and quality care was provided; ensuring continuity of care. Further review of the policy evidenced "Ongoing care conferences shall be conducted to evaluate the client's status and progress ... All caregivers ... shall have access to the Client Plan of Care and will be expected to participate in ... coordination activities, as appropriate." The policy indicated the primary care nurse assumed responsibility for updating or changing the care plan, and communicating changes to caregivers within 24 hours following the care conference of changes. 2. A review of the plan of care for patient #4, for the certification period of 3/8/22 - 5/6/22, failed to evidence the clinician contacted the physician for case coordination purposes and to review the care plan. A review of the comprehensive recertification assessment, dated 3/3/22, indicated "Physician contacted: No." The document failed to evidence the clinician contacted the patient's physician or a representative of the patient's assisted living facility for case coordination purposes and to review findings during the patient's recertification assessment. A review of the nurse visit note dated 3/16/22 evidenced the patient had a fasting blood sugar of 223. The visit note failed to evidence parameters for the patient's blood sugar and failed to evidence the clinician notified the physician of the patient's blood sugar. On 3/17/22 at 4:30 PM, the surveyor observed the clinician obtaining vital signs for patient #4. Upon completion of the blood pressure, the clinician stated, "188/90. You must be upset. Are you nervous?" The clinician failed to repeat the blood pressure, failed to review the patient's medication box to determine if the patient's blood pressure medication was missed, and failed to notifiy the patient's physician of the elevated blood pressure results. 3. . A review of the plan of care for patient #6, for the certification period of 1/16/22 - 3/16/22, failed to evidence the clinician contacted the patient's assisted living facility to review medications and determine if any changes occurred since the previous recertification period; failed to indicate the clinician contacted the patient's physician to review the medications and update the plan of care, including the patient's active and pertinent diagnoses. A review of the patient's comprehensive reassessment, dated 1/13/22, failed to evidence the clinician contacted the patient's physician to review findings and update the plan of care and failed to evidence the clinician contacted the assisted living facility to coordinate care and services. A review of the home health aide visit notes dated 1/17/22 - 3/14/22 failed to evidence the home health aide reported any concerns to the Registered Nurse or case manager; failed to report the patient was refusing a shower multiple days in a row; and failed to notify the Registered Nurse concerning the patient's skin rash and breakdown, drainage, and odor. On 3/17/22 at 12:11 PM, person U (representative for patient #6) was interviewed concerning services and patient care. Person U stated they had not received a call from the agency for at least 2 months. Person U specified that no one had called to report the patient was refusing a shower, or to report the patient had a rash and had open areas with foul-smelling drainage. On 3/18/22 at 9:30 AM, employee N was interviewed as to why they did not contact the clinician concerning the patient's skin, odor, rash, and refusal to bath, Employee N had no additional comments. 4. A review of the plan of care for patient #7, for the certification period of 2/7/22 - 4/7/22 evidenced a section for coordination of care, which indicated the clinician spoke with the patient's waiver provider and verified the patient received 15 hours per week with no duplication of services. The plan of care failed to evidence the clinician verified services provided by both agencies to determine if the patient's needs were met, and failed to evidence the agency contacted the patient's physician to review the plan of care and continuing orders.

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 record review, observation, and interview the agency failed to ensure all personnel having direct patient contact implemented standard precautions, including proper hand hygiene, proper bathing, and proper personal care; and failed to ensure all clinicians used aseptic technique during subcutaneous injection of a medication and blood glucose monitoring in 4 of 7 home visits observed. (Patient #1, 4, 5, 7) Findings include: 410 IAC 17-12-1(m) 6. During a home visit observation on 3-17-2022 at 9:05 AM, with Patient #1, the home health aide (HHA), employee J was observed providing shower assistance. Employee J completed hand hygiene and donned clean gloves assisted patient #1 to the shower chair and pulled the shower curtain. The patient sat in the shower chair and began to wash independently as much as possible. At 9:20 AM, the HHA washed the patient's back, legs, peri area, and buttocks, then used the handheld shower to rinse. The HHA handed the handheld shower to the patient for the patient to do an independent final rinse. At 9:26 AM, the HHA placed the towel on the floor and helped the patient step out of the shower and onto the towel without removing soiled gloves and performing hand hygiene, and donning new gloves. Employee J handed the patient a clean towel to dry off with and assisted as the patient needed. At 9:30 AM, employee J assisted the patient in drying their posterior legs, buttocks, and peri areas. The HHA then assisted the patient in getting their brief on. Employee J hung the towels from the floor that was used on the patient on the hooks on the wall. The HHA handed patient #1 a comb to comb their hair without removing gloves and performing hand hygiene. Employee J assisted the patient to their room and applied lotion to the patient’s legs, back, and arms. At 9:31 AM, employee J removed their gloves without performing hand hygiene. Employee J then dressed; first socks, then shorts, shirt, and tennis shoes. The HHA failed to change gloves and sanitize hands after coming in contact with possible body fluids, excretions, or mucous membranes. The HHA failed to change gloves and sanitize hands after coming in contact with soiled linens and contaminated items. 7. During an interview on 3-17-2022 at 12:50 PM, the HHA, employee L, when queried about hand hygiene and gloves changes, confirmed gloves are changed and hand hygiene is to be completed between dirty to clean procedures. 8. During an interview on 3-18-2022 at 9:45 AM, the director of clinical services, employee A, confirmed hand hygiene and glove changes are to be completed by staff between dirty and clean procedures. 1. A review of agency policy #2-360, titled "Infection Prevention/Control," indicated "Standard precautions apply to blood, all body fluids, secretions, excretions, non-intact skin, and mucous membranes ... Hands are washed if contaminated with blood or body fluid, immediately after gloves are removed, between client contacts, and when indicated to prevent transfer of microorganisms ... Gloves are worn when touching blood body fluids, secretions, excretions, non-intact skin, mucous membranes, or contaminated items." 2. A review of agency policy #4-330, titled "Handwashing/Hand Hygiene" indicated thorough hand washing//hand antisepsis is required of all employees. Indications for handwashing included before invasive procedures, before and after client care, when there is prolonged or intense contact with the client (bathing), between tasks on the same client, before putting on and after removing gloves, after touching potentially contaminated objects, and when hands are visibly soiled. Decontaminate hands after contact with intact skin, body fluids, excretions, non-intact skin, and wound dressings. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the client. 3. On 3/17/22 at 4:30 PM, employee M was observed preparing to obtain a blood sugar and administer insulin to Patient #4. Employee M was observed completing hand hygiene with soap and water for approximately 10 seconds, and then donned gloves. Employee M was observed changing gloves after arranging supplies, but failed to complete had hygiene between changes. Employee M obtained an alcohol swab and cleaned the finger of Patient #4, who stated, "We don't usually use alcohol." Employee M used the lancet pen but failed to obtain blood from the patient. Employee M notified the patient of another "stick" and repeated the attempt using the same alcohol swab and lancet, without results. Employee M obtained a new lancet, cleaned the patient's finger with the same alcohol swab, and successfully obtained the blood sample. Employee M was then observed to give the patient the same alcohol swab to hold pressure/wipe the finger while employee M administered the patient's Humalog in the abdomen. Employee M failed to swab the injection site with alcohol prior to the administration of the insulin. When queried as to why the employee used the same alcohol swab 4 times, and why a dirty lancet was used, employee M stated being nervous. 4. On 3/17/22 at 8:10 AM, a home visit was initiated with Patient #5, observed employee G (home health aide/hha) providing personal care for Patient 5. At the opening of the visit, the aide was observed completing appropriate handwashing with soap and water. Employee G then donned nitryl gloves and proceeded to remove slide the patient's pants off, remove the patient's soiled brief, roll the brief up and discard it in the trash, followed immediately by assisting the patient to remove a layer of socks from the patient's feet, revealing white socks underneath, and don a black sock over the patient's white socks, leaving the patient wearing white socks from under the ones just removed. The employee failed to change gloves after handling the patient's discarded brief. Employee G was then observed assisting with the removal of the patient's pants and catheter bag adjustment. The patient was noted to have a towel over their genitals, and was observed emptying the catheter bag in the toilet, but was not observed washing the genitals, completing catheter care, or completing hand hygiene after the catheter bag was emptied. Employee G assisted patient #5 in putting on a new brief and was observed sorting through the patient's closet for a pair of sweats requested by the patient without changing gloves since donning the first pair. The aide failed to remove gloves and complete hand hygiene after handling contaminated or soiled material and before moving to a clean task. 5. On 3/17/22 at 8:20 AM, employee H (home health aide), was observed completing hand hygiene appropriately prior to donning gloves and preparing to assist Patient #7 with a sink bath. The aide was observed to fill the sink with warm soapy water, rinse the patient's washcloth, and return it so the patient could complete peri-care. Upon completion of peri-care, the aide rinsed the cloth in the sink water, and was observed washing vigorously between the patient's buttocks, followed immediately by washing the patient’s buttock cheeks and down both thighs. Employee G was then observed to rinse the washcloth in the sink water again, and hand it to the patient with instructions to “wash your front one more time." Employee G assisted patient #7 to dress without changing gloves or completing hand hygiene.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the nurse updated and evaluated the plan of care to ensure all the patients' needs were being met and failed to ensure the plan of care was individualized based on the patient's needs for 12 of 12 active records reviewed. (Patient #1, 2, 3, 4, 5, 6, 7, 8, 14, 15, 16, 17) Findings include: 1. A review of agency policy #3-660, titled “Care Plans,” indicated “The Care Plan shall include, but not be limited to: Nursing diagnosis(es)/problems and needs identified. Reasonable, measurable, and realistic goals as determined by the assessment and client expectations. A list of specific interventions with plans for implementation. Indicators for measuring goal achievement and identified time frames. The physician Plan of Care may be used as a care plan if specific interventions are clearly identified for home care staff to address client needs." 2. A review of the plan of care for Patient #4, for the certification period of 3/8/22 - 5/6/22, failed to include the patient's sliding scale for Humalog (a short acting injectable insulin); failed to indicate that Humalog is injected 15 minutes before meals or immediately after eating; failed to include PRN (as needed) qualifiers/indicators for interventions and medications ordered as needed; failed to include all DME (durable medical equipment) and supplies including lancets, glucometer strips, alcohol wipes, weekly medication box, briefs/pads; failed to include all safety measures, functional limitations, and nutritional requirements including diabetic precautions, type of diet, and dyspnea with minimal exertion; failed to indicate all medications were reviewed; failed to include patient specific blood pressure and blood sugar parameter; failed to include patient specific, individualized, and measurable goals; failed to indicate the patient’s progress toward goals; failed to include the patient’s knowledge level and understanding of diabetes and self-care; failed to include the patient’s rehabilitation potential; and failed to include any discharge plans. The nurse failed to update and evaluate the effectiveness of the plan of care for Patient 6. On 3/17/22 at 4:30 PM, Patient #4 was interviewed during a home visit. The patient was an unreliable historian due to cognitive delays and verbally indicated being unable to identify or set up their own medications and injectables. During the home visit, the nurse was observed using the patient's glucometer, strips, and lancets. A weekly medication box belonging to the patient was observed on the kitchen table. 3. A review of the plan of care for Patient #5, for certification period 2/17/22 – 4/17/22, failed to indicate all medications included the reason prescribed; failed to indicate the patient’s complete health status including pain level and response to pain medication; failed to include all functional limitations including the suprapubic catheter and bilateral foot drop; failed to include all pertinent diagnoses, including but not limited to, chronic pain, bladder dysfunction, presence of a suprapubic catheter, and heart disease; failed to indicate all nutritional requirements and type of diet, related to the absence of all teeth or dentures; failed to include realistic, individualized, and patient-specific goals which were measurable; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC (skilled nursing facility/long term care)" but failed to include patient-specific and individualized discharge plans. The nurse failed to update and evaluate the effectiveness of the plan of care for Patient 6. On 3/17/22 at 8:30 AM, Patient #5 was interviewed during a home visit. When queried as to whether the patient needed help with oral care, the patient denied wearing dentures and stated having no teeth at all. 4. A review of the clinical record for Patient #6, for the certification period of 1/16/22 – 3/16/22, failed to include accurate and pertinent diagnoses including candida skin infection, seizure disorder, and short term memory impairment; failed to indicate all medications included the correct dose, frequency, the reason for use; failed to include the discontinued date for azithromycin; failed to include a comprehensive seizure plan that included how to position the patient and how to protect the airway; failed to include individualized, patient-specific goals that are measurable; failed to include the patient’s progress toward goals; failed to include the patient’s psychosocial status, including effects of memory loss, ability to accurately use judgment to direct self-care needs; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC " but failed to include patient-specific and individualized discharge plans. The nurse failed to update and evaluate the effectiveness of the plan of care for Patient 6. 5. On 3/17/22 at 9:30 AM, person U was interviewed concerning Patient #6. Person U stated the patient currently had a dormant glioblastoma (a type of brain tumor). The patient had a history of 2 surgical resections, chemotherapy, and radiation therapy which caused significant personality changes and affected the patient’s social awareness, judgment, and memory, which rendered the patient incapable of living independently. Person U stated the patient had not fallen in over a year and had no history of falling. Person U stated patient #6 had a history of frequent candida skin infections due to obesity, particularly under the breasts, abdominal folds, and behind the knees, and was to receive a full shower 3x/week from the agency and 2x/week from entity V (assisted living facility), for a total of 5 full showers/week. Person U indicated becoming aware approximately 2 months ago that the patient was refusing baths and had a rash, and requested an immediate phone call any time the patient refused a shower because person U could redirect the patient without causing distress. Person U stated the agency agreed to call if the patient refused bathing, but person U had received no calls since November 2021. On 3/8/22, person U entered the patient’s room and smelled a foul odor, specifically of yeast, and noted drainage had seeped through the patient’s shirt over the sternum and under the breasts. The patient was having difficulty walking due to the irritation caused by the rash and excoriation behind the patient's knees. person U also noted the patient had a rash from below the sternum to the top of the sternum and under both breasts. Individual U stated the drainage was puss-like and bleeding. Individual U contacted a nurse from entity V, who assisted the patient with a shower. Person U stated the nurse stated after seeing the rash, they would have called 911 due to the pain and extent of the rash. Patient #6 saw their PCP on 3/9/22 and was prescribed antifungal cream 2x/day and nystatin powder 4x/day, to be applied by entity V employees. The nurse failed to update and evaluate the effectiveness of the plan of care for Patient 6. 6. A review of the clinical record for Patient #7, for the certification period of 2/7/22 – 4/7/22, failed to include that the patient was profoundly hard of hearing bilaterally and required the aide to shout directly into the patient’s ear from very close range; failed to include the hearing impairment in safety measures; failed to include goals that were patient-specific, individualized, and measurable; failed to indicate the patient’s progress toward goals; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC " but failed to include patient-specific and individualized discharge plans. The nurse failed to update and evaluate the effectiveness of the plan of care for Patient 7. 7. A review of the clinical record for Patient #8, for the certification period of 2/11/22 – 4/11/22, indicated medications were reviewed and reconciled, with no changes, but failed to evidence the patient was receiving hydrocortisone cream 1%, fluconazole cream 5%, vitamin D3, and Vitamin B12 per the patient’s active medical record provided by the facility. The plan of care also failed to include individualized, patient-specific goals that were measurable; and included discharge plans of "Patient will discharge when home health services no longer needed or upon permanent transfer to SNF/LTC " but failed to include patient-specific and individualized discharge plans. The nurse failed to update and evaluate the effectiveness of the plan of care for Patient 8.