Every finding on record at Raw Home Healthcare Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 08/04, 08/05, and 08/06/2025. Active Census: 7 At this Emergency Preparedness survey, Raw Home Health Care Services, LLC. 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 8/11/2025.

This visit was for an Initial Federal Certification and State Licensure survey for a Home Health Provider. Survey Dates: 08/04, 08/05, and 08/06/2025. 12-Month Unduplicated Skilled Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA Home Health Aide DON Director of Nursing RN Registered Nurse OASIS Outcome and Assessment Information Set POC Plan of Care LPN Licensed Practical Nurse SOC Start of care SN Skilled Nursing QR completed by Area 3 on 8/11/2025.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide patients with written notice of the agency’s transfer and discharge policies for 3 of 3 admission packets reviewed during home visits conducted. (Patients: #1, 2, and 3) Findings Include: 1. A review of the agency’s admission packet provided by the Administrator on 08/05/2025, failed to contain the agency’s discharge and transfer policies. 2. During a home visit at Patient #1’s residence on 08/04/2025 at 4:00 PM, SOC date of 04/24/2025, reviewed the agency's admission packet, which failed to contain the agency’s transfer and discharge policies. 3. During a home visit at Patient #2’s residence on 08/05/2025 at 10:00 AM, SOC date of 05/31/2025, reviewed the agency's admission packet, which failed to contain the agency’s transfer and discharge policies. 4. During a home visit at Patient #3’s residence on 08/05/2025 at 3:45 PM, SOC date of 04/18/2025, reviewed the agency's admission packet, which failed to contain the agency’s transfer and discharge policies. During an interview on 08/05/2025 at 12:39 PM, the Administrator communicated they had changed the admission packets and had removed documents containing the transfer and discharge policies from the previous admission packet. 410 IAC 17-12-3(a)1(A)(B)

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the Administrator’s name and contact information to voice grievances for 3 of 3 admission packets of home visits conducted (Patients: #1, 2, and 3), with the potential to affect all active patients. (Patients: #4, 5, 6, and 7) Findings Include: 1. A review of an agency document, titled “Your Rights & Responsibilities as a Client” indicated but was not limited to, “ … 40. Be informed of the procedure for submitting a complaint/grievance … Contact, Administrator … ” 2. On 08/05/2025, a review of an agency admission packet contained an agency document titled “Your Rights & Responsibilities as a Client” indicated but was not limited to “…2. Notify Raw Home Health Care Services, by phone at (317) 550-5181 … ”. The Admission packet failed to contain the Administrator’s name and contact information. 3. During a home visit at Patient #1’s residence on 08/04/2025 at 4:00 PM, SOC date of 04/24/2025, when asked, Patient #1 if they knew who and how to call if they had concerns with the agency’s care provided, Patient #1’s family member and caregiver, Person 4, indicated they would for Patient #1. A review of the agency's admission packet failed to list the Administrator's name and their contact information. 4. During a home visit at Patient #2’s residence on 08/05/2025 at 10:00 AM, SOC date of 05/31/2025, observed HHA 1 perform a bed bath for Patient #2. A review of the agency's admission packet failed to contain the Administrator's name and their contact information. 5. During a home visit at Patient #3’s residence on 08/05/2025 at 3:45 PM, SOC date of 04/18/2025, when questioned Patient #3, if they knew who and how to call if they had concerns with the agency’s care provided, Patient #3 stated that they would have their son, and caregiver Person 5 call someone if they had concerns with the agency's care provided. A review of the agency's admission packet failed to contain the Administrator's name and their contact information. During an interview on 08/05/2025 at 12:39 PM, the Administrator confirmed their name and contact information had been missed.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the patient and the patient’s legal representative with an OASIS privacy notice upon admission for 3 of 3 admission packets of home visits conducted. (Patients: #1, 2, and 3) Findings Include: 1. A review of the agency’s admission packet provided by the Administrator on 08/05/2025, failed to contain an OASIS privacy notice. 2. During a home visit at Patient #1’s residence on 08/04/2025 at 4:00 PM, SOC date of 04/24/2025, observed the Administrator/RN performing a skilled nursing assessment. A review of the agency's admission packet failed to contain an OASIS privacy notice. 3. During a home visit at Patient #2’s residence on 08/05/2025 at 10:00 AM, SOC date of 05/32/2025, a review of the agency's admission packet failed to contain an OASIS privacy notice. 4. During a home visit at Patient #3’s residence on 08/05/2025 at 3:45 PM, SOC date of 04/18/2025, observed LPN 1 performing a skilled nursing assessment. A review of the agency's admission packet failed to contain an OASIS privacy notice. During an interview on 08/05/2025 at 12:39 PM, the Administrator confirmed they had changed admission packets and had removed the document OASIS privacy notice from the current agency's admission packet.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients had been provided with the Indiana Department of Health State toll-free home health telephone hotline to receive complaints or questions for 3 of 3 admission packets of home visits conducted patients (Patients: #1, 2, and 3), with the potential to affect all active patients. (Patients: #4, 5, 6, and 7) Findings Include: 1. A review of the agency’s admission packet contained an agency document titled “Your Rights & Responsibilities as a Client.” The client rights and responsibilities indicated but was not limited to, “ … 42. Be informed of your state’s hotline and agencies contact information make suggestions or complaints … Department of Family and Protective Services 1-800-252-5400 … ” and listed Raw Home Health Care Services phone number but failed to list the Indiana Department of Health state toll free hotline, its contact information, hours of operation, and its purpose is to receive complaints or questions regarding HHAs. 2. During a home visit at Patient #1’s residence on 08/04/2025 at 4:00 PM, SOC date of 04/24/2025, when questioned, Patient #1 if they knew who and how to call if they had concerns with the agency’s care provided, Patient #1’s family member and caregiver, Person 4, indicated they would for Patient #1. A review of the agency's admission folder failed to list the Indiana Department of Health state toll-free hotline, its contact information, hours of operation, and its purpose, which is to receive complaints or questions regarding HHAs. 3. During a home visit at Patient #2’s residence on 08/05/2025 at 10:00 AM, SOC date of 05/31/2025, observed HHA 1 perform a bed bath, to non-verbal, and dependent on care, Patient #2 when questioned the family member and caregiver, HHA 1 communicted they knew who and how to call if they had concerns, they would call the agency. A review of the agency's admission folder failed to list the Indiana Department of Health state toll-free hotline, its contact information, hours of operation, and its purpose, which is to receive complaints or questions regarding HHAs. 4. During a home visit at Patient #3’s residence on 08/05/2025 at 3:45 PM, SOC date of 04/18/2025, when questioned Patient #3, if they knew who and how to call if they had concerns with the agency’s care provided, Patient #3 stated that they would have their son, and caregiver Person 5 call someone if they had concerns with the agency's care provided. A review of the agency's admission folder failed to list the Indiana Department of Health state toll-free hotline, its contact information, hours of operation, and its purpose, which is to receive complaints or questions regarding HHAs. 5. A review of the active clinical records for Patients #4, 5, 6, and 7 contained an agency document titled “Your Rights & Responsibilities as a Client.” The client rights and responsibilities indicated but was not limited to, “ … 42. Be informed of your state’s hotline and agencies contact information make suggestions or complaints … Department of Family and Protective Services 1-800-252-5400 … ” and listed Raw Home Health Care Services phone number but failed to list the Indiana Department of Health state toll free hotline, its contact information, hours of operation, and its purpose is to receive complaints or questions regarding HHAs. During an interview on 08/05/2025 at 12:39 PM, the Administrator confirmed they had changed admission packets and had removed sections that contained the required information. 410 IAC 17-12-3(b)(2)(C)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC was individualized and included all necessary elements, including allergies, nutrition, caregiver status, seizure plan, other entities providing care, onset dates of diagnoses, and hospitalization risk, for 3 of 7 active clinical records reviewed. (Patients: #1, 2, and 5) Findings Include: 1. A review of an undated agency policy titled, “Plan of Care” indicated but was not limited to, “ … Diagnoses … Equipment … Identification of any services furnished by other providers … Coordination of care with other agencies … Activities permitted … Nutritional requirements … Food or drug allergies … ” 2. During a home visit at Patient #1’s residence on 08/04/2025 at 4:00 PM, observed the Administrator/DON providing renal diet education to Patient #1 and their caregiver, Person 4. Person 4 made the Administrator/DON aware that Patient #1’s dialysis clinic days were Tuesday, Thursday, and Saturday at Entity 2, a dialysis in-center facility. The Administrator/DON informed communicated Patient #1 were new to dialysis starting in March 2025. A review of the clinical record for Patient #1, SOC date of 04/24/2025, contained a POC for the recertification period 06/23/2025 to 08/21/2025. The POC indicated, but was not limited to, diagnoses of Type 2 diabetes mellitus with diabetic chronic kidney disease, Essential Hypertension, Chronic diastolic (congestive) heart failure, and Chronic Kidney Disease, Stage 4 (severe). The POC failed to evidence the diagnoses dates of onset, the patient’s risk for hospitalization, and failed to include other agencies involved in care, including personal care agencies. During an interview on 08/06/2025 at 9:35 AM, the Administrator/DON indicated the POCs should be complete and provided a complete picture of the patient’s care needs. 3. During a home visit at Patient #2’s residence on 08/05/2025 at 10:00 AM, observed HHA 1 providing a bed bath to Patient #2. Observed two feeding tubes placed on Patient #2’s abdomen, and Patient #2 had jerking, uncontrolled movements. HHA 1, and the mother of Patient #2, communicated Patient #2 was blind and had their last seizure last month, and storms frequently. When asked regarding a seizure plan, HHA 1 indicated they were unaware of a plan. HHA 1 reported Patient #2 has a nasal spray for seizures, the parents use as needed for seizures. A review of the clinical record for Patient #2, SOC date of 05/31/2025, contained a POC for the recertification period 07/30/2025 to 09/27/2025, electronically dated 08/01/2025, and signed by the Administrator/DON. The POC indicated but was not limited to diagnoses of Other Seizures, Other Specified Functional Intestinal Disorders, Spastic Quadriplegic Cerebral Palsy (condition that affects muscles and movement characterized by increased muscle tone making muscles stiff and movements jerky and awkward), and Intracranial hypotension following ventricle shunting (condition where there is significant decrease in the intracranial pressure due to over drainage of cerebrospinal fluid though the shunt), the diagnoses failed to indicate onset dates, failed to list Autonomic Disfunction (condition where the autonomic nervous system does not work properly affecting blood flow, breathing, sweating, urination, and digestion), Jejunostomy tube (a surgical opening (stoma) through the skin at the front of the abdomen and the wall of the jejunum (part of the small intestine) used to supply long -term liquid nutrition in patients who cannot consume food orally), and Cortical Blindness ( a condition of loss of visual perception due to damage in certain areas of the brain). The section titled “Medications” indicated but was not limited to Patient #2, received Levetiracetam (an antiepileptic drug used to treat seizures) 100 milligrams(mg)/milliliter (ml), twice a day for seizures via g-tube, and Valtoco ( a fast acting and long lasting nasal spray used in emergency situation for treatment of acute repetitive seizures) 10 mg/.1ml nasal liquid. The section subtitled “Nutrition Requirements” had been left blank. The POC failed to evidence the patient’s risk for hospitalization, failed to include other agencies involved in care, including personal care agencies, and failed to include seizure plans with interventions. During an interview with the Administrator/ DON on 08/06/2025 at 1:17 PM, when asked if the agency had a seizure protocol, the Administrator could not provide one. When questioned what their seizure protocol was for Patient #2, the Administrator stated the agency did not have one. 4. A review of the clinical record for Patient #5, SOC date of 05/01/2025, contained a POC for the incorrect certification period 06/30/2025 to 08/28/2025, electronically dated 05/02/2025, and signed by the Administrator/DON. The POC indicated, but was not limited to, diagnoses of Cerebellar Stroke Syndrome, Alzheimer’s Disease, and Major Depressive Disorder. The sections titled “Nutritional Requirements”, “Allergies,” and “Functional Limitations” had been left blank. The POC failed to evidence the patient’s risk for hospitalization, failed to include other agencies involved in care, including personal care agencies. A review of a “Communication Note” dated 05/05/2025, electronically signed by the Administrator/DON, indicated communication between the Administrator and Entity 1, a personal services agency. During an interview on 08/06/2025 at 1:17 PM, when questioned about the blank sections on the POC for Patient #5, the Administrator/DON confirmed the sections were blank and communicated the POCs should be completely filled out. 410 IAC 17-13-1(a)(1)(D)(vi, vii,viii,x, xiii)

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 patient's clinical records included documentation of services the patient received by other agencies and failed to coordinate care delivery to meet the patient’s needs for 1 of 1 active clinical records reviewed (Patient: #1) of patients receiving in-center dialysis services. Findings include: 1. A review an undated agency policy titled “Coordination of Patient Care” indicated but was not limited to, “ … 4. Care will be coordinated with other known external HCA’s providing care and services to the same patient … 5. Documentation of care coordination will be maintained in the patient’s medical record … ” 2. During a home visit at Patient #1’s residence on 05/04/2025 at 4:00 PM, the Administrator/RN indicated Patient #1 had their Central Venous Catheter (CVC) (a flexible tube placed in the large vein above the heart that delivers medications and blood products) replaced for dialysis treatments. Person 4, the daughter, and Attendant for Entity 3, a personal care agency was interviewed and indicated Patient #1 went to Entity 2, an in-center dialysis treatment center every Tuesday, Thursday, and Friday. Person 4 further communicated they worked for Entity 3, a personal service agency, providing 8 waiver hours during the day 7 days a week for Patient #1. A review of the POC for the recertification period for 06/23/2025 to 08/02/2025, failed to evidence Patient #1 had received waiver services from another agency or in-center dialysis center services. A review of the communication notes dated 04/24/2025 through 08/04/2025, failed to evidence care coordination with Entity 2 or Entity 3. During an interview on 08/05/2025 at 4:50 PM, when asked regarding the documentation and coordination of care with Entity 2 and Entity 3, the Administrator /RN communicated they had not coordinated care or communicated with Entity 2 or Entity 3. 410 IAC 17-14-1(a)(1)(F)

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the DON’s name and contact information for 3 of 3 admission packets of home visits conducted (Patients: #1, 2, and 3), with the potential to affect all active patients. (Patients: #4, 5, 6, and 7) Findings Include: 1. A review of an agency document, titled “Your Rights & Responsibilities as a Client” indicated but was not limited to, “ … 40. Be informed of the procedure for submitting a complaint/grievance … Contact, Supervisor … ” 2. On 08/05/2025, a review of an agency admission packet, contained but was not limited to “…2. Notify Raw Home Health Care Services, by phone at (317) 550-5181 … ”. The Admission packet failed to contain the DON’s name and contact information. 3. During a home visit at Patient #1’s residence on 08/04/2025 at 4:00 PM, SOC date of 04/24/2025, when asked, Patient #1 if they knew who and how to call if they had concerns with the agency’s care provided, Patient #1’s family member and caregiver, Person 4, indicated they would for Patient #1. A review of the agency's admission packet failed to list the DON and their contact information. 4. During a home visit at Patient #2’s residence on 08/05/2025 at 10:00 AM, SOC date of 05/31/2025, observed HHA 1 perform a bed bath for Patient #2. A review of the agency's admission packet failed to contain the DON and their contact information. 5. During a home visit at Patient #3’s residence on 08/05/2025 at 3:45 PM, SOC date of 04/18/2025, when questioned Patient #3, if they knew who and how to call if they had concerns with the agency’s care provided, Patient #3 stated that they would have their son, and caregiver Person 5 call someone if they had concerns with the agency's care provided. A review of the agency's admission packet failed to contain the DON and their contact information. During an interview on 08/05/2025 at 12:39 PM, the Administrator/DON confirmed their name and contact information had been missed.

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 DON/Case Manager failed to ensure the aide care plan was individualized and patient-specific for 1 of 1 active patients receiving HHA services. (Patient: #2) Findings Include: 1. A review of an undated agency policy titled “Plan of Care” indicated, but was not limited to, “Services will be provided in accordance with a Plan of Care based on the patient’s diagnoses and assessment of immediate and long-range needs … ” 2. During a home visit at Patient #2’s residence on 08/05/2025 at 10:00 AM, observed HHA 1 providing a bed bath to Patient #2. Observed 2 feeding tubes placed on Patient #2’s abdomen, and Patient #2 had jerking, uncontrolled movements. HHA 1, and the mother of Patient #2, communicated Patient #2 was blind and had their last seizure last month, and storms frequently. When asked regarding a seizure plan, HHA 1 indicated they were unaware of a plan. HHA 1 reported Patient #2 has a nasal spray for seizures, the parents use as needed for seizures. A review of the clinical record for Patient #2, SOC date of 05/31/2025, contained a POC for the recertification period 07/30/2025 to 09/27/2025, electronically dated 08/01/2025, and signed by the Administrator/DON. The POC indicated but was not limited to diagnoses of Other Seizures, Other Specified Functional Intestinal Disorders, Spastic Quadriplegic Cerebral Palsy (condition that affects muscles and movement characterized by increased muscle tone making muscles stiff and movements jerky and awkward), and Intracranial hypotension following ventricle shunting (condition where there is significant decrease in the intracranial pressure due to over drainage of cerebrospinal fluid though the shunt), the diagnoses failed to indicate onset dates, failed to list Autonomic Disfunction (condition where the autonomic nervous system does not work properly affecting blood flow, breathing, sweating, urination, and digestion), Jejunostomy tube (a surgical opening (stoma) through the skin at the front of the abdomen and the wall of the jejunum (part of the small intestine) used to supply long -term liquid nutrition in patients who cannot consume food orally), and Cortical Blindness ( a condition of loss of visual perception due to damage in certain areas of the brain). A review of the HHA Care Plan dated 06/09/2025, and signed by the Administrator/DON, overseeing Patient #2’s care, indicated Patient #2 had a primary diagnosis of Other seizures, NPO with tube feedings, seizure precaution, fall precaution, paralysis, complete bed rest, and bed bath every visit. The HHA Care Plan failed to be individualized to the patient’s specific needs regarding safety needs for seizures, autonomic dysfunction episodes, and abdominal jejunostomy tube site appearance and care. During an interview on 08/06/2025 at 1:17 PM, when asked if they could show the seizure plan for HHA 1 while providing care for Patient #2, the Administrator/DON could not provide one. When asked about what their seizure protocol was for Patient #2, the Administrator stated the agency did not have one. 410 IAC 17-13-2(a)

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 observation, record review, and interview, the Administrator failed to ensure they were responsible for the day-to-day operations of the home health agency in regards ensuring patient safety and 24 hour on call availability for 1 of 1 agency. Findings Include: 1. A review of an undated agency policy titled “After Hours Accessibility” indicated, but was not limited to, “The Agency provided on-call coverage 7 days a week, 24 hours a day as necessary to meet the patient’s needs … 3. The on-call staff is available at all times by telephone … ” 2. A review of the personnel file for the Administrator contained a signed and dated 12/04/2024, agency document titled “Job Description Administrator”, which indicated, but was not limited to, “ … 28. Ensure 24-hour/day, seven (7) days/week on-call coverage … ” 3. During the Entrance Conference on 08/04/2025 at 9:45 AM, when asked regarding the after-hours/on-call handling, the Administrator stated, “I carry the phone and call back within an hour. The office phone is transferred to my cell after 2:00 PM. I will triage over the phone and make a visit if needed.” 4. On 08/04/2025 at 7:32 AM, called the agency 24-hour number (317) 550-5181, received a message, “The office is currently closed. If you know your party’s extension, you may dial it now. If you need dial by directory, go to the main menu.” Left a voicemail for a return call, but no return call had been received. During an interview on 08/05/2025 at 12:28 PM, the Administrator had been made aware of the call placed to the agency's on-call number (317) 550-5181 at 7:32 AM, during on-call hours, and no return call had been received. The Administrator confirmed the agency's answering machine message had been confusing and confirmed they had not returned the call. 410 IAC 17-12-1(c)(1)