Every finding on record at Ready and Willing 2 Help Healthcare LLC

This visit was for a Federal/State complaint survey of a HHA Provider. Survey Dates: 01/22/2026 and 01/23/2026. Complaint#: IN002715880 with unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide EMR Electronic Medical Record RN Registered Nurse OASIS Outcome and Assessment Information Set CM Clinical Manager HIPAA Health Insurance Portability Act POC Plan of Care PHI Protected Health Information SOC Start of Care SN Skilled Nursing QR completed by Area 3 on 2/3/2026.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (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: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to investigate and document complaints for 1 of 1 patient complaints reviewed. (Patient: #7) Findings Include: 1. A review of an agency policy, effective date of 04/2024, titled “Grievances/Complaint: Internal & External,” indicated but was not limited to. “ … 1. Ready and Willing 2 Help Healthcare will investigate all complaints/grievances … 3. Upon receiving a patient/family complaint/grievance, written or verbal, the receiving person will: … b. Complete a Compliant Report … d. Investigate the incident … h. Respond to complainant in writing as to the resolution … within 10 days … m. Complaints will be retained for a period of three years … ” 2. During the entrance conference on 01/22/2026 at 8:38 AM, when asked about who handled the complaints and if the agency had received complaints, the Administrator reported the agency had no complaints and the complaints were documented using a complaint form and log sheet. 3. A review of agency documents titled “Patient Complaint Log” evidenced no complaints had been logged. 4. A review of the clinical record for Patient #7 SOC 11/08/2025, and discharge date 12/17/2025, contained a communication note dated 12/16/2025, electronically signed by the former Administrator/Clinical Manager. The communication note, titled “On-Call Communication note,” stated that a call had been received from Patient #7 at 11:55 PM on 12/15/2025, reporting a medication error in the medication box. Patient #7 reported not enough levothyroxine (a medication to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone, causing fatigue, weight gain, cold intolerance, and depression) and too much cetirizine (a medication used for the treatment of allergies). The note further indicated that Patient #7 had been feeling nauseated and had been able to keep water and Gatorade down. The note evidence the former Administrator/Clinical Manager notified the physician. During an interview on 01/22/2026 at 11:05 AM, Patient #7 communicated they reported a complaint to Admin 1, the owner of the agency, their concerns with the Alternate Administrator/Alternate Clinical Director putting the lids on incorrectly, missing the lids of the thyroid medication and the allergy medication, after Patient #7 had instructed them not to set up their thyroid medication. Patient #7 reported not taking their thyroid medication daily as ordered. Patient #7 further indicated they labeled the lids to help them remember to take their medications as ordered. Patient #7 stated, “I refused to have that nurse come to my house again. [Administrator1, the owner] acted like they did not care.” On 01/22/2026 at 12:00 PM, called Entity 5, the physician's office for Peron 9 Patient #7’s provider for information regarding follow-up calls and appointments. Person 10, an office triage nurse, provided the email address for Person 11, the office manager, for the PHI release letter regarding Patient #7’s follow-up appointment on 12/19/2025 and agency communication regarding Patient #7. Release letter sent, and received no response from Entity 5. 5. During an interview on 01/22/2026 at 1:03 PM, Administrator1 confirmed Patient #7 had called and complained regarding the medication setup and the Alternate Administrator/Alternate Clinical Manager, and wanted the former Administrator/Clinical Manager to do their visits from now on. Admin 1 further communicated Patient #7 has complaints due to her traumatic brain injury and doesn’t always tell the truth, and this was caused by the former Administrator/Clinical Manager making up stories. When asked about the complaint investigation and documentation, Administrator 1 confirmed they had not documented the complaint, and per the agency policy, it should have been documented and investigated. 410 IAC 17-12-3(c)(1)(A)(B)

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to investigate and document complaints and resolutions for 1 of 1 patient complaints reviewed. (Patient: #7) Findings Include: 1. A review of an agency policy, effective date of 04/2024, titled “Grievances/Complaint: Internal & External,” indicated, but was not limited to. “ … 1. Ready and Willing 2 Help Healthcare will investigate all complaints/grievances … 3. Upon receiving a patient/family complaint/grievance, written or verbal, the receiving person will: … b. Complete a Compliant Report … d. Investigate the incident … h. Respond to complainant in writing as to the resolution … within 10 days … m. Complaints will be retained for a period of three years … ” 2. A review of agency documents titled “Patient Complaint Log” evidenced no complaints with resolution had been logged. 3. A review of the clinical record for Patient #7, SOC 11/08/2025, and discharge date 12/17/2025, contained a communication note dated 12/16/2025, electronically signed by the former Administrator/Clinical Manager. The communication note, titled “On-Call Communication note,” stated that a call was received from Patient #7 at 11:55 PM on 12/15/2025, reporting a medication error in the medication box. Patient #7 reports not enough levothyroxine (a medication to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone, causing fatigue, weight gain, cold intolerance, and depression) and too much cetirizine (a medication used for the treatment of allergies). The note further indicated that Patient #7 had been feeling nauseated and had been able to keep water and Gatorade down. The note evidence the former Administrator/Clinical Manager notified the physician. During an interview on 01/22/2026 at 11:05 AM, Patient #7 communicated they reported a complaint to Administrator 1, the owner of the agency, their concerns with the Alternate Administrator/Alternate Clinical Director putting the lids on incorrectly, missing the lids of the thyroid medication and the allergy medication, after Patient #7 had instructed them not to set up their thyroid medication. Patient #7 reported not taking their thyroid medication daily as ordered. Patient #7 further indicated the agency had not contacted them regarding the investigation or resolution. 4. During an interview on 01/22/2026 at 1:03 PM, Administrator 1 confirmed Patient #7 had called and complained regarding the medication set up and the Alternate Administrator/Alternate Clinical Manager and wanted the former Administrator/Clinical Manager to do their visits from now on. Administrator 1 further communicated Patient #7 has complaints due to her traumatic brain injury and doesn’t always tell the truth, and this was caused by the former Administrator/Clinical Manager making up stories. When asked about the complaint documentation, investigation, and resolution, Administrator 1 could not provide any documentation regarding Patient #7's complaint, the agency's investigation, or resolution. 410 IAC 17-12-3(c)(2)

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a comprehensive OASIS discharge assessment had been completed for 10 of 10 discharged patient records reviewed. (Patients: #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings Include: 1. A review of an agency policy, effective date of 04/2024, titled “OASIS,” indicated, but was not limited to. “ … Time Points for CMS Compliance: Start of Care (SOC), Resumption of care (ROC) following an inpatient facility stay, Transfer to inpatient facility, Re-certification (every 56-60 days) or significant change in condition, Discharge … 5. Discharge- must be completed within 48 hours of discharge of a patient … ” 2. A review of an agency document dated 01/22/2026, titled “Ready and Willing 2 Help Healthcare Clients Discharge,” listed the SOC dates and discharge dates for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 2 test patients, indicating all the patients had been discharged from the agency. 3. A review of the clinical record for Patient #1, SOC date 11/05/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 4. A review of the clinical record for Patient #2, SOC date 11/03/2025, and discharge date of 12/15/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 5. A review of the clinical record for Patient #3, SOC date 11/03/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 6. A review of the clinical record for Patient #4, SOC date 11/05/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 7. A review of the clinical record for Patient #5, SOC date 11/03/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 8. A review of the clinical record for Patient #6, SOC date 11/03/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 9. A review of the clinical record for Patient #7, SOC date 11/05/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 10. A review of the clinical record for Patient #8, SOC date 11/05/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 11. A review of the clinical record for Patient #9, SOC date 11/03/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. 12. A review of the clinical record for Patient #10, SOC date 11/05/2025, and discharge date of 12/10/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. During an interview on 01/22/2025 at 3:08 PM, upon reviewing the discharge charts of 10 patients and asking about the location of the discharge OASIS comprehensive assessments, the Alternate Administrator/Alternate Clinical Manager reported they had not been completed.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary containing necessary medical information pertinent to the patient’s care had been provided to the healthcare practitioner and receiving agency, ensuring safe transfer and discharge of care for 10 of 10 patients discharged from care. (Patient: Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings Include: 1. A review of an agency policy, effective date of 04/2024, titled “Discharge/Reduction in Services,” indicated, but was not limited to. “When the patient’s POC changes and this change results in discharge or reduction of services, the patient, or their representative, as well as their primary medical provider, will be notified and involved in planning decisions, including discharge from the Agency in accordance with federal & state regulations … ” 2. On 01/22/2026 at 8:38 AM, the Administrator and the Alternate Administrator, via conference call, communicated the agency’s current census had been 0. The Administrator further indicated that all patients had been discharged because the agency needed to be back on track with compliance and could not bill for services. 3. A review of the clinical record for Patient #1 SOC date 11/05/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/05/2025 through 12/10/2025, contained an unsigned communication note dated 12/10/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #1’s primary medical provider had been notified of Patient #1’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #1’s primary medical provider or a discharge order from Patient #1’s primary medical provider noting Patient #1’s primary medical provider had been involved in the discharge planning for Patient #1. 4. A review of the clinical record for Patient #2 SOC date 11/03/2025, and discharge date of 12/15/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/03/2025 through 12/15/2025 contained an unsigned communication note dated 12/15/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #2’s primary medical provider had been notified of Patient #1’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #2’s primary medical provider, or a discharge order from Patient #2’s primary medical provider noted Patient #2’s primary medical provider had been involved in Patient #2's discharge planning. 5. A review of the clinical record for Patient #3 SOC date 11/03/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/03/2025 through 12/08/2025, contained an unsigned communication note dated 12/08/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #3’s primary medical provider had been notified of Patient #3’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #3’s primary medical provider, or a discharge order from Patient #3’s primary medical provider noting Patient #3’s primary medical provider had been involved in Patient #3's discharge planning. 6. A review of the clinical record for Patient #4 SOC date 11/05/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/05/2025 through 12/10/2025, contained an unsigned communication note dated 12/10/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to contain a communication note that Patient #4’s primary medical provider had been notified of Patient #4’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #4’s primary medical provider or a discharge order from Patient #4’s primary medical provider noted Patient #4’s primary medical provider had been involved in the discharge planning for Patient #4. 7. A review of the clinical record for Patient #5 SOC date 11/03/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/03/2025 through 12/09/2025, contained an unsigned communication note dated 12/09/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #5’s primary medical provider had been notified of Patient #5’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #5’s primary medical provider, or a discharge order from Patient #5’s primary medical provider noting Patient #5’s primary medical provider had been involved in Patient #5's discharge planning. 8. A review of the clinical record for Patient #6 SOC date 11/03/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/03/2025 through 12/09/2025, contained an unsigned communication note dated 12/09/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #6’s primary medical provider had been notified of Patient 6’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #6’s primary medical provider or a discharge order from Patient #6’s primary medical provider noting Patient #6’s primary medical provider had been involved in the discharge planning for Patient #6. 9. A review of the clinical record for Patient #7 SOC date 11/05/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/05/2025 through 12/17/2025, contained an unsigned communication note dated 12/17/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #7’s primary medical provider had been notified of Patient #7’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #7’s primary medical provider or a discharge order from Patient #7’s primary medical provider noting Patient #7’s primary medical provider had been involved in the discharge planning for Patient #7. 10. A review of the clinical record for Patient #8 SOC date 11/05/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/05/2025 through 12/05/2025, contained an unsigned communication note dated 12/05/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #8’s primary medical provider had been notified of Patient #8’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #8’s primary medical provider or a discharge order from Patient #8’s primary medical provider noting Patient #8’s primary medical provider had been involved in the discharge planning for Patient #8. 11. A review of the clinical record for Patient #9 SOC date 11/03/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/03/2025 through 12/04/2025, contained an unsigned communication note dated 12/04/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #9’s primary medical provider had been notified of Patient #9’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #9’s primary medical provider or a discharge order from Patient #9’s primary medical provider noting Patient #9’s primary medical provider had been involved in the discharge planning for Patient #9. 12. A review of the clinical record for Patient #10 SOC date 11/05/2025, and discharge date of 12/10/2025, contained documents titled “Communication Notes.” A review of the communication notes dated 11/05/2025 through 12/04/2025, contained an unsigned communication note dated 12/04/2025. The communication note indicated, “Patient wishes to be discharged and would no longer like to receive services.” The communication notes failed to evidence Patient #10’s primary medical provider had been notified of Patient #10’s discharge planning or discharge from the agency. The record failed to contain a discharge summary had been completed and sent to Patient #10’s primary medical provider or a discharge order from Patient #10’s primary medical provider noting Patient #10’s primary medical provider had been involved in the discharge planning for Patient #10. During an interview on 01/22/2025 at 3:08 PM, upon reviewing the 10 patients' discharge charts and asking for documentation for notification to the primary medical provider or verbal orders being obtained to discharge the 10 patients, the Alternate Administrator/Alternate Clinical Manager communicated they had not notified the primary medical providers, received orders, or completed discharge summaries. The Clinical Manager further stated, “The patients were pro bono to get the initial survey completed. The agency could not bill, so they had to be discharged, or we would go bankrupt. We have 30 days to get an order from the physician.” 410 IAC 17-13-2(a)(b)(9)

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: The agency failed to discuss changes to the patient’s POC regarding early discharge with the patient’s responsible physician for 10 of 10 discharged patients. (Patients: #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings Include: 1. A review of an agency policy, effective date of 04/2024, titled “Discharge/Reduction in Services,” indicated, but was not limited to. “When the patient’s POC changes and this change results in discharge or reduction of services, the patient, or their representative, as well as their primary medical provider, will be notified and involved in planning decisions, including discharge from the Agency in accordance with federal & state regulations … ” 2. A review of the clinical record for Patient #1 SOC date 11/05/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/05/2025 to 01/03/2025. The POC indicated Patient #1 had orders for SN one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #1 had been seen weekly from 11/05/2025 through 12/03/2025, with the last SN visit documented on 12/03/2025. A review of agency documents titled “Communication Notes” dated 11/05/2025 through 12/10/2025, contained an unsigned communication note dated 12/10/2025. The communication note indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #1’s primary medical provider had been notified of Patient #1’s discharge planning or discharge from the agency. 3. A review of the clinical record for Patient #2 SOC date 11/03/2025, and discharge date of 12/15/2025, contained a POC for the certification period 11/03/2025 to 01/01/2026. The POC indicated Patient #2 had orders for SN one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #2 had been seen weekly from 11/03/2025 through 12/11/2025, with the last SN visit documented on 12/11/2025. A review of the agency documents titled “Communication Notes” dated 11/03/2025 through 12/15/2025, contained an unsigned communication note dated 12/15/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #2’s primary medical provider had been notified of Patient #2’s discharge planning or discharge from the agency. 4. A review of the clinical record for Patient #3 SOC date 11/03/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/03/2025 to 01/01/2026. The POC indicated Patient #3 had orders for Skilled Nursing one time a week for 9 weeks for medication setup, and a HHA one time a week for 9 weeks for personal care assistance. A review of the Skilled Nurse visit notes evidenced Patient #3 had been seen weekly from 11/03/2025 through 12/03/2025, with the last visit documented on 12/03/2025. A review of the HHA visit notes evidenced Patient #3 had been seen weekly from 11/03/2025 through 12/05/2025, with the last visit documented on 12/05/2025. A review of the agency documents titled “Communication Notes” dated 11/03/2025 through 12/08/2025, contained an unsigned communication note dated 12/08/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #3’s primary medical provider had been notified of Patient #3’s discharge planning or discharge from the agency. 5. A review of the clinical record for Patient #4 SOC date 11/05/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/08/2025 to 01/03/2026. The POC indicated Patient #4 had orders for SN one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #4 received weekly SN visits from 11/05/2025 through 12/09/2025, with the last visit documented on 12/09/2025. A review of agency documents titled “Communication Notes” dated 11/05/2025 through 12/10/2025, contained an unsigned communication note dated 12/10/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #4’s primary medical provider had been notified of Patient #4’s discharge planning or discharge from the agency. 6. A review of the clinical record for Patient #5 SOC date 11/03/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/03/2025 to 01/01/2026. The POC indicated Patient #5 had orders for Skilled Nursing one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #5 received weekly SN visits from 11/03/2025 through 12/08/2025, with the last visit documented on 12/08/2025. A review of agency documents titled “Communication Notes” dated 11/03/2025 through 12/09/2025, contained an unsigned communication note dated 12/09/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #5’s primary medical provider had been notified of Patient #5’s discharge planning or discharge from the agency. 7. A review of the clinical record for Patient #6 SOC date 11/03/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/03/2025 to 01/01/2026. The POC indicated Patient #6 had orders for Skilled Nursing one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #6 received weekly SN visits from 11/03/2025 through 12/08/2025, with the last visit documented on 12/08/2025. A review of agency documents titled “Communication Notes” dated 11/03/2025 through 12/09/2025, contained an unsigned communication note dated 12/09/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #6’s primary medical provider had been notified of Patient 6’s discharge planning or discharge from the agency. 8. A review of the clinical record for Patient #7 SOC date 11/05/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/05/2025 to 01/08/2026. The POC indicated Patient #7 had orders for Skilled Nursing one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #7 received weekly SN visits from 11/05/2025 through 12/10/2025, with the last visit documented on 12/10/2025. A review of agency documents titled “Communication Notes” dated 11/05/2025 through 12/17/2025, contained an unsigned communication note dated 12/17/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #7’s primary medical provider had been notified of Patient #7’s discharge planning or discharge from the agency. 9. A review of the clinical record for Patient #8 SOC date 11/05/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/05/2025 to 01/08/2026. The POC indicated Patient #8 had orders for Skilled Nursing one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #8 received weekly SN visits from 11/05/2025 through 12/04/2025, with the last visit documented on 12/04/2025. A review of agency documents titled “Communication Notes.” dated 11/05/2025 through 12/05/2025, contained an unsigned communication note dated 12/05/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #8’s primary medical provider had been notified of Patient #8’s discharge planning or discharge from the agency. 10. A review of the clinical record for Patient #9 SOC date 11/03/2025, and discharge date of 12/04/2025, contained a POC for the certification period 11/03/2025 to 01/01/2026. The POC indicated Patient #9 had orders for Skilled Nursing one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #9 received weekly SN visit from 11/03/2025 through 12/03/2025, with the last visit documented on 12/03/2025. A review of agency documents titled “Communication Notes” dated 11/03/2025 through 12/04/2025, contained an unsigned communication note dated 12/04/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #9’s primary medical provider had been notified of Patient #9’s discharge planning or discharge from the agency. 11. A review of the clinical record for Patient #10 SOC date 11/05/2025, and discharge date of 12/10/2025, contained a POC for the certification period 11/05/2025 to 01/08/2026. The POC indicated Patient #10 had orders for Skilled Nursing one time a week for 9 weeks for medication setup. A review of the Skilled Nurse visit notes evidenced Patient #10 received weekly SN visits from 11/05/2025 through 12/03/2025, with the last visit documented on 12/03/2025. A review of agency documents titled “Communication Notes” dated 11/05/2025 through 12/04/2025, contained an unsigned communication note dated 12/04/2025. The communicated noted indicated, “Patient wishes to be discharged and no longer like to receive services.” The communication notes failed to contain a communication note that Patient #10’s primary medical provider had been notified of Patient #10’s discharge planning or discharge from the agency. 12. During an interview on 01/22/2026 at 12:17 PM, when asked about notifying the patients and patients’ physicians regarding early discharge, the former employer RN case manager for Patients #2, 4, 5, and 6 stated, “I told my patients another nurse would be resuming their care. I had a short-term contract with the agency, working until the surveyors left after their initial survey. No, I was not asked to discharge any patients.” 13. During an interview on 01/22/2025 at 3:08 PM, upon reviewing the 10 patients' discharge charts and asking for documentation for notification to the primary medical provider or verbal orders being obtained to discharge the 10 patients, the Alternate Administrator/Alternate Clinical Manager and Clinical Manager communicated they had not notified the primary medical providers, received orders, or completed discharge summaries.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was written and sent to the primary care physician who is responsible for the patient's care after discharge within 5 business days of the patients discharge for 10 of 10 discharged records reviewed. (Patients: #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings include: 1. A review of an agency policy, effective date of 04/2024, titled “Discharge/Reduction in Services,” indicated but was not limited to. “When the patient’s POC changes and this change results in discharge or reduction of services, the patient, or their representative, as well as their primary medical provider, will be notified and involved in planning decisions, including discharge from the Agency in accordance with federal & state regulations … ” 2. A review of an agency document dated 01/22/2026, titled “Ready and Willing 2 Help Healthcare Clients Discharge,” listed the SOC dates and discharge dates for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 2 test patients, indicating all the patients had been discharged from the agency. 3. A review of the patient records for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 failed to evidence discharge summaries had been completed and were sent to the primary care provider responsible for care following discharge. During an interview on 01/22/2025 at 3:08 PM, upon reviewing the discharge charts of 10 patients and asking about the location of discharge summaries, the Alternate Administrator/Alternate Clinical Manager communicated they had not completed discharge summaries. 410 IAC 17-15-1(a)(7)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure access controls preventing unauthorized access to patient records and failed to automatically terminate access to a former employee, allowing deletion of patient records and unauthorized access for 1 of 1 agency. Findings Include: 1. A review of an agency policy, effective date of 04/2024, titled “Health Insurance Portability and Accountability Act [HIPAA]”, indicated but was not limited to. “ … Ready and Willing 2 Help Healthcare will ensure all members of its workforce comply with security policies of the organization as well as state and federal regulations regarding Protected Health Information (PHI) as per HIPAA guidelines … Investigate any security incidents or violations and mitigate to the extent possible any negative effects that the incident may have had in a timely manner … ” 2. A review of an agency policy, effective date of 04/2024, titled “Electronic,” indicated, but was not limited to. “ … All legal requirements for maintaining, protecting, and storing paper medical records must be followed for electronic records … 6. Terminating Employee’s access to Electronic Systems: To protect the integrity & privacy of Ready and Willing 2 Help Healthcare information, when an employee with access to the Agency electronic systems terminates employment with Ready and Willing 2 Help Healthcare, their log-on to the Agency’s electronic systems is terminated from all electronic systems … On the date of termination, the terminated employee’s access codes/log-ons to any/all electronic systems will be deleted from the system … ” During an interview on 01/22/2026 at 2:50 PM, when asked about missing documentation, the Alternate Administrator/Alternate Clinical Manager, reported the former Administrator/Clinical Manager stated, “The [Former Administrator/Clinical Manager] sabotaged my Axxess training, locked me out of Axxess (the agency’s electronic medical record system), deleted documents completed in the patient’s records. I reported this to [the owner] and the new Clinical Manager.” 3. During an interview on 01/23/2026 at 2:13 PM, Admin1, the owner of the agency, communicated that the former Administrator/Clinical Manager had been terminated on 01/08/2026, for failure to return calls from the owner and staff and show up for work since 12/16/2025. Administrator 1 stated, “She was missing in action, and I needed assistance with the plan of correction to submit to the state for our initial survey.” Administrator1 further indicated the former employee failed to return their agency computer and phone, and they had no way of disabling the former employee's devices. 410 IAC 17-12-3(b)(3)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 12/09, 12/10, and 12/11/2025 Active Census: 10 At this Emergency Preparedness survey, Ready and Willing 2 Help Home Healthcare, 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 12/15/2025.

This visit was for an initial Federal Medicaid of a Home Health provider. Survey Dates: 12/09, 12/10, and 12/11/2025 12-Month Unduplicated Skilled Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA- Home Health Aide POC-Plan of Care SOC- Start of Care RN-Registered Nurse SN- Skilled Nursing OASIS- Outcome and Assessment Information Set ADL- Activities of Daily Living DME- Durable Medical Equipment CM-Clinical Manager

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 assessments accurately reflected the patients’ current health, psychosocial, and functional status in 4 of 10 active records reviewed. (Patients: #1, 3, 4, and 7) Findings Include: 4. A review of the clinical record for Patient #1, SOC date of 11/05/2025, contained an initial OASIS comprehensive assessment dated 11/05/2025, signed by the Administrator/CM, Case Manager for Patient #1. The comprehensive assessment section, allergies, listed Dapsone and Lisinopril, and in the comments noted No Known Drug Allergies (NKDA). Primary diagnosis had been left blank, Secondary Diagnosis listed Systemic Lupus Erythematosus (a chronic condition in which the immune system attacks healthy tissue in various parts of the body) , and Other Diagnoses had been left blank. In the section titled “Special Treatments, Procedures, and Programs” subsection Dialysis, the box had been left blank, and in the subsection Peritoneal Dialysis, the box had been left blank. The section titled “Integumentary Status” indicated skin turgor as good, skin color pink, and condition dry, but failed to list Patient #1 had a dialysis catheter in their abdomen or assess the access site. The section titled “Dialysis” had been left blank. The section titled “Nutrition” indicated Within Normal Limits (WNL), and Patient #1 had a regular diet, failing to include fluid restriction, renal diet, and daily weight. The assessment failed to provide a complete and accurate account of the patient's significant medical history and complex needs and failed to include all services involved in the patient’s care. During an interview on 12/11/2025 at 9:30 AM, Patient #1 communicated they were on the kidney transplant list. Patient #1 further reported their Systemic Lupus Erythematous had caused her kidneys to no longer function. The patient further stated they had been completing peritoneal dialysis (a cleansing fluid called dialysate passes through a flexible tube into part of the abdomen, acting as a filter absorbing the waste products form the blood vessels in the lining. After a set amount of time the fluid with the waste flow out of the abdomen threw the tube and is thrown away) since 2023. Patient #1 indicated they were a patient at Entity 2’s peritoneal dialysis home program, a dialysis facility, and completed 4 dialysis exchanges a day. Patient #1 indicated they had to document on a log sheet their weight every am, along with checking their blood pressure and pulse before and after their dialysis treatments. A review of document titled “Office Visit Progress Note” dated 10/28/2025, signed by Patient #1’s primary provider, Person 6, with Entity 7 a primary care physician’s office, noted Patient #1 completed peritoneal dialysis at home, 4 exchanges a day, and allergies Dapsone and Lisinopril. The note further contained the following diagnoses: Hypertension (high blood pressure), Systemic Lupus Erythematosus, Unspecified Organ Involvement, End Stage Renal Disease (ESRD) (a condition where the kidneys can longer remove waste and access fluid from the blood effectively), and Depression. The note contained a section titled “Medication List at End of Visit” listing the following: Amlodipine (used to treat high blood pressure) 10 milligrams (mg) by mouth daily, Calcitriol (used to treat low calcium absorption) 0.5 microgram( mcg) by mouth daily, Carvedilol (used to treat high blood pressure) 25 mg by mouth two times a day with meals, Chlorhexidine 0.12% solution (used for skin disinfection, and cleaning wounds), and Mycophenolate (used to decrease immune response to transplanted organs) 500mg take two tablets by mouth two times a day oral. During an interview on 12/11/2025 at 9:46 AM, the Administrator/CM and Case Manager for Patient #1 reviewed the patient’s clinical record. When asked about the comprehensive assessment, they stated, “The comprehensive assessment should reflect the whole picture of the patient.” The Administrator/CM and Case Manager acknowledged they had not documented Patient #1’s dialysis treatments, peritoneal catheter access, diet, or diagnoses, and failed to capture the full scope of the patient’s medical needs. 5. A review of the clinical record for Patient #7, SOC 11/05/2025, contained an initial OASIS comprehensive assessment dated 11/05/2025, signed by the Administrator/CM, Case Manager for Patient #7. The comprehensive assessment section titled “Allergies” listed bee pollen and Morphine but failed to list bee stings. The Primary Diagnosis listed Hypotension (low blood pressure), and Secondary Diagnosis as Schizophrenia (a serious mental health condition that affects how people think, behave, and feel), and Other Diagnoses listed Injury of Sciatic Nerve at Hip ad Thigh Level (an injury to a nerve causing pain, weakness, and numbness in the lower back and legs), and Unspecified Asthma(a condition that causes airways to swell, narrow and fill with mucus making it difficult to breath), but failed to list Type 2 Diabetes Mellitus. Comorbidities listed none of the above which had Diabetes Mellitus left blank. The section titled “Respiratory” noted Lung sounds marked, put failed to list CPAP. The section titled “Endocrine” had been marked Within Normal Limits (WNL) failing to document Patient #7’s blood sugars. And glucometer used. The section titled “Coordination of Care” failed to evidence Patient #7 received Attendant care services from Entity 1, a Personal Services Agency, for 4 hours 3 times a week. A review of a document titled “Office Visit Note” dated 10/30/2025. Signed by Person 9, a practitioner at Entity 8, a primary care center, for Patient #7, listed Patient #7’s diagnoses as follows; Gastroesophageal Reflux Disease (condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), Migraines with Visual Aura (involving sensory disturbances, particularly visual changes that occur before or during a migraine attack), Essential Hypertension (high blood pressure), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and sues sugar as fuel), and Polypharmacy (taking multiple drugs). The note indicated refills had been provided for lancets to check fingerstick daily, and EpiPen 0.3 milliliters solution auto-injection (an auto injection containing 0.3 milligrams (mg) of Epinephrine, a drug used to treat severe allergic reaction) as directed, and left knee brace. During a home visit on 12/10/2025 at 2:45 PM, Patient #7 displayed their Continuous Positive Airway Pressure (CPAP) ( a medical device used to push air continuously through the airway to keep the airways open during sleep) device at their bedside, noting nightly used. When asked about the EpiPen, Patient #7 reported they have a severe allergy to bee stings and kept an EpiPen on hand. They also reported checking their blood sugar once daily with a glucometer and monitoring their blood pressure daily with a blood pressure cuff. Regarding additional support, Patient #7 said they received attendant care for four hours a day, three times per week, to assist with shopping, cleaning, and groceries. They also mentioned occasionally wearing a left knee brace. The assessment failed to provide a complete and accurate account of the patient's significant medical history and complex needs and failed to include all services involved in the patient’s care. During an interview on 12/11/2025 at 9:23 AM, questions were raised regarding Patient #7’s severe allergy to bee stings requiring an EpiPen for immediate self-injection, use of CPAP at night, clarification of the primary diagnosis (hypotension versus hypertension), and management of blood sugars. The Administrator/CM and Case Manager for Patient #7 acknowledged they had not addressed blood sugars and that the diagnosis of hypotension versus hypertension had been documented incorrectly. The Administrator/CM further stated they were unaware that Patient #7 had a severe allergy to bee stings or that the patient used a CPAP device. 410 IAC 17-14-1(a)(1)(A) 1. An agency policy with an effective date of 04/2024 titled "Assessments" indicated but was not limited to, " … a. THE COMPREHENSIVE ASSESSMENT MUST ACCURATELY REFLECT THE PATIENT'S STATUS AND MUST INCLUDE: i. Current health, psychosocial, functional … status …" 2. A review of Patient #3's active clinical record evidenced a SOC comprehensive assessment dated 11/03/2025 by RN 1 indicated the patient was on a regular diet and included for the "Nutritional Goals" subsection the patient would maintain a heart healthy diet. The subsection titled "Activities Permitted" evidenced the patient was up as tolerated with a cane or a wheelchair. The section titled "Prior Device Use" revealed the patient had a motorized wheelchair. Under the "Mobility" section, it evidenced the patient used a manual wheelchair. During an interview with RN 1 and the Administrator on 12/11/2025 at 10:15 AM, they explained Patient #3 was being educated to adhere to a heart healthy diet, used a rollator to move around, and indicated the patient had not used the wheelchair and they were unsure if it was motorized or manual. 3. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 11/05/2025 for the initial certification period from 11/05/2025 to 01/03/2026. The POC evidenced the following diagnoses: Type 2 Diabetes Mellitus, Moderate intellectual disability, low level of personal hygiene, persistent asthma, and Narcolepsy (a disorder where the person falls asleep at random during daily activities). The POC evidenced the medication 300 mg of Abilify Maintena (assists with mood and thought stabilization) every 30 days injected into the muscle. One of the patient's barrier to their health status was they were an unmotivated learner. The Nutrition section evidenced the patient was on a regular diet. The "Goals" section evidenced the patient was to be compliant with their diabetic diet. A review of Patient #4's clinical record evidenced a SOC comprehensive assessment dated 11/05/2025 by RN 1. The document revealed the patient was on a regular diet, but under the "Nutritional Interventions" subsection indicated the patient was educated on a Diabetic diet. The section for the "Management of Injectable Medications" evidenced the patient was unable to give themselves the injection and required another person to perform the task. Under "Client Strengths" the box next to "Motivated learner" was marked. The SOC assessment failed to evidence the patient's nutritional requirement, the individual who provided care and administered medications for the patient, and accurately reflected the patient's motivation to learn based on the POC. During an interview with RN 1 and the Administrator on 12/11/2025 at 12:45 PM, they indicated Patient #4 no longer took Abilify as of October 8, 2025 and had no other medications needing to be administered through the muscle. They explained the patient was supposed to be on a carb controlled diet and it should be listed on the assessment. They indicated the patient will be motivated to learn at a visit, then the next visit they were unmotivated. They explained they would be more clear in their assessment regarding the patient's willingness to learn.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC was individualized and included all medications, reasons for why the patient takes the as needed medication, all pertinent diagnoses, DME and supplies, and nutritional requirements for 8 of 10 active clinical records reviewed. (Patients #1, 2, 3, 4, 5, 6, 7, 9, and 10) Findings Include: 8. A review of the active clinical record for Patient #1, SOC date of 11/05/2025, contained an initial POC for the certification period 11/05/2025 to 01/03/2026. The POC indicated but was not limited to primary diagnosis of End Stage Renal Disease (a condition where the kidneys can longer remove waste and access fluid from the blood effectively, and other diagnosis Systemic Lupus Erythematosus (a chronic condition in which the immune system attacks healthy tissue in various parts of the body), but failed to list Hypertension (high blood pressure), and Depression. The section titled “Medications: Dose/Frequency” listed the following: Amlodipine (used to treat high blood pressure) 10 milligrams (mg) by mouth daily, indication had been left blank, Carvedilol (used to treat high blood pressure) 25 mg by mouth two times a day with meals, indication high blood pressure, and Mycophenolate (used to decrease immune response to transplanted organs) 500 mg take two tablets by mouth two times a day oral, indication had been left blank, but failed to list Calcitriol (used to treat low calcium absorption) 0.5 microgram (mcg) by mouth daily, Chlorhexidine 0.12% solution (used for skin disinfection, and cleaning wounds), and Mycophenolate (used to decrease immune response to transplanted organs) 500 mg take two tablets by mouth two times a day oral. The section titled “Nutritional Requirements” listed regular, failing to address Patient #1’s fluid restriction and renal diet. The section titled “DME and Supplies” listed alcohol pads, dressing supplies, exam gloves, gauze pads, and sterile gloves, but failed to listed blood pressure cuff, scale, dialysis supplies, and dialysate. A review of a document dated 08/29/2025, received form Entity 2, Patient #1’s dialysis treatment facility, titled “Patient Transfer” contained orders for Continuous Ambulatory Peritoneal Dialysis (CAPD) (a cleansing fluid called dialysate passes through a flexible tube into part of the abdomen, acting as a filter absorbing the waste products form the blood vessels in the lining. After a set amount of time the fluid with the waste flows out of the abdomen threw the tube and is thrown away) 4 exchanges 7 times a week. The section titled “Nutrition” indicated Patient #1 fluids 1000-1800 milliliters and sodium and potassium restrictions, and supplemental nutrition of Jimmy Bars 3 times a week. During an interview on 12/11/2025 at 9:46 AM, the Administrator/CM and Patient #1’s Case Manager communicated they had not documented fluid restrictions, special nutritional requirements, or dialysis treatment supplies on Patient #1’s POC. 9. A review of the clinical record for Patient #7, SOC 11/05/2025, contained a POC for the initial certification period 11/05/2025 to 01/03/2026. The POC section titled “Medications” failed to list the EpiPen 0.3 milliliters solution auto-injection (an auto injection containing 0.3 milligrams (mg) of Epinephrine, a drug used to treat severe allergic reaction) as directed. The section titled “Allergies” listed bee pollen and Morphine but failed to list bee stings. The Primary Diagnosis listed Hypotension (low blood pressure), which Patient #7 had a diagnosis of Hypertension (high blood pressure) and Secondary Diagnosis as Schizophrenia (a serious mental health condition that affects how people think, behave, and feel), and Other Diagnoses listed Injury of Sciatic Nerve at Hip ad Thigh Level (an injury to a nerve causing pain, weakness, and numbness in the lower back and legs), and Unspecified Asthma(a condition that causes airways to swell, narrow and fill with mucus making it difficult to breath), but failed to list Type 2 Diabetes Mellitus. The section titled “DME and Supplies” listed cane, oxygen, walker, elevated toilet seat, grab bars, alcohol pads, and chux/under pads, but failed to list Patient #7 used a CPAP machine and supplies, blood pressure cuff, knee brace, glucometer, lancets, and test strips. A review of a document titled “Office Visit Note” dated 10/30/2025. Signed by Person 9, a practitioner at Entity 8, a primary care center, for Patient #7, listed Patient #7’s diagnoses as follows; Gastroesophageal Reflux Disease (condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), Migraines with Visual Aura (involving sensory disturbances, particularly visual changes that occur before or during a migraine attack), Essential Hypertension (high blood pressure), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), and Polypharmacy (taking multiple drugs). The note indicated refills had been provided for lancets to check fingerstick daily, and EpiPen 0.3 milliliters solution auto-injection (an auto injection containing 0.3 milligrams (mg) of Epinephrine, a drug used to treat severe allergic reaction) as directed, and left knee brace. During a home visit on 12/10/2025 at 2:45 PM, Patient #7 displayed their Continuous Positive Airway Pressure (CPAP) ( a medical device used to push air continuously through the airway to keep the airways open during sleep) device at their bedside, noting nightly used. When asked about the EpiPen, Patient #7 stated they have a severe allergy to bee stings and kept an EpiPen on hand. They also reported checking their blood sugar once daily with a glucometer and monitoring their blood pressure daily with a blood pressure cuff. Regarding additional support, Patient #7 said they received attendant care for four hours a day, three times per week, to assist with shopping, cleaning, and groceries. They also mentioned occasionally wearing a left knee brace. During an interview on 12/11/2025 at 9:23 AM, when asked about Patient #7’s severe allergy to bee stings requiring an EpiPen for immediate self-injection if stung, use of CPAP at night, the primary diagnoses of hypotension versus hypertension, and management of blood sugars, the Administrator/CM and Case Manager for Patient #7 indicated they had not addressed blood sugars, and the diagnosis of hypotension versus hypertension had been documented incorrectly. The Administrator/CM further indicated they were unaware that Patient #7 had a severe allergy to bee stings or they used a CPAP. 410 IAC 17-13-1(a)(1)(B)(C)(ii, iv, viii, ix, xiii) 1. An agency policy with an effective date of 04/2024 titled "Plan of Care (POC)" indicated but was not limited to, " … 4. POC INCLUDES: … a. All pertinent diagnosis … c. … supplies and equipment needed … i. Nutritional requirements, j. All medications and treatments …" 2. A review of Patient #2's active clinical record evidenced a POC with a SOC date of 11/04/2025 and an initial certification period from 11/03/2025 to 01/01/2026. The POC evidenced the following diagnoses: Hypertension (high blood pressure), Spondylosis (a condition where the spine degenerates causing pain and numbness), Hypercholesterolemia (a large amount of cholesterol in the blood), and pain. The POC evidenced the patient was on a Regular and Heart Healthy diet. The POC revealed the patient took the following medications: 10 Milligrams (mg) of Amlodipine Besylate (to treat hypertension) daily, 20 mg of Atorvastatin (to treat high cholesterol) daily, 5mg of Cyclobenzaprine three times a day as needed for muscle spasms, Lidocaine 5% External patch every 24 hours as need for pain, 40 mg of Lisinopril (to treat hypertension) daily, and 50 mg of Metoprolol (to treat hypertension) daily. The section titled "Orders for Discipline and Treatments" indicated but was not limited to, " … SN to instruct client when (s)he starts feeling chest pain, tightness, or squeezing in the chest to take nitroglycerin. Client may take 1 tablet of nitroglycerin (a medication used to relax the blood vessels and improve blood flow) every 5 minutes. …". The patient's goals included but were not limited to, " … Client will verbalize understanding not to eat 4 hours before bedtime to reduce acid reflux/indigestion by: 90 days. …" Patient #2's clinical record evidenced a Start of Care assessment completed on 11/03/2025 by RN 1. A review of Patient #2's active clinical record evidenced the patient's history and physical from their primary physician's office, dated 10/13/2025. The document evidenced the patient had Gastroesophageal reflux disease (GERD, a condition where the stomach acid goes back up the throat causing heart burn). Patient #2's clinical record evidenced a document titled "Medication Profile" and failed to evidence the patient had Nitroglycerin ordered as a medication. Patient #2's POC failed to include the correct SOC date, all diagnoses related to their care, specify the ordered diet, and only include goals for medications the patient was taking. During an interview with RN 1 and the Administrator on 12/11/2025 at 10:00 AM, RN 1 explained Patient #2's GERD diagnosis should have been included on their POC with their goal to educate to prevent reflux from occurring. RN 1 indicated the patient had no history of a heart attack and was not on Nitroglycerin. The Administrator and RN 1 explained the patient was on a Heart Healthy diet. 3. A review of Patient #3's active clinical record evidenced a POC with a SOC date of 11/03/2025 and an initial certification period from 11/03/2025 to 01/01/2026. The POC evidenced the following diagnoses: Congestive Heart Failure (a condition where the heart muscles are weakened, not allowing enough blood to flow to meet the body's needs), Fibromyalgia (a condition causing pain, sleep issues, and tiredness), Hypertension, Type 2 Diabetes Mellitus (a condition where the body is unable to make enough insulin, leading to high blood sugar), Asthma with exacerbation (restricted airflow causing shortness of breath and wheezing), and Bipolar disorder (a condition causing severe mood swings with high energy and irritability or extreme sadness). The POC revealed the patient was on a regular diet. The section titled "DME and Supplies" evidenced the patient had a Nebulizer, cane, bedside commode, wheelchair, walker, Chux/underpads, Diabetic supplies, exam gloves, and adult diapers. The section titled "Orders for Discipline and Treatments" indicated but was not limited to, " … SN to instruct client when (s)he starts feeling chest pain, tightness, or squeezing in the chest to take nitroglycerin. Client may take 1 tablet of nitroglycerin every 5 minutes. …". The goals evidenced the patient would adhere to a heart healthy diet. Patient #3's clinical record contained a document titled "Medication Profile" failed to evidence the patient took Nitroglycerin. During a home visit at Patient #3's residence on 12/10/2025 at 4:25 PM, the patient was observed using a rollator to move around their residence. While observing HHA 1, assisting the patient with a shower, it was evidenced the patient used a shower chair to sit in the shower. A review of the patient's medications failed to evidence the patient took Nitroglycerin as needed. Patient #3's POC failed to evidence the patient's rollator and shower bench, the correct diet, include goals for medications the patient was taking. During an interview with RN 1 and the Administrator on 12/11/2025 at 10:15 AM, RN 1 explained Patient #3 was on a heart healthy diet, was not on Nitroglycerin, and had a rollator and shower bench the patient used. They explained the POC should reflect all of the patient's information. 4. A review of Patient #4's active clinical record evidenced a POC with a SOC date of 11/05/2025 and an initial certification period from 11/05/2025 to 01/03/2026. The POC evidenced the following diagnoses: Type 2 Diabetes Mellitus, Moderate intellectual disability, low level of personal hygiene, persistent asthma, and Narcolepsy (a disorder where the person falls asleep at random during daily activities). The POC evidenced the medication 300 mg of Abilify Maintena (assists with mood and thought stabilization) every 30 days injected into the muscle. The Nutrition section evidenced the patient was on a regular diet. The "Goals" section evidenced the patient was to be compliant with their diabetic diet. The POC failed to evidence the patient's diabetic diet. During an interview with RN 1 and the Administrator on 12/11/2025 at 12:45 PM, they indicated Patient #4 no longer took Abilify as of October 8, 2025 and would need to remove it from the medication list and POC. They explained the patient was supposed to be on a carb controlled diet and it should be listed on the POC. 5. A review of Patient #5's active clinical record evidenced a POC with a SOC date of 11/03/2025 and an initial certification period from 11/03/2025 to 01/01/2026. The POC evidenced the following diagnoses: Hypertension, Atrial Fibrillation (an irregular heartbeat), Hypothyroidism (a condition where the thyroid cannot make enough of the hormone causing fatigue and muscle aches), Constipation (trouble having a bowel movement), and Asthma with exacerbation. The POC revealed the patient took the following medications: 108 micrograms (mcg) of Albuterol Sulfate as needed every 4 hours for shortness of breath, 1 milligram (mg) of Anastrozole (used to treat menopause) daily, 81 mg of Aspirin (prevent blood clots) daily, 80 mg of Atorvastatin (for high cholesterol) daily, 80-4.5 mcg Budesonide-Formoterol Fumarate (help with breathing) 2 times a day, 1 percent of Diclofenac Sodium external gel 4 times a day as needed for pain, 240 mg of Diltiazem (for high blood pressure) daily, 100 mg Docusate Sodium twice a day as needed for constipation, 5 mg of Eliquis (prevents blood clots) twice a day, 1 mg of Folic acid (helps in the production of red blood cells) daily, 30 mg of Isosorbide Mononitrate (prevent chest pain) daily, 112 mcg of Levothyroxine Sodium (hormone replacement medication when the thyroid cannot produce enough) daily, 10 mg of Loratadine (allergy relief) daily, 50 mg of Metoprolol Succinate (treat high blood pressure) daily, 10 mg Montelukast Sodium (treat asthma) daily, 3350 17 grams (g) of Polyethylene Glycol as needed for constipation, and 80 mg of Simethicone three times a day as needed for gas. The POC listed the following for the patient's DME: Walker, oxygen, grab bars, cane, chux/underpads, exam gloves, and adult diapers. Patient #5's clinical record contained a document titled "Medication Profile" failed to evidence the patient's oxygen. The POC failed to list the patient's Oxygen as a medication and the patient's nasal cannula and oxygen concentrator. During an interview with the Administrator, RN 1, and the Alternate Administrator on 12/11/2025 at 12:31 PM, RN 1 confirmed Patient #5 was on oxygen and used a nasal cannula. They indicated oxygen was considered a medication and should be on the medication list and include the oxygen supplies. 6. A review of Patient #6's active clinical record evidenced a POC with a SOC date of 11/03/2025 and an initial certification period from 11/03/2025 to 01/01/2026. The POC evidenced the following diagnoses: Chronic Obstructive Pulmonary disease (COPD, a disease causing blockage in the airway, making it difficult to breath), Hypertension, Benign Prostatic hyperplasia (enlarged prostate gland causing frequent urination and urgency), and GERD. The POC revealed the following medications for the patient: 500 mg of Acetaminophen as needed every 6 hours for pain, 5 mg of Amlodipine Besylate daily, 81 mg of Aspirin daily, 40 mg of Atorvastatin Calcium daily, 150 mg of Buproprion twice a day for smoking cessation, 10 mg Fluoxetine (assists with regulating moods) daily, 25 mg of Hydrochlorothiazide (assists the body in eliminating excess water and salt) daily, 25 mg of Hydroxyzine (to treat anxiety)three times a day, 25 mg of Metoprolol Succinate daily, 10 mg of Montelukast Sodium daily, 20 mg of Omeprazole (reduces the amount of acid in the stomach) daily, and 0.4 mg of Tamsulosin (improves urine flow) daily. The POC listed the following for the patient's DME: oxygen, grab bars, tub/shower bench, alcohol pads, exam gloves, and probe covers. The "Orders" evidenced the nurse was to assess the patient's oxygen saturation for each visit with the patient on 3 liters of oxygen. The "Goals" section revealed the patient learned to record their blood pressure daily. A review of a progress note from Patient #6's physician dated 01/15/2025 evidenced the patient took 108 mcg of Albuterol Sulfate every 4 hours as needed for shortness of breath, 3350 17 grams (g) of Polyethylene Glycol daily, and 200-62.5-25 mcg of Trelegy Ellipta daily (assist with breathing). The POC failed to include all of the patient's DME and medications. During an interview with Patient #6 on 12/11/2025 at 11:45 AM, they confirmed they took Albuterol and Trelegy to help with their breathing and used Polyethylene Glycol for constipation. They said they were on oxygen and used a nasal cannula with an oxygen concentrator. During an interview with RN 1 and the Administrator on 12/11/2025 at 12:36 PM, they indicated oxygen was a medication and should be included as a medication on the POC with the medications to assist with breathing and constipation. They explained the patient's nasal cannula, oxygen concentrator, and Nebulizer should be listed on the POC. When queried regarding the goal for the patient to monitor their blood pressure daily, they explained the patient had a blood pressure monitor and cuff which should have been included on the POC. 7. A review of Patient #9's active clinical record evidenced a POC with a SOC date of 11/03/2025 and an initial certification period from 11/03/2025 to 01/01/2026. The POC evidenced the following diagnoses: Generalized Idiopathic Epilepsy (a condition where, because of family history, seizures are started in both sides of the brain) , Age-related physical debility, Major Depressive disorder, muscle weakness, urinary incontinence, Lymphedema (fluid built up in the arms or legs because of a buildup of protein), and cataracts (the eyes have a cloud over the lens causing blurred vision). The POC included the following medications: 90 mcg of Albuterol as needed for inflammation of the airway, 10 mg of Atorvastatin Calcium daily, 10 mg of Cetirizine (treat allergies) daily, 8 percent of Ciclopirox topical solution (an antifungal medication to treat a fungal infection) daily, 500 mg of Depakote (used to treat seizures) twice a day. 2 percent Ketoconazole shampoo twice a week for fungal infection, 330 mg of Levocarnitine (converts fat into energy) twice daily, 15 mg of Mirtazapine daily for depression, and a Multivitamin daily. A review of Patient #9's health information from their physician dated 11/06/2025 evidenced the patient took 1 mg of Folic Acid daily. Patient #9's clinical record contained a document titled "Medication Profile" failed to evidence the patient's Folic Acid. During an interview with RN 1 and the Administrator on 12/11/2025 at 12:45 PM, the Administrator, the CM for Patient #9, indicated the patient was taking Folic acid and it should be included on the POC and medication list.

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 they coordinated care and documented the coordination with other agencies providing services to patients for 1 of 1 active clinical record reviewed (Patient #1) with a patient on Dialysis (a treatment used to remove waste and excess fluid from the blood when the kidneys no longer function appropriately) and 2 of 4 active clinical records (Patient #4 and #7) reviewed who received services from a personal service agency. Findings Include: 1. An agency policy with an effective date of 04/2024 titled "Coordination of Care/Patient Education" indicated but was not limited to, " … Coordination of care will occur for each of the Agency's patients. … will assume responsibility for coordination of care … with all medical providers … and other providers of health care for the patient. …" 2. A review of the clinical record for Patient #1, SOC 11/05/2025, contained an initial comprehensive assessment, dated 11/05/2025 signed by the Administrator/CM, the Case Manager for Patient #7. The section titled "Coordination of Care" contained a checked the box for Medical Doctor (MD), and noted Person 6, the patient’s primary care provider. The initial comprehensive assessment failed to evidence coordination of care with Entity 2, a Dialysis Incenter and Home Program Treatment Facility. A review of the agency documents titled “Communication Notes” dated 11/05/2025 to current date failed to evidence coordination of care had been completed with Entity 2. During an interview on 12/10/2025 at 10:04 AM, Person 3, the RN overseeing Entity 2’s home program, confirmed Patient #1 received care from Entity 2, and would fax Patient #1’s orders for dialysis treatments. 3. During an interview on 12/11/2025 at 9:46 AM, when asked about the coordination of care with Patient #1’s dialysis treatment center, Entity 2, the Administrator/CM, Case Manager for Patient #1 stated, “No it was not done.” 4. A review of Patient #3's evidenced a SOC comprehensive assessment dated 11/03/2025 by RN 1. The SOC assessment evidenced the patient received services Monday through Friday, 3:30 PM to 8:30 PM, Monday through Friday from Entity 1, a personal service agency. The document failed to evidence who the RN spoke with at Entity 1. During an interview with RN 1 and the Administrator on 12/11/2025 at 10:15 AM, they explained the coordination of care was to be included in the coordination notes and they had not included who they spoke with from Entity 1. 5. A review of the clinical record for Patient #7, SOC 11/05/2025, contained an initial comprehensive assessment, dated 11/05/2025 signed by the Administrator/CM, the Case Manager for Patient #7. The section titled "Coordination of Care" indicated Entity 1, a Personal Services Agency, but failed to evidence what services Patient #7 received or identify with whom care coordination had occurred. A review of the agency documents titled “Communication Notes” dated 11/05/2025 to current date failed to evidence coordination of care had been completed with Entity 1, the Personal Care Agency providing Attendant care services 3 times a week for 4 hours a day to Patient #7. During a home visit on 12/10/2025 at 2:45 PM, when questioned about any other assistance received, Patient #7 stated, “An Aide comes 3 days a week for 4 hours to help me with errands, cleaning, transportation, and groceries if needed.” During an interview on 12/11/2025 at 9:23 AM, Admin 1, the owner of Entity 1, a Personal Services Agency, confirmed Patient #7 received Attendant care services from Entity 1. The Administrator/CM, and Case Manager for Patient #7 reported they were unaware of the Attendant care services being provided by Entity 1. 6. During the entrance conference on 12/09/2025 at 9:44 AM, the Administrator/CM indicated they did not share any patients with any other entities. 7. During an interview with RN 1 and the Administrator on 12/11/2025 at 10:15 AM, they explained the coordination of care was to be included in the coordination notes and visit notes. 410 IAC 17-14-1(a)(1)(F)