Every finding on record at Reid-Anc Home Care Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 09/11/2025 - 09/12/2025 & 09/15/2025 - 09/17/2025 Active Census:171 At this Emergency Preparedness survey, Reid ANC Home Health was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 09/11/2025 - 09/12/2025 & 09/15/2025 - 09/17/2025 12-Month Unduplicated Skilled Admissions: 1237 Survey was Partially Extended on 09/15/2025 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR Completed on 09/29/2025 by A4.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to complete a comprehensive review of medications for 2 of 5 skilled nursing home visits completed. (Patient #1, 4) Findings Include: 1.A policy titled, "Plan of Care and Physician and Allowed Practitioner Orders" revised 03/05/2024 indicated the plan of care should be based upon a current assessment of the patient's needs for care and must include all medications. 2. A policy titled, "Medication Profile" revised 01/21/2025 indicated the medication profile will be updated at resumption of care, recertification, at discharge, and with any medication changes. 3. During a home visit on 09/15/2025 at 10:00 AM, RN 9 reviewed Patient #1's current medications with him/her using a hospitalization discharge summary from Patient #1's last hospitalization and compared that list to the agency medication list. The medication bottles in the home were not reviewed by RN 9. The clinical record for Patient #1 evidenced the following: A document titled, "Client Medication Report" dated 09/11/2025 and a document titled, "Home Health Certification and Plan of Care" for recertification period 07/20/2025 - 09/17/2025 for Patient #1 included the following medications Patient #1 was no longer taking: Azelastine/Fluticasone Nasal Spray (medication used to treat seasonal allergies), Vitamin B-12 (supplement), Diclofenac 1% Topical Gel (used to treat pain), Miralax (used to treat constipation), Vesicare (used to treat an overactive bladder). The following medications listed in the plan of care and medication report were incorrect doses/frequencies: Omeprazole (used to treat acid reflux) 20 mg daily, Patient #1 was taking 40 mg twice a day. Potassium Chloride (supplement) 20 milliequivalents daily, Patient #1 was taking twice daily. During an interview on 09/15/2025 at 11:05 AM, RN 9 indicated she was unsure when Patient #1's last hospitalization was that she was using to complete the medication review. Patient #1 indicated he/she thought it was in May of 2025, and RN 9 indicated she thought it was either June or July of 2025. When the medication review was completed with Patient #1 the surveyor asked about medications listed on the medication report and plan of care that were not discussed to include Azelastine/Fluticasone, Vitamin B=12, Diclofenac, Miralax, and Vesicare. RN 9 asked Patient #1 about the medications and Patient #1 indicated he/she was not taking any of those medications. RN 9 indicated that all medications are reviewed at each recertification and that she had completed the last recertification but failed to review the medications. RN 9 could not advise when the last medication review was completed with Patient #1. During an interview on 09/15/2025 at 11:00 AM, Patient #1 indicated that the agency does not look at his/her medication bottles when reviewing current home medications, staff typically ask if he/she is taking any new medications during visits. 4. During a home observation on 09/12/2025 at 2:15 PM, RN 9 failed to review medications for Patient #4 during the home visit. 5. During an interview on 09/15/2025 at 2:45 PM, the Administrator indicated the expectation if that staff review medications at every visit.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the revised plan of care included information concerning the patient's progress towards measurable outcomes and goals for 3 of 3 revised plan of cares reviewed. (Patient #1, 3, 5) Findings include: A clinical record for Patient #3, SOC 09/04/2024, certification period 08/20/2025 to 10/28/2025, failed to evidence information concerning the patient's progress toward measurable outcomes and goals. A clinical record for Patient #5, SOC 10/23/2024, certification period 08/19/2025 to 10/17/2025, failed to evidence information concerning the patient's progress toward measurable outcomes and goals. A policy titled, "Plan of Care and Physician and Allowed Practitioner Orders", revised 03/05/2024, indicated the plan of care must include progress towards goals identified and measured outcomes. A clinical record for Patient #1, SOC 04/07/2022, certification period 07/20/2025 - 09/17/2025, failed to evidence information concerning the patient's progress toward measurable goals and outcomes. During an interview on 09/16/2025 at 1:40 PM, the Administrator indicated the updated plan of care does not include progress towards patient goals and outcomes.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to integrate services between the agency and Entity #1 on 1 of 1 clinical records reviewed. (Patient #2) Findings include: The clinical record for Patient #2, SOC 08/20/2025, failed to evidence documentation of communication between the home health agency and entity #1. During an interview on 09/12/2025 at 11:15 AM, LPN #1 indicated that she was unaware of who writes the orders for Patient #2. She indicated that she always checks in with Entity #1's nurse for any new orders. A policy titled, "Case Conference and Coordination of Services" revised 07/2/2022 indicated care will be coordinated with other involved external organizations. Relevant information will be shared to facilitate appropriate continuity and care coordination. During an interview on 09/15/2025 at 3:40 PM, the Administrator indicated care conference meetings regarding patients are completed weekly with agency staff. Patients residing in assisted living facilities like Patient #2 are discussed, however, the assisted living facility coordination is not documented in the patient's medical record.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure services listed in the plan of care were provided for 1 of 5 skilled nursing assessments completed. (Patient #4) Findings Include: A policy titled, "Plan of Care and Physician and Allowed Practitioner Orders" revised 03/05/2024 indicated all care and services provided are according to current physician or allowed practitioners orders. A document titled, "Home Health Certification and Plan of Care", certification period of 08/31/2025 - 10/29/2025 for Patient #4 indicated orders for a respiratory assessment and vital signs to be completed During an observation of a skilled home visit for Patient #4 on 09/12/2025 from 2:15 PM - 4:00 PM, RN 9 failed to assess Patient #4's respiratory status, and failed to obtain his/her vital signs to include a blood pressure, pulse, and respiration rate. Patient #4 was audibly heard wheezing. RN 9 asked Patient #4 if he/she was wheezing during his/her wound care treatment with Patient #4 responding, "I don't know". During an interview on 09/15/2025 at 11:05 AM, RN 9 indicated she did not complete a respiratory assessment for Patient #4 to include auscultating (listening) his/her lungs or obtain a blood pressure, pulse, or respiration rate despite hearing audible wheezing. RN 9 indicated she obtained Patient #4's temperature as it was the most relevant part of the assessment due to wound findings. During an interview on 09/15/2025 at 2:45 PM, the Administrator indicated that a respiratory assessment would include auscultating the lungs if present on the plan of care. She also indicated the expectation is for clinical staff to obtain vital signs at each visit.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: March 10th, 13th, 14th, 15th, and 16th of 2023. Unduplicated 12 Month Census: 1364 At this Emergency Preparedness survey, Reid-ANC Home Care Services was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed on 3/22/2023 A4

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to include Federal and State emergency preparedness contact information in their communication plan which had the potential to negatively affect all agency staff and patients. Findings include: 1. Review of Policy #31.36 “Emergency Operations Plan,” revised 12/12/2022, indicated but not limited to “…the Agency will coordinate efforts with other community healthcare entities an Emergency Management Agencies… Those agencies include the Local Health Department and Local State, and Federal Emergency Management Offices… The Agency will seek assistance from these Agencies as needed during times of emergency… Notifying Federal, State, and Local emergency response officials when on-duty employees or patients are unaccounted for…” 2. Review of the Emergency Operation Plan (EOP) Workbook – Communication Plan failed to evidence contact information for Federal and State emergency preparedness officials. 3. During an interview on 03/15/2023, the Administrator pointed out the radio and television stations to monitor for information and indicated the agency is part of Area 6. When asked if Area 6 acts as a liaison between the agency and Federal and State emergency preparedness officials, the Administrator indicated they were not.

This survey was for a Federal recertification and State Re-Licensure. March 10th, 13th, 14th, 15th, & 16th of 2023. Facility ID: IN005952 12 Month Unduplicated Census: 1364 Partially Extended Survey Announced 3/15/2023 at 4:50 PM, These deficiencies reflect State findings in accordance with 410 IAC 17.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the home health agency failed to review all of the patient’s medications for 4 of 7 patients with home visit observations (Patient #6, 9, 10, and 11.) 1. A policy titled, "Medication Administration and Management," revised on 12/19/2022 was provided by the clinic manager on 03/14/2023 at 2:45 PM. The policy indicated but was not limited to, "1. Medication Assessment by a Qualified Clinician: The qualifying clinician assesses all the current medications at start of care, resumption of care, recertification of services, and anytime a change or update is made to the medication profile. Assessments include an evaluation to identify any potential adverse effects and drug reactions; including: Ineffective drug therapy, Significant side effects, Significant drug interactions, Duplicate drug therapy, and Noncompliance with drug therapy. The assessment is documented in the Patient Medical Record." ... "Medication changes and/or updates during an episode of care are recorded on the patient's medication profile through a physician or allowed practitioner's order." 2. During a home visit observation on 03/13/2023 beginning at 12:32 PM for Patient #6, with the patient’s permission, reviewed medications in medicine cabinet with the patient. Medications observed included but not limited to Tadafil 5 mg (milligrams) which the patient reported taking 1 time per day, a bottle of over-the-counter multivitamins which the patient reported taking 1 time per day, and Vitamin B-12 which the patient reported taking 1 time per week. Review of Patient #6’s clinical record evidenced a medication list printed on 03/13/2023. The medication list failed to include Tadafil 5 mg, the multivitamin, and Vitamin B-12. 3. During a home visit observation on 03/14/2023 beginning at 09:48 AM for Patient #9, with the patient’s permission, reviewed medications in the home with the patient. Medications observed in the patient’s medicine bag included but not limited to over-the-counter iron supplement 65 mg. Patient #9 reported taking this supplement daily for at least the past year. Review of Patient #9’s clinical record evidenced a medication list printed on 03/13/2023. The medication list failed to include the iron supplement. 4. During a home visit observation on 03/14/2023 beginning at 03:32 PM for Patient #10, with the patient’s permission, reviewed medications in the home with the patient’s son who manages the patient’s medications. Medications observed to not be in the home included but not limited to melatonin (a supplement used as a sleep aid) and multivitamin. Patient #10’s son reported the melatonin was no longer in the compliance packs once the patient’s mirtazapine was added to the compliance packs and reported the patient only had and was taking the multivitamin for the first two weeks after they started with the home health agency. Review of Patient #10’s clinical record evidenced a start of care of 01/26/2023 and a medication list printed on 03/13/2023. The agency failed to remove the melatonin and multivitamin from the patient’s medication list. 5. During a home visit observation on 03/14/2023 beginning at 12:08 PM for Patient #11, with the patient’s permission, reviewed medications in the home with the patient. Medications observed included but not limited to Senna 8.6 mg tablets (used to treat constipation) which the patient reported they took as needed; Super Chelated Multi Mineral supplement, Curamed Healthy Inflammation Response supplement, and Vitamin C 500 mg supplement which the patient reported they took daily; and cranberry concentrate 4200 mg, Curamin Extra Strength Pain Relief supplement, tart cherry 3,000 mg supplement, and Osteo Bioflex triple strength supplement which the patient reported they took two times daily. Review of Patient #11’s clinical record evidenced a medication list printed on 03/13/2023. The medication list failed to include Senna 8.6 mg tablets, Super Chelated Mineral supplement, Curamed Healthy Inflammation Response supplement, Vitamin C 500 mg, cranberry concentrate 4200 mg, Curamin Extra Strength Pain Relief supplement, tart cherry 3,000 mg supplement, and Osteo Bioflex triple strength supplement. 410 IAC 17-14-1(a)(1)(B)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, policy review, and interview, the home health agency failed to follow accepted standards of practice and their own policies to prevent the transmission of infections and communicable diseases for 2 of 4 skilled nursing home visits observed (Patient #6 and 11.) 2. During a home visit observation on 03/13/2023 beginning at 12:32 PM for Patient #6, RN (Registered Nurse) C dropped a syringe of normal saline (0.9% saline solution) on the floor, picked it up, put it in the sharps container, and continued priming syringes and tubing for a PICC line blood draw. RN C failed to perform hand hygiene and don new gloves after disposing of the dropped syringe and before touching other supplies that were used for patient care. 3. During a home visit observation on 03/14/2023 beginning at 12:08 PM for Patient #11, LPN (Licensed Practical Nurse) E removed the patient’s abdominal wound dressing and dropped it on the floor. LPN E picked up the dressing from the floor, placed in trash bag, and then cleansed the patient’s abdominal wound with normal saline. LPN E failed to perform hand hygiene and don new gloves prior to cleansing the patient's wound. 5. During an interview on 03/15/2023 at 12:30 PM, the clinical manager informed surveyor LPN E indicated they had performed hand hygiene after picking up the dressing from the floor when telling the clinical manager about the event. Informed clinical manager LPN E did performed hand hygiene before applying the new dressing but had failed to perform hand hygiene after they picked up the dressing from the floor and prior to cleansing the wound with normal saline. The clinical manager verbalized understanding of the timeline of events during the dressing change. 410 IAC 17-12-1(m) 1. A policy titled, "Hand Hygiene," revised on 08/10/2022 was provided by the clinic manager on 3/14/2023 at 2:45 PM. The policy indicated, but was not limited to, "Hand Hygiene is performed by all employees to maintain cleanliness of their hands and to prevent cross contamination and the spread of infection." ... "Procedure: 1. Hand hygiene is performed:" .... "Before donning sterile gloves to perform an invasive procedure: such as, indwelling Foley catheter. After contact with blood, body fluids, secretions and excretions, mucous membranes, non-intact skin, and wound dressings, whether or not gloves are worn." ... "If moving from a contaminated-body site to a clean-body site during patient care." ... "After removing gloves." ... "4. Use of Gloves:" ... "Standard and Universal Precautions should be followed in determining use of gloves." ... "Change gloves between tasks and procedures on the same patient to prevent cross contamination." .. "Remove gloves promptly after use and discard in an appropriate container. Perform Hand Hygiene." 4. During an interview 03/14/2023 at 3:19 PM, the clinic manager was advised of two home visit observations for Patient #6 and #11 where staff were observed completing PICC (Peripherally Inserted Central Catheter) medication administration and wound care services. During both home visit observations, staff were observed dropping items on the floor, retrieving those items from the floor mid-care with gloves donned, then continuing care without changing gloves and washing and/or sanitizing hands. The clinic manager agreed that staff should have removed gloves, completed hand hygiene, and then replaced with new, clean gloves prior to resuming care. The clinic manager also indicated speaking with one of the nurses who agreed she did drop an item on the floor, but did change gloves and completed hand hygiene.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure additional precautions were taken with unvaccinated staff to mitigate the spread of COVID-19 in 1 of 1 agencies reviewed. Findings Include: 1. A policy titled, "CommonSpirit Health Administrative Policy Subject: COVID-19 Vaccination," effective April 15, 2022, was provided by the Clinical Manager on 2/10/2023 at 1:50 PM. The policy indicated, but was not limited to, "Requirements" ... "3. CommonSpirit recognizes medical and religious exemptions to the COVID-19 vaccination requirement, in accordance with applicable law. However, all persons approved for an exemption are subject to masking, COVID-19 surveillance testing, and other requirements established by CommonSpirit from time to time, without exception. Instructions on the frequency of testing will be provided upon receipt of an approved exemption. 4. Any relaxation of mitigation strategies such as universal masking, social distancing, and surveillance testing is subject to CDC guidance and will be evaluated by CommonSpirit on an ongoing basis." 2. A document titled, "CommonSpirit: Surveillance Testing for COVID-19 Has Been Suspended At This Time," dated September 14, 2022, was provided by the administrator on 3/14/2023 at 2:00 PM. The document indicated, but was not limited to, "Surveillance testing for COVID-19 of health care workers who are not fully vaccinated (i.e., have religious or medical exemptions) is being suspended at this time by the CommonSpirit COIVD Command Center. This change is effective immediately, or as soon as leaders at your facility are able to successfully implement it. Please keep in mind that, as with other COVID-19 requirements and safety measures, state and local laws, regulations, and public health orders supersede our practices at CommonSpirit Health. Additionally, CommonSpirit divisions may choose to have a more stringent process and continue testing if they believe it is warranted." 3. An untitled document was provided by the Administrator on 3/13/2023 at 9:35 PM. The summarized document showed a current list of all personnel with the COVID-19 vaccination status including religious/medical exemptions. All staff were found to be fully vaccinated except one, PT L (Physical Therapist), who holds an approved religious exemption. 4. During an interview on 3/14/2023 at 2:00 PM, the Administrator indicated that the agency revised their COVID-19 policy in September of 2022 in regards to unvaccinated staff who hold an approved religious or medical waiver. The agency had been completing weekly COVID-19 testing as an additional precaution for unvaccinated staff up until September 9, 2022. The administrator indicated that all staff, in addition to the one staff member who holds a religious exemption, follow CDC guidelines in regards to COVID-19 with no additional precautions for the unvaccinated.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure all physician ordered services were completed in the plan of care in 1 of 17 records reviewed. (Patient #2) Findings Include: 1. A policy titled, "Physical Therapy Services," revised 02/12/2022 was provided by the Clinical Manager on 03/14/2023 at 10:00 AM. The policy indicated but was not limited to, "1. The duties of the Therapist include the following: Initial Assessment" ... "5. The Physical Therapist is to make an initial home visit to assess the patient and institute a treatment program in accordance with the physician's and if indicated, allowed practitioner's orders that can be performed by the patient or a responsible person in the home, supervised by the nurse of therapy employees each visit, and periodically reevaluated by the Therapist." 2. A document titled, "Discharge Order," dated 12/14/2022 for Patient #2 was provided by the clinical manager on 03/14/2023 at 10:00 AM. The document indicated a new physician order for PT (physical therapy), OT (occupational therapy), and NSG (nursing) services to start on 12/18/2022. 3. A summarized document titled, "Client Coordination Note Report," dated 12/28/2022 for Patient #2 was provided by the clinical manager on 03/14/2023 at 10:00 AM, indicating a missed visit notification on 12/24/2022. The documented reason for the PT (physical therapy) missed visit was due to bad weather and faxed to the physician. 4. A new physician order was obtained by the agency on 12/28/2023 at 9:33 AM for Patient #2 for a PT evaluation on 01/03/2023. No further documentation was found in the medical record indicating this visit was completed, missed, or discontinued. 5. A documented titled, "Home Health Certification and Plan of Care," for Patient #2, certification period of 12/20/2022 through 02/17/2023 indicated the following: Frequency/Duration of Visits: PT (physical therapy) 1WK1 (Once a week times one week) 6. During an interview at 9:45 AM on 03/13/2023, the clinic manager agreed that the physical therapist did not complete an initial assessment for Patient #2 and was never evaluated during the admission by any physical therapist.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient's medical record would be provided upon request and free of charge in 1 of 1 agencies reviewed. Findings Include: 410 IAC 17-12-3(b)(3) 1. A policy titled, "Bill of Rights and Responsibilities," revised on 02/24/2023 was provided by the clinic manager on 03/16/2023 at 12:14 PM. The policy indicated, but was not limited to, "1. Each patient, upon admission, is given information regarding the Patient Bill of Rights and Responsibilities in language the patient can reasonably be expected to understand, which includes:" ... "Be advised on the Company's Policies and Procedures regarding the disclosure of Patient Medical Records." 2. An admission booklet titled, "Patient Orientation for Home Health Care Services," was provided by the clinic manager on 03/10/2023 at 12:30 PM. Within the booklet a section titled, "Section 3. Notice of Privacy Practices," indicated but was not limited to, "Requesting Your information (Access or Copy): In most cases when you ask in writing, you can look at or get a copy of your protected health information in your medical records or applicable parts of your billing record in paper or electronic format. You may also request that we send electronic copies directly to a person or entity choses by you. We will give you a form to fill out to make the request. You can look at medical information about you for free. If you request paper or electronic copies of the information, we may charge a fee to cover the cost of copying, mailing, and supplies." ... "If we say no to your request to look at the information or get a copy of it, we will tell you why in writing." 3. During an interview on 03/14/2023 at 12:19 PM the clinic manager agreed that the booklet is provided to all new patients upon admission and that the verbiage in the patient bill of rights states that patient's requesting copies of their medical records can be denied and/or charged a fee, however, indicated that patients have never been denied access to their medical record or charged a fee. The clinic manager was unaware of this verbiage in the agency's booklet.