Every finding on record at Servant's Heart Home Health Services, Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: July 7, 8, 9, 10, 11, 14, 15, 16, 2025 Active Census: 32 At this Emergency Preparedness survey, Servant's Heart Home Health Services was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review, EP document review and interview, the home health agency failed to review and update the facility-based and community-based risk assessment every two years (See E0006), failed to ensure an individualized patient emergency plan was developed as part of the comprehensive assessment and kept on file at the agency (See E0017), ailed to ensure its EP plan identified and implemented a triage classification for all patients (See E0021), failed to develop and maintain a communciation plan which included the names and contact information for all staff and patients’ physicians (See E0030), failed to develop and maintain an EP communication plan which included contact information for regional and local EP officials for all counties served (See E0031), failed to develop a communication plan which included a method for sharing information and medical documentation with other health providers during an emergency (See E0033), and failed to conduct an after-action review of its 2023 EP testing exercise (See E0039). The cumulative effect of these systemic issues evidenced the agency failed to maintain a comprehensive emergency preparedness plan, which resulted in Servant's Heart Home Health Services being found out of compliance with Condition for Participation 42 CFR 418.113 Emergency preparedness

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on EP document review and interview, the home health agency failed to review and update the facility-based and community-based risk assessment every two years, which had the potential to affect all active patients and staff. Findings include: 1. The agency’s EP documentation included a hazard and vulnerability risk assessment (HVA). The documentation failed to evidence the date the risk assessment was completed. 2. During an interview on 7/16/2025 beginning at 1:41 PM, Alternate Administrator was unsure of the date the HVA was completed. Alternate Administrator reported it may have been “several years” since the HVA was reviewed and updated.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review, EP document review, and interview, the home health agency failed to ensure an individualized patient emergency plan was developed as part of the comprehensive assessment for 3 of 7 records reviewed of a patient admitted on or after 4/18/2024 (Patient #3, 4, 5) and failed to ensure an individualized patient emergency plan was kept on file at the agency for 20 of 32 active patients (Patient #1, 2, 4, 5, 6, 7, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25). Findings include: 3. Patient #4’s clinical record evidenced a SOC date of 2/24/2025. The record indicated a SOC comprehensive assessment was conducted on 2/24/2025. The record failed to evidence a patient emergency plan was developed as part of the comprehensive assessment. During an interview on 7/15/2025 beginning at 4:24 PM, when asked if Patient had an emergency plan, CM responded “not really.” 4. Patient #5’s clinical record evidenced a SOC date of 1/14/2025. The record indicated a SOC comprehensive assessment was conducted on 1/14/2025. The record failed to evidence a patient emergency plan was developed as part of the comprehensive assessment. During an interview on 7/15/2025 beginning at 4:10 PM, when asked if Patient had an emergency plan, CM responded Patient resided at an assisted living facility which had its own EP plan for Patient. CM stated the agency did not create a patient emergency plan as part of the comprehensive assessment. 5. Review of the agency’s EP plan failed to evidence a copy of the patient emergency plan for 20 of 32 active patients (Patient #1, 2, 4, 5, 6, 7, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25). During an interview on 7/15/2025 beginning at 3:24 PM, Administrator reported the agency’s current EMR had no place to document a patient emergency plan. Administrator reported she had began creating a patient emergency plan for all patients in 2024, but estimated 50% of patients did not currently have a patient emergency plan. 1. The undated agency policy “Client Admission Process” indicated the professional admitting the patient to services would develop an emergency plan with the patient. 2. A home visit observation occurred on 7/8/2025 beginning at 12:40 PM with Patient #3. During the visit, Patient #3 allowed the surveyor to review the handbook provided by the agency. The handbook failed to include an individualized disaster plan. The review of Patient #3’s clinical record evidenced a document titled “My Personal Disaster Plan.” The document evidenced a section “My Pet’s Disaster Plan,” which indicated Patient #3 had a female dog and included the dog’s name. The document evidenced Patient #3’s signature and date of 4/18/2024. The document included the signature of the Administrator/ Alternate CM. The remainder of the document was blank. During an interview on 7/14/2025 beginning at 4:10 PM, the Alternate Administrator reviewed the document and indicated it was part of the disaster plan but was incomplete.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on EP review and interview, the home health agency failed to ensure its EP plan identified and implemented a triage classification for all patients, which had the potential to affect all active patients. Findings include: 1. An agency policy “Emergency Management Policy” indicated the agency would identify a “classification system … to determine client acuity and need for services during an emergency. This classification would be used to assure clients with immediate needs are seen during this time or alternate arrangements are made … The agency will maintain a current prioritized list of patients who need continued services during an emergency ….” 2. The agency’s EP plan failed to evidence a triage classification system had been identified and implemented to determine each active patient’s acuity and need for services during an emergency. 3. During an interview on 7/16/2025 beginning at 1:41 PM, Alternate Administrator reported the agency’s EMR did not have a way to document a patient’s triage classification.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on EP review and interview, the home health agency failed to develop and maintain a communication plan which included the names and contact information for all staff and patients’ physicians, which had the potential to affect all patients and staff. Findings include: 1. EP documentation failed to evidence a communication plan which included the names and contact information for all staff and patients’ physicians. 2. During an interview on 7/16/2025 beginning at 1:41 PM, Alternate Administrator reported the agency did not have a communication plan which included contact information for all current employees and all patients’ physicians.

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 EP review and interview, the home health agency failed to develop and maintain an EP communication plan which included contact information for regional and local EP officials for all counties served, which had the potential to affect all active patients and staff. Findings include: 1. The agency’s “Geographic Area Served” form, completed on 7/08/2025, evidenced the agency served the following counties: Boone, Carroll, Cass, Clinton, Fulton, Grant, Hamilton, Hendricks, Howard, Madison, Marion, Miami, Pulaski, Tippecanoe, Tipton, Wabash, and White. 2. EP documentation failed to evidence contact information for regional and local EP officials for the following counties served: Boone, Carroll, Clinton, Fulton, Grant, Hamilton, Hendricks, Madison, Marion, Pulaski, Tippecanoe, Tipton, Wabash, and White. 3. During an interview on 7/16/2025 beginning at 1:41 PM, Alternate Administrator reported the agency did not have contact information for regional and local EP officials outside of Cass, Howard, or Miami county. Alternate Administrator reported the agency did currently have one patient and one employee residing in Hamilton county.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on EP review and interview, the home health agency failed to develop a communication plan which included a method for sharing information and medical documentation with other health providers during an emergency, which had the potential to affect all agency patients. Findings include: 1. The EP communication plan failed to evidence a method for sharing information and medical documentation for patients under the agency’s care with other health care providers to maintain continuity of care. 2. During an interview on 7/16/2025 beginning at 1:41 PM, Alternate Administrator reported the agency’s EP plan did not evidence a method for sharing information and medical documentation with other providers.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on EP review and interview, the home health agency failed to conduct an after-action review of its 2023 EP testing exercise, which had the potential to affect all active patients and staff. Findings include: 1. The agency’s EP documentation evidenced agency staff attended a community tabletop exercise on 6/22/2023. The documentation failed to evidence the agency conducted an after-action review and revised the EP plan as needed. 2. During an interview on 7/16/2025 beginning at 1:41 PM, Administrator reported an after action review was conducted via Zoom with all community attendees, however the agency was unable to provide documentation evidencing the agency’s analysis of its EP plan based on the exercise nor if any changes to the EP plan were made.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: July 7, 8, 9, 10, 11, 14, 15, 16, 2025 12-Month Unduplicated Skilled Admissions: 6 A Fully Extended Survey was announced on July 10, 2025 at 4:32 PM. An Immediate Jeopardy related to 42 CFR 484.60 Condition of participation: Care planning, coordination of services, and quality of care was identified and announced on 7/11/2025 at 2:25 PM. The agency was determined to have removed the immediacy component of the immediate jeopardy on 7/16/2025 at 5:49 PM. During this Federal Recertification Survey, Servant's Heart Home Health Services was found to be out of compliance with Conditions of Participation 42 CFR §484.60 Care planning, coordination of services, and quality of care, 484.65 Quality assessment and performance improvement, 484.75 Skilled professional services, 484.80 Home health aide services, and 484.102 Emergency preparedness. Based on the Condition-level deficiencies during the July 16, 2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on July 10, 2025. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning July 16, 2025 and continuing through July 15, 2027. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN - Registered Nurse, LPN - Licensed Practice Nurse, HHA - Home Health Aide, CM - Clinical Manager, SN - Skilled Nurse, PSA - Personal Service Agency, POC -Plan of Care, DME - Durable Medical Equipment, SOC - Start of Care, EMR - Electronic Medical Record, QAPI - Quality Assurance Performance Improvement, ROC - Resumption of Care. EP - Emergency Preparedness QR 7/24/25 A2

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide the name and contact information for the current Administrator for 1 of 1 home visits with a patient handbook available (Patient #3). Findings include: A home visit observation occurred on 7/8/2025 beginning at 12:40 PM with Patient #3. During the visit, Patient #3 allowed the surveyor to review the handbook provided by the agency. The handbook failed to evidence the name and contact information for the Administrator. The handbook evidenced the contact information for the Alternate Administrator. During an interview on 7/9/2025 beginning at 3:50 PM, the Alternate Administrator indicated the patient handbook contained incorrect information.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to document its investigation of complaints regarding treatment or care for 1 of 1 complaint documented between 7/07/2024 – 7/07/2025 (Patient #9). Findings include: 1. The undated agency policy “Patient’s Rights and Responsibilities/Grievance Procedure” indicated the agency would document the existence of all complaints, the status of the investigation, and the complaint resolution. 2. The agency’s complaint log evidenced a complaint was reported by Person O, caregiver to Patient #9, on 9/27/2024. Person O was “very upset” and reported “[Former Employee P] was neglecting to give [Patient #8] appropriate care … [The nurse] left [Patient] in bed all afternoon, and when [Person O] arrived home, [Patient’s tube] feeding was clumped up and all over [Patient].” The complaint documentation failed to evidence the agency’s investigation of Person O’s complaint During an interview on 7/15/2025 beginning at 2:56 PM, Alternate Administrator reported she investigated Person O’s complaint regarding Patient #9’s care, however the agency was unable to provide documentation of the investigation. 410 IAC 17-12-3(c)(a)(2)

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure an initial assessment to determine a patient’s immediate care and support needs was conducted within 48 hours of referral for 3 of 7 records reviewed of a patient referred on or after March 1, 2024 (Patient #3, 4, 5). Findings include: 3. Patient #4’s clinical record evidenced a referral date of 1/31/2025 and a SOC date of 2/26/2025. The record failed to evidence an initial assessment was conducted to determine Patient’s immediate care and support needs until 2/26/2025, which was 26 days after the referral date. During an interview on 7/10/2025 beginning at 10:09 AM, CM reported an initial assessment should be completed “within a few days” of receiving the referral. CM reported Former Employee L, an RN, conducted the initial assessment during the SOC comprehensive assessment on 2/26/2025. She was unsure the reason an initial assessment was not conducted within 48 hours of referral. 4. Patient #5’s clinical record evidenced a referral date of 1/07/2025 and a SOC date of 1/14/2025. The record failed to evidence an initial assessment was conducted to determine Patient’s immediate care and support needs until 1/14/2025, which was seven days after the referral date. During an interview on 7/15/2025 beginning at 2:40 PM, Administrator reported when a patient was referred, the agency would need to obtain insurance approval for services prior to an assessment being conducted. Administrator reported Patient’s insurance required a prior authorization (PA) which included creating a “generic” POC and having it signed by the ordering provider. The POC would be created based on information received in the referral and sent to the physician for signature prior to an initial assessment being conducted. Administrator stated Patient’s initial assessment was conducted on 1/14/2025 due to staff availability. 410 IAC 17-14-1(a)(1)(A) 1. The undated agency policy, “Client Admission Process” indicated the skilled professional would complete the initial assessment within 48 hours of the referral. 2. Patient #3’s clinical record evidenced a “Client Profile.” The document identified a referral date of 3/1/2024. The clinical record included a “Home Evaluation Order” signed and dated 4/2/2024 by Person E, Patient #3’s primary care provider. The order indicated the agency received a referral for SN and HHA services. The order stated, “We are requesting an authorization to evaluate [Patient #3] for medical need for these services ….” The clinical record included a “Nursing Admission Assessment Form” completed and signed by the Administrator /Alternate CM on 4/16/2024. A review of Patient #3’s POC for certification period 6/12/2025 – 8/10/2025 evidenced a start of care date of 4/18/2024. During an interview on 7/14/2025 beginning at 4:05 PM, the Alternate Administrator indicated the initial assessment was required within 48 hours of the referral. When asked, the Alternate Administrator indicated the referral date of 3/1/2024 was incorrect. The Alternate Administrator indicated the initial/admission assessment was not completed within 48 hours of the referral.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the comprehensive assessment included a complete and thorough assessment of Patient’s medical and health needs for 2 of 3 records reviewed of a patient with a wound identified at recertification (Patient #4, 5). Findings include: 1. Patient #4’s clinical record indicated Patient’s diagnoses included Diabetes Type 2 and Patient’s medications included Novolog (a short-acting insulin) to be given three times a day before meals according to a sliding scale (insulin dosing where the amount given is based on the patient’s blood sugar level), Lantus (a long acting insulin), Metformin (an oral diabetes medication), and Januvia (an oral diabetes medication). The record included a recertification comprehensive assessment completed on 6/26/2025 by CM. The nurse noted Patient had a Stage 2 pressure ulcer (type of wound caused by prolonged pressure to a bony area) to the left buttock. The record failed to evidence a complete wound assessment was conducted during the comprehensive assessment, including wound bed tissue, surrounding skin appearance, wound edges, presence or absence of signs and symptoms of infection, etc. The assessment also failed to evidence an assessment of Patient’s current diabetes status, including average blood sugar levels, presence or absence of complications, etc. During an interview on 7/10/2025 beginning at 10:09 AM, CM reported when she was conducting a recertification comprehensive assessment, she would “try” to ask Entity A’s, an assisted living facility, nursing staff about how Patient’s blood sugar levels had been. CM stated Patient was noncompliant with their medications and diabetic diet. During an interview on 7/09/2025 beginning at 4:15 PM, Person B, an employee of Entity A, reported the entity’s nursing staff checked Patient’s blood sugar four times a day. During an interview on 7/15/2025 beginning at 4:24 PM, CM reported her assessment of Patient’s wound included type of wound, measurement, and the “best treatment for it.” 2. Patient #5’s clinical record included a recertification comprehensive assessment completed on 5/13/2025 by CM. The assessment indicated Patient had a venous leg ulcer (VLU, type of wound caused by decreased blood flow back to the heart) to the right lower leg). The record failed to evidence a complete wound assessment was conducted during the comprehensive assessment, including wound bed tissue, surrounding skin appearance, wound edges, presence or absence of signs and symptoms of infection, etc. During an interview on 7/10/2025 beginning at 3:51 PM, CM stated her assessment of the wound included “mainly the amount of drainage.” 410 IAC 17-14-1(a)(1)(B)

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to update an assessment within 48 hours following a hospitalization for 1 of 2 home health aide only patients with a hospital discharge (Patient #7). Findings include: The undated agency policy “Client Reassessment /Update of Comprehensive Assessment” indicated a reassessment is required within 48 hours of the client’s return home from a hospital admission of more than 24 hours. The undated agency policy “Services on Hold” stated, “When patient services are resumed following hospitalization … a reassessment visit will be completed.” Patient #7’s clinical record included brief notes regarding a hospitalization on 5/17/2025 – 5/22/2025 for a “cardiac episode.” The record failed to evidence a reassessment following the hospitalization. During an interview on 7/10/2025 starting at 10:46 AM, the CM indicated they did not complete a reassessment visit following the hospitalization. The CM indicated the agency does not do reassessments following hospitalization for patients who received home health aide only services. They indicated the post-hospitalization reassessment visit is completed for patients who received skilled nursing services.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the individualized POC included the frequency and duration of visits to be made, nutritional requirements, all medications, a description of the patient’s risk for emergency department visits and hospital re-admission, and measurable goals identified by the agency during the comprehensive assessment (see G574), failed to promptly alert the relevant physician(s)/practitioner(s) to a change in patient condition and service orders not being met (see G590), failed to revise the POC to include the patient’s progress towards their goals (see G592), failed to coordinate care with assisted living facility staff (see G608), failed to provide a current medication list (see G616), and failed to provide a current POC to the patient (see G618). An Immediate Jeopardy related to 42 CFR 484.60 Condition of participation: Care planning, coordination of services, and quality of care was identified and announced on 7/11/2025 at 2:25 PM. The agency was determined to have removed the immediacy component of the immediate jeopardy on 7/16/2025 at 5:49 PM. The cumulative effects of these systemic issues evidenced the agency failed to meet the patient’s needs, failed to create an individualized POC, and failed to furnish services in accordance with accepted standards of practice, which resulted in Servant's Heart Home Health Services being found out of compliance with 42 CFR 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Based on observation, record review, and interview, the home health agency failed to meet the patient’s medical and nursing needs and failed to provide services according to the patient’s POC for 2 of 2 records reviewed which evidenced the patient’s wounds had worsened (Patient #4, 5). Findings include: 1. The undated agency policy “Skilled Nursing Visits” indicated the RN’s responsibilities include “… Regularly reevaluates the client needs and coordinates the necessary services … Initiates the Plan of Care and necessary revisions and updates … Informs the physician and other personnel of changes in the client condition and needs ….” SN activities could also include “observation and assessment. 2. Patient #5’s clinical record indicated a SOC date of 1/14/2025. A POC for the recertification period of 5/14/2025 – 7/12/2025 included orders for SN visits three times a week “for wound care. SN to assess wounds for infection, healing status and complications.” Patient was noted to have a venous leg ulcer (VLU, type of wound caused by decreased blood flow back to the heart) to the right lower leg which required wound care to be performed daily. Person D, a physician, was Patient’s primary care provider. Patient resided at Entity H, an assisted living facility. Person J, family member to Patient, performed wound care on days where Patient was not seen by home health or by Entity C, a wound clinic. A recertification comprehensive assessment dated 5/13/2025 indicated Patient’s wound measured 12 centimeters (cm) in length by 21 cm in width by 0.1 cm in depth (12 cm x 21 cm x 0.1 cm) with a “moderate” amount of serous drainage (clear to yellow drainage from a wound). Patient reported no pain. The assessment failed to evidence a further assessment of the wound, including wound bed tissue description, presence or absence of signs and symptoms of infection, etc. SN visit notes dated 5/14/2025, 5/15/2025, 5/20/2025, 5/21/2025, 5/22/2025, 5/27/2025, and 5/29/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurements, presence or absence of signs and symptoms of infection, etc. Patient denied pain during all visits. A wound clinic note from Entity C dated 5/29/2025 evidenced Patient’s wound measured 21 cm x 24.5 cm x 0.1 cm, an increase from the last noted measurement of 9 cm in length and 3.5 cm in width. The wound bed included over 50% of “nonviable slough/fibrin” (dead tissue which can impede wound healing) with serous drainage. Patient reported intermittent pain to the wound. SN visit notes dated 6/03/2025, 6/04/2025, and 6/05/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurements, presence or absence of signs and symptoms of infection, etc. On 06/04/2025, Patient reported pain to the right lower leg rated a “5” or “6” out of 10 on a 0-10 numeric pain scale. On 6/05/2025, Patient reported pain to the right lower leg rated a “6” or “7” out of 10 on a 0-10 numeric pain scale. The record failed to evidence Patient’s physician or Entity C was notified of the pain to the right lower leg. A wound clinic note from Entity C evidenced Patient was seen on 6/09/2025. Patient’s wound measured 21 cm x 26 cm x 0.1 cm, an increase from the last noted measurement of 1.5 cm in width. Patient’s pain to the leg wound was now continuous. SN visit notes dated 6/10/2025 and 6/11/2025 noted Patient had “heavy” drainage but failed to evidence a description of the drainage. On 6/11/2025, Patient reported pain when touching the wound. The record failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. A SN visit note dated 6/12/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. A SN visit note dated 6/17/2025 indicated Patient had been started on Keflex and Doxycycline, two antibiotics, on 6/13/2025 after developing “an odor and greenish drainage” to their wound. Patient had subsequently developed “small blisters” and redness to the right leg, and the antibiotics were discontinued on 6/14/2025. Patient was started on two different antibiotics, Zyvox and Rocephin, on 6/17/2025. CM noted Patient’s leg “looked better with no blisters.” The record failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, drainage description, presence or absence of signs and symptoms of infection, etc. SN visit notes dated 6/18/2025 and 6/19/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. CM noted Patient had “heavy” drainage on 6/18/2025 and the wound was “constantly moist” on 6/19/2025. The record failed to evidence a further description of the drainage, such as color, presence or absence of odor, etc. A physician rounding note from Person D dated 6/19/2025 indicated Patient had redness and swelling to the right lower leg with drainage. A wound clinic visit note from Entity C evidenced Patient was seen on 6/23/2025. Patient’s wound was noted to have “worsened.” The wound measured 21 cm x 25 cm x 0.1 cm. A SN visit dated 6/24/2025 failed to evidence CM obtained Patient’s vital signs or pain rating. The record failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. Records from Entity F, an emergency department (ED), evidenced Patient was taken to the ED on 6/24/2025 for “right leg pain with increasing weakness and difficulty getting around” for three days. Patient’s VLU was noted to be “overtly infected.” Patient’s blood pressure on arrival to the ED was 99/53. Patient was admitted to Entity G, an acute care hospital. Records from Entity G evidenced Patient was admitted to the hospital on 6/25/2025 with diagnoses including sepsis (an infection in the bloodstream) and cellulitis (infection of the skin) with wound infection. During the Entrance Conference conducted on 7/07/2025 beginning at 9:43 AM, Alternate Administrator reported wounds should be assessed and measured at least weekly. During an interview on 7/10/2025 beginning at 3:51 PM, CM reported prior to Patient beginning antibiotics, the wound’s drainage increased and turned green. When asked if she reported these changes to Person D or Entity C, CM stated she reported this to Person I, an employee of Entity H, and said “I didn’t know if [Person D] needed to look at it.” CM stated her assessment of the wound included “mainly the amount of drainage.” She was unable to measure the wounds, and stated this was the responsibility of Entity C. CM reported she did receive visit notes from Entity C, however the record failed to evidence visit notes between 5/05/2025 – 6/23/2025. The nurse described Patient’s wound bed as “white … looks like the … surface of the moon.” When asked if there was any eschar or slough, CM reported there was occasionally dry skin. CM reported Patient’s pain level “depended on the day.” CM stated on 6/24/2025, prior to Patient being taken to Entity F, Patient’s wound “looked about the same,” and the nurse did not note any changes in Patient. Staff of Entity H reportedly became concerned on Patient’s condition later in the day on 6/24/2025 and took Patient to be evaluated in an ED. During an interview on 7/11/2025 beginning at 3:04 PM, Person I reported Patient was started on antibiotics after Person J reported the wound was “red and soiling.” Person I stated there was no report of Patient’s wound worsening by agency staff prior to Patient being taken to the ED. During an interview on 7/14/2025 beginning at 10:28 AM, Person J reported prior to Patient’s hospitalization, the caregiver changed Patient’s wound dressing three to four times per week. Patient began having green drainage and an odor to the wound approximately two weeks before Patient was hospitalized. Person J reported they requested Patient be started on antibiotics due to concerns the caregiver had for a possible infection. The caregiver stated on 6/24/2025, Person I reported Patient was “looking really bad,” was confused, incontinent of bowel and bladder (unable to control their stool and urine), and had fallen repeatedly. Person J reported due to Patient’s history of neuropathy (decreased sensation), Patient would need to be in “a lot of pain” to notice. 3. Patient #4’s clinical record indicated a SOC date of 2/24/2025 with orders for home health aide visits five days a week. Patient was enrolled in both Medicare and Medicaid, and the home health services were billed through Medicaid. Patient resided at Entity A, an assisted living facility. An HHA visit note dated 5/27/2025 evidenced HHA 3 noted “an open area that was bleeding.” The aide documented she notified Patient’s nurse of the wound. An HHA visit note dated 5/30/2025 evidenced Patient had an “open area on [his/her] inner thigh.” Patient reportedly told CM that he/she had the area evaluated by the doctor and the doctor “didn’t see anything.” An HHA supervisory visit note dated 5/30/25, documented by CM, failed to evidence Patient’s wound was assessed during the visit. An HHA visit note dated 6/13/2025 evidenced HHA 3 “contacted [the] nurse about [an] open area.” A recertification comprehensive assessment dated 6/26/2025 evidenced Patient had a Stage 2 pressure ulcer (type of wound caused by prolonged pressure to a bony area, graded by “stages” from 1 to 4 and unstageable) to the left buttock measuring 2 cm x 2 cm x 0.1 cm. CM documented she notified Patient’s PCP of the wound. This was the first documented nurse assessment of the wound. A POC for the recertification period of 6/26/2025 – 8/24/2025 included orders for both SN and HHA visits. SN visits were to be done twice a week with interventions to include Calmoseptine (a barrier cream) and a foam dressing. The POC was signed by Patient’s ordering provider on 6/30/2025. The record failed to evidence a SN visit was conducted the week of 6/28/2025 – 7/04/2025. A SN visit dated 7/08/2025 by CM evidenced Patient’s wound measured 3.4 cm x 2.0 cm x 0.1 cm, an increase by 1.4 cm in length. This was the first documented wound assessment since the recertification assessment on 6/26/2025. A home visit observation was conducted on 7/09/2025 beginning at 1:04 PM. An approximate dime-sized Stage II pressure ulcer was observed on Patient's left lower buttock/upper thigh. Patient reported they had a foam dressing on the area, but it had fallen off, and the wound was open-to-air. Patient required assistance with toileting, transferring, ambulating, showering, and performing personal care. During the visit, HHA 2 performed wound care by applying a barrier cream and covering with a foam dressing. During an interview on 7/09/2025 beginning at 1:53 PM, HHA 2 reported Patient had the pressure ulcer wound for approximately three weeks. The aide reported Patient's wound did not start "as big" as it currently was and first appeared as "peeled skin." HHA 2 reported HHA 3 had notified CM of the area, and the aides had been applying barrier cream to the area while they waited for SN services to be approved by insurance. During an interview on 7/09/2025 beginning at 2:12 PM, Patient #4 reported the agency "just started" providing wound care to the left buttock wound. Patient #4 reported prior to that week there had been no one available to provide wound care. During an interview on 7/09/2025 beginning at 4:15 PM, Person B, an employee of Entity A, reported the facility was not notified of Patient's left buttocks wound by the home health agency. During an interview on 7/10/2025 beginning at 10:09 AM, CM stated she was first notified of the wound on 6/26/25 by HHA 2. CM reported when she assessed the wound, it was "one big area." CM sent an order to Patient's PCP to add SN services and "suggested treatment" of applying barrier cream and a foam dressing. Signed orders were received from the PCP on 6/30/25. CM reported the agency had to wait for insurance to approve the addition of SN services before SN visits could begin. CM reported while waiting for insurance approval, she instructed HHA 2 and HHA 3 to apply barrier cream only to the wound as it was "better than nothing." CM reported she did not inform Entity A staff of the wound. During a follow-up interview on 7/10/2025 beginning at 4:12 PM, CM reported Entity A was Patient's main caregiver. She stated Patient did not have any other caregivers to perform wound care. During a follow-up interview on 7/11/2025 beginning at 10:42 AM, CM reported she did not refer Patient to a Medicare agency for SN services when the wound was identified as it had been "complicated" in the past providing HHA services with Medicaid to a patient receiving SN services with Medicare. CM reported she was informed on 6/13/25 by HHA 3 of a wound to Patient's left buttock, and stated it was reported as "red ... a little open," but was not a Stage II pressure ulcer. CM reported she advised HHA 3 to "keep an eye" on the area and she did not assess the wound until the recertification visit on 6/26/25. CM reported the wound did get worse. During an interview on 7/15/2025 beginning at 12:13 PM, HHA 3 reported she was unsure how long Patient had the left buttocks wound. The aide notified CM of the wound and the nurse had come to visit Patient shortly afterwards. Patient reportedly “lied” to CM during the visit, saying he/she had seen the doctor and the doctor did not find any wounds. HHA reported after CM left, the aide assisted Patient with a shower, and found the wound was still present. HHA 3 notified CM that the wound was still present, and CM reportedly stated she would have to come back and assess the wound, and would also work on getting insurance approval for SN services. HHA 3 reported she did not perform any treatment to the wound, as she could not find anything that was “appropriate.” 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the individualized POC included the frequency and duration of visits to be made, nutritional requirements, all medications, a description of the patient’s risk for emergency department visits and hospital re-admission, and measurable goals identified by the agency during the comprehensive assessment for 5 of 8 active records reviewed (Patient #1, 2, 4, 5, 11). Findings include: 2. Patient #2’s clinical record included a POC for the recertification period of 5/24/2025 – 7/22/2025. The POC failed to evidence a description of Patient’s risk for emergency department visits and hospital re-admission. A home visit observation was conducted on 7/08/2025 beginning at 4:02 PM with Patient #2. During the visit, RN 1 administered Patient’s tube feeding, which consisted of 8.5 ounces of Kate Farms Pediatric Peptide 1.5 formula mixed with 6.5 ounces of water. RN 1 reported Patient was to receive tube feeds every three hours at a rate of 600 milliliters (ml) per hour (ml/hr). Patient could also eat and drink but required liquids to be a pudding-thick consistency and all foods and drinks to be lactose free. The POC failed to evidence these dietary and nutrition requirements. The POC included an order for Mupirocin 2% Topical Ointment (antibiotic applied to the skin) which was to be applied twice a day “to affected areas.” The POC failed to evidence clear directions on where to apply the medication. A recertification comprehensive assessment was completed on 5/20/2025 by RN 1. The assessment evidenced goals which included Patient would remain safe at home and would maintain an optimal level of hygiene. The POC evidenced goals which included Patient would exhibit a stable neurological status, would be free from falls, would receive adequate nutrition, and would remain free from adverse medication reactions. The POC failed to include all goals identified in the comprehensive assessment. During an interview on 7/08/2025 beginning at 4:41 PM, RN 1 reported Patient’s Mupirocin was to be applied to his/her left nostril as needed for redness. The nurse reported she could not find Patient’s tube feed orders, dietary restrictions, or risks for hospitalization on the POC. During an interview on 7/09/2025 beginning at 3:48 PM, RN 1 reported when conducting a recertification comprehensive assessment, she used goals already developed by the agency, and had been directed by administrative staff to not create new goals without approval. 3. Patient #4’s clinical record included a POC for the recertification period of 6/26/2025 – 8/24/2025. The POC failed to evidence a description of Patient’s risk for emergency department visits and hospital re-admission. The POC included a visit frequency order for HHA visits two hours per visit, three days per week and one hour per visit, two days per week, for a total of eight hours per week. A recertification comprehensive assessment was completed on 6/26/2025 by CM. The assessment evidenced goals which included but were not limited to Patient would maintain an optimal level of symptom control. The POC evidenced goals which included but were not limited to Patient’s skin integrity would remain intact and Patient would exhibit not signs or symptoms of infection. The POC failed to include all goals identified in the comprehensive assessment. The POC included a medication list which indicated Patient’s active medications included Jardiance (an oral diabetes medication). Review of Entity A’s, an assisted living facility, medication list failed to evidence Patient was taking Jardiance. During an interview on 7/09/2025 beginning at 4:15 PM, Person B, an employee of Entity A, reported Patient was not currently taking Jardiance. During an interview on 7/10/2025 beginning at 10:09 AM, CM reported Patient’s HHA visit frequency order had been documented incorrectly on the POC. The visit frequency should have been HHA visits two hours per visit, two visits a week and one hour per visit, three times a week, for a total of seven hours per week. During an interview on 7/10/2025 beginning at 4:12 PM, CM reported the agency did not include a patient’s risk for emergency department visits and re-hospitalization on the POC. CM stated the agency was not Patient’s primary caregiver, so the goals were “not very specific.” CM was unsure if she had obtained a copy of Entity A’s medication list during the recertification comprehensive assessment visit to reconcile Patient’s medications. 4. Patient #5’s clinical record included a POC for the recertification period of 5/14/2025 – 7/12/2025. The POC failed to evidence a description of Patient’s risk for emergency department visits and hospital re-admission. A recertification comprehensive assessment was completed on 5/13/2025 by CM. The assessment evidenced goals which included but were not limited to Patient would maintain an optimal level of symptom control. The POC evidenced goals which included but were not limited to Patient’s skin would not have any more open areas and Patient would not have any signs or symptoms of infection. The POC failed to include goals identified in the comprehensive assessment. During an interview on 7/15/2025 beginning at 4:10 PM, CM reported the POC did not include Patient’s risk for emergency department visits and re-hospitalization. 5. Patient #11’s clinical record included a POC for the recertification period of 6/21/2025 – 8/19/2025. The POC failed to evidence a description of the patient’s risk for emergency department visits and hospital re-admission. During an interview on 7/16/2025 beginning at 3:22 PM, Administrator reported Patient’s risk for emergency department visits and hospital re-admission were not included on the POC. 410 IAC 17-13-1(a)(1)(B)(2)(iii), 410 IAC 17-13-1(a)(1)(B)(3, 4) 1.Patient #1’s clinical record evidenced hospital discharge orders dated 6/3/2025, which included a medication list. The list included amiodarone (used to treat severe heart rhythm problems) 200 mg (milligrams) twice a day; acetaminophen – hydrocodone (narcotic pain reliever) 325 mg- 10 mg; mexiletine (used to treat abnormal heart rhythms) 150 mg three times a day; periactin 4 mg daily as needed; torsemide (a diuretic) 10 mg three tablets once daily. Patient #1’s POC for certification period 6/7/2025 – 8/5/2025 evidenced a medication list with amiodarone 100 mg daily; acetaminophen – hydrocodone 325 mg – 5 mg; and torsemide 10 mg once daily. The POC failed to evidence the correct dosage for amiodarone, acetaminophen – hydrocodone, and torsemide. The POC failed to include mexiletine or periactin. The agency failed to document updated medication on the POC. During an interview on 7/10/2025 beginning at 10:46 AM, the CM indicated they just updated Patient #1’s medication list. When asked, the CM indicated they got the medication list from Patient #1’s February 2025 hospital discharge paperwork. When asked about using the 6/3/2025 hospital discharge paperwork, the CM indicated they did not have the paperwork and Patient #1 told the CM nothing had changed regarding medications.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to promptly alert the relevant physician(s)/practitioner(s) to a change in patient condition and service orders not being met for 5 of 5 records reviewed which indicated a change in patient condition and/or service orders not being met (Patient #2, 4, 5, 7, 11). 6. Patient #7’s clinical record evidenced a POC for certification period 5/4/2025 – 7/2/2025. The POC indicated Patient #7 would receive Home Health Aide services for 2 hours per visit for 3 visits per week. The record included documentation Patient #7 would receive attendant care for 20 hours per week and homemaker services for 40 hours per month. The record evidenced patient #7 received aide services for a total of 13.75 hours per month. Patient #7 received a total of 21.25 hours of attendant care and 22 hours of homemaker services per month. During an interview on 7/14/2025 beginning at 4:05 PM, the Alternate Administrator indicated the physician was not notified of the reduced hours. The Alternate Administrator indicated that the patient did not receive all the hours due to staffing issues. 410 IAC 17-13-1(a)(2) Findings include: 1. The undated agency policy “Medical Supervision” indicated the agency was responsible for “prompt reporting of a change in patient condition.” 2. Patient #5’s clinical record indicated a SOC date of 1/14/2025. A POC for the recertification period of 5/14/2025 – 7/12/2025 included orders for SN visits three times a week “for wound care. SN to assess wounds for infection, healing status and complications.” Patient was noted to have a venous leg ulcer (VLU, type of wound caused by decreased blood flow back to the heart) to the right lower leg which required wound care to be performed daily. Person D, a physician, was Patient’s primary care provider. Patient resided at Entity H, an assisted living facility. Person J, family member to Patient, performed wound care on days where Patient was not seen by home health or by Entity C, a wound clinic. A recertification comprehensive assessment dated 5/13/2025 indicated Patient’s wound measured 12 centimeters (cm) in length by 21 cm in width by 0.1 cm in depth (12 cm x 21 cm x 0.1 cm) with a “moderate” amount of serous drainage (clear to yellow drainage from a wound). Patient reported no pain. A wound clinic note from Entity C dated 5/29/2025 evidenced Patient’s wound measured 21 cm x 24.5 cm x 0.1 cm, an increase from the last noted measurement of 9 cm in length and 3.5 cm in width. The wound bed included over 50% of “nonviable slough/fibrin” (dead tissue which can impede wound healing) with serous drainage. The record failed to evidence the agency had notified Patient’s physician or Entity C of the increase in wound measurement or presence of nonviable tissue. A SN visit note dated 06/04/2025 indicated Patient reported pain to the right lower leg rated a “5” or “6” out of 10 on a 0-10 numeric pain scale. This was the first agency visit where Patient reported pain to the wound. The record failed to evidence Patient’s physician or Entity C was notified of the pain to the right lower leg. A SN visit note dated 6/05/2025 indicated Patient reported pain to the right lower leg rated a “6” or “7” out of 10 on a 0-10 numeric pain scale. The record failed to evidence Patient’s physician or Entity C was notified of the pain to the right lower leg. A wound clinic note from Entity C evidenced Patient was seen on 6/09/2025. Patient’s wound measured 21 cm x 26 cm x 0.1 cm, an increase from the last measurement of 1.5 cm in width. SN visit notes dated 6/10/2025 and 6/11/2025 noted Patient had “heavy” drainage but failed to evidence a description of the drainage. On 6/11/2025, Patient reported pain when touching the wound. The record failed to evidence Patient’s physician or Entity C was notified of the increased drainage nor pain to the right lower leg. No SN visits were conducted between 6/13/2025 – 6/16/2025. A SN visit note dated 6/17/2025 indicated Patient had been started on Keflex and Doxycycline, two antibiotics, on 6/13/2025 after developing “an odor and greenish drainage” to their wound. After beginning the antibiotics, Patient had developed “small blisters” and redness to the right leg, and the antibiotics were discontinued on 6/14/2025. Two different antibiotics, Zyvox and Rocephin, were started on 6/17/2025. CM noted Patient’s leg “looked better with no blisters.” A wound clinic visit note from Entity C evidenced Patient was seen on 6/23/2025. Patient’s wound was noted to have “worsened.” A SN visit dated 6/24/2025 failed to evidence CM obtained Patient’s vital signs, pain rating, or wound assessment. Records from Entity F, an emergency department (ED), evidenced Patient was taken to the ED on 6/24/2025 for “right leg pain with increasing weakness and difficulty getting around” for three days. Patient’s VLU was noted to be “overtly infected.” Patient was admitted to Entity G, an acute care hospital. Records from Entity G evidenced Patient was admitted to the hospital on 6/25/2025 with diagnoses including sepsis (an infection in the bloodstream) and cellulitis (infection of the skin) with wound infection. During an interview on 7/10/2025 beginning at 3:51 PM, CM reported prior to Patient beginning antibiotics, the wound’s drainage increased and turned green. CM stated she thought the wound did not appear infected. When asked if she reported the drainage changes to Person D or Entity C, CM stated she reported this to Person I, an employee of Entity H, and said “I didn’t know if [Person D] needed to look at it.” During an interview on 7/11/2025 beginning at 3:04 PM, Person I reported Patient was started on antibiotics after Person J reported the wound was “red and soiling.” Person I stated there was no report of Patient’s wound worsening by agency staff prior to Patient being taken to the ED. During an interview on 7/14/2025 beginning at 10:28 AM, Person J reported Patient began having green drainage and an odor to the wound approximately two weeks before Patient was hospitalized. Person J reported they requested Patient be started on antibiotics due to concerns the caregiver had for a possible infection. The caregiver stated on 6/24/2025, Person I reported Patient was “looking really bad,” was confused, incontinent of bowel and bladder (unable to control their stool and urine), and had fallen repeatedly. Person J reported due to Patient’s history of neuropathy (decreased sensation), Patient would need to be in “a lot of pain” to notice. 3. Patient #4’s clinical record indicated a SOC date of 2/24/2025 with orders for HHA visits five days a week. Patient resided at Entity A, an assisted living facility. An HHA visit note dated 5/27/2025 evidenced HHA 3 noted “an open area that was bleeding.” The aide documented she notified Patient’s nurse of the wound. An HHA visit note dated 5/30/2025 evidenced Patient had an “open area on [his/her] inner thigh.” Patient reportedly told a nurse that he/she had the area evaluated by the doctor and the doctor “didn’t see anything.” An HHA supervisory visit note dated 5/30/25, documented by CM, failed to evidence Patient’s wound was assessed during the visit. An HHA visit note dated 6/13/2025 evidenced HHA 3 “contacted [the] nurse about [an] open area.” A recertification comprehensive assessment dated 6/26/2025 evidenced Patient had a Stage 2 pressure ulcer (type of wound caused by prolonged pressure to a bony area, graded by “stages” from 1 to 4 and unstageable) to the left buttock measuring 2 cm x 2 cm x 0.1 cm. CM documented she notified Patient’s PCP of the wound. This was the first documented provider notification of the wound. During an interview on 7/10/2025 beginning at 10:09 AM, CM reported she did not assess Patient’s wound until the recertification comprehensive assessment on 6/26/2025 and then notified Patient’ PCP of the wound. 4. Patient #2’s clinical record indicated Person K, a physician, was listed as Patient’s home health attending provider. A POC for the recertification period of 5/24/2025 – 7/22/2025 indicated Patient was to receive SN services with visits of eight hours per day, five days per week. The record indicated between the weeks of 5/24/2025 – 7/04/2025, Patient received only one SN visit per week, lasting 2 – 2.75 hours. The record failed to evidence the reason additional were not conducted and failed to evidence Person K was notified of the missed visits. During a recertification comprehensive assessment on 5/20/2025, RN 1 noted Patient’s temperature was 102.9 degrees Fahrenheit axillary (in the armpit). The record failed to evidence Person K was notified of the fever. A SN visit note dated 7/01/2025 evidenced Patient’s caregiver reported to RN 1 that Patient had been taken to an urgent care clinic on 6/26/2025, was diagnosed with strep throat, and was started on a 10-day course of Amoxicillin (an antibiotic). The record failed to evidence Person K was notified of the new illness and medication. During an interview on 7/08/2025 beginning at 4:41 PM, RN 1 reported Patient’s visit frequency was not met due to staff availability. The nurse stated it was CM or Administrator’s responsibility to notify the physician for missed visits. RN 1 stated she would report a temperature above 103 degrees Fahrenheit to the physician, so the 5/20/2025 temperature was not reported. RN 1 also stated she notified CM of Patient’s urgent care visit and new medication on 7/01/2025 but did not notify Person K. During an interview on 7/10/2025 beginning at 10:42 AM, CM reported it was RN 1’s responsibility to contact Person K to report a change in Patient’s condition. She was unsure if Person K was notified of the agency failing to provide all SN visits as ordered. 5. Patient #11’s clinical record included a POC for the recertification period of 6/21/2025 – 8/19/2025 indicated Patient was to receive HHA services with visits of five hours per day, three days per week. The record indicated between the week of 6/14/2025 – 6/20/2025, Patient received no HHA visits. The record failed to evidence the reason the visits were not conducted and failed to evidence Patient’s physician was notified of the missed visits. During an interview on 7/16/2025 beginning at 3:22 PM, Administrator and Alternate Administrator reported HHA visits were not conducted the week of 6/14/2025 – 6/20/2025 due to staff availability. Alternate Administrator reported the record did not indicate Patient’s physician was notified of the missed visits.

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 home health agency failed to revise the POC to include the patient’s progress towards their goals for 7 of 8 active records reviewed (Patient #1, 2, 3, 5, 6, 7, 11). Findings include: 4. Patient #2’s clinical record included a POC for the recertification period of 5/24/2025 – 7/22/2025. The POC failed to evidence Patient’s progress towards their goals. During an interview on 7/08/2025 beginning at 4:41 PM, RN 1 reported she was Patient’s RN case manager. The nurse reported she did not indicate Patient’s progress towards their goals on the recertification POC. 5. Patient #5’s clinical record included a POC for the recertification period of 5/14/2025 – 7/12/2025. The POC failed to evidence Patient’s progress towards their goals. During an interview on 7/15/2025 beginning at 4:10 PM, CM reported she did not indicate Patient’s progress towards their goals on the recertification POC. 6. Patient #11’s clinical record included a POC for the recertification period of 6/21/2025 – 8/19/2025. The POC failed to evidence Patient’s progress towards their goals. During an interview on 7/16/2025 beginning at 3:22 PM, CM reported she did not indicate Patient’s progress towards their goals on the recertification POC. 1. Patient #1’s clinical record evidenced a POC for certification period 6/7/2025 – 8/5/2025. The POC failed to identify Patient #1’s progress towards established goals. 2. Patient #6’s clinical record evidenced a POC for certification period 6/18/2025 – 8/17/2025. The POC failed to identify Patient #6’s progress towards established goals. 3. Patient #7’s clinical record evidenced a POC for certification period 5/4/2025 – 7/2/2025. The POC failed to identify Patient #7’s progress towards established goals. During an interview on 7/10/2025 beginning at 10:46 AM, the CM indicated they do not include progress towards goals on the POCs for Patients # 1, 6, and 7. The CM indicated the patients’ progress towards goals would be included on individual SN visit notes.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to coordinate care with assisted living facility (ALF) staff for 1 of 2 records reviewed of a patient with a wound who resided in an ALF (Patient #4). Findings include: 1. Patient #4’s clinical record indicated a SOC date of 2/24/2025 with orders for home health aide visits five days a week. Patient resided at Entity A, an ALF. An HHA visit note dated 5/27/2025 evidenced HHA 3 noted “an open area that was bleeding.” The record failed to evidence Entity A staff were notified of the wound. An HHA visit note dated 5/30/2025 evidenced Patient had an “open area on [his/her] inner thigh.” The record failed to evidence Entity A staff were notified of the wound. An HHA supervisory visit note dated 5/30/25, documented by CM, failed to evidence Entity A staff were notified of the wound. An HHA visit note dated 6/13/2025 evidenced HHA 3 “contacted [the] nurse about [an] open area.” The record failed to evidence Entity A staff were notified of the wound. A recertification comprehensive assessment dated 6/26/2025 evidenced Patient had a Stage 2 pressure ulcer (type of wound caused by prolonged pressure to a bony area, graded by “stages” from 1 to 4 and unstageable) to the left buttock measuring 2 centimeters (cm) in length by 2 cm in width by 0.1 cm in depth (2 cm x 2 cm x 0.1 cm). The record failed to evidence Entity A staff were notified of the wound. A SN visit dated 7/08/2025 by CM evidenced Patient’s wound measured 3.4 cm x 2.0 cm x 0.1 cm, an increase by 1.4 cm in length. The record failed to evidence Entity A staff were notified of the wound. A home visit observation was conducted on 7/09/2025 beginning at 1:04 PM. An approximate dime-sized Stage II pressure ulcer was observed on Patient's left lower buttock/upper thigh. Patient reported they had a foam dressing on the area, but it had fallen off, and the wound was open-to-air. The aide failed to notify Entity A staff of the wound during the visit. During an interview on 7/09/2025 beginning at 1:53 PM, HHA 2 reported Patient had the pressure ulcer wound for approximately three weeks. When asked who was notified of the wound, HHA 2 stated HHA 3 reported the wound to CM. During an interview on 7/09/2025 beginning at 4:15 PM, Person B, an employee of Entity A, reported the facility was not notified of Patient's left buttocks wound by the home health agency. During an interview on 7/10/2025 beginning at 10:09 AM, CM reported she did not inform Entity A staff of Patient’s wound. During a follow-up interview on 7/10/2025 beginning at 4:12 PM, CM reported Entity A was Patient's main caregiver. She stated Patient did not have any other caregivers to perform wound care. During an interview on 7/15/2025 beginning at 12:13 PM, HHA 3 reported she was unsure how long Patient had the left buttocks wound. HHA 3 reported she informed Entity A staff of the wound. The record failed to evidence documentation of the notification. IAC 17-14-1(a)(1)(F)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide a current medication list for 1 of 1 home visits with a patient handbook available (Patient #3). Findings include: A home visit observation occurred on 7/8/2025 beginning at 12:40 PM with Patient #3. During the visit, Patient #3 allowed the surveyor to review the handbook provided by the agency. The handbook failed to evidence a current medication list. During an interview at the home visit, Patient #3 indicated the agency did not provide a medication list to the patient. During an interview on 7/14/2025 beginning at 4:05 PM, the Alternate Administrator indicated patients should have a medication profile in their home. They indicated the agency did not have a medication profile with their current EMR

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide a current POC to the patient for 1 of 1 home visit observation where the patient handbook was available (Patient #3). A home visit observation occurred on 7/8/2025 beginning at 12:40 PM with Patient #3. During the visit, Patient #3 allowed the surveyor to review the handbook provided by the agency. The handbook included two POCs, with certification periods of 2/12/2025 – 4/12/2025 and 4/13/2025 – 6/11/2025. “Pt [patient] Copy” was written in red ink at the top of the POCs. The handbook failed to include the current POC, for certification period 6/12/2025 – 8/10/2025. The review of Patient #3’s clinical record included a POC for certification period 6/12/2025 – 8/10/2025. “Pt Copy” was written in red ink at the top of the POC. During an interview on 7/9/2025 beginning at 3:50 PM, the Alternate Administrator indicated each patient should have a copy of their current POC in their home.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on QAPI document review and interview, governing body document review, and interview, the home health agency failed to conduct QAPI meetings at the pre-determined frequency and analyze quality indicators (see G642) and failed to conduct and document performance improvement projects (see G658). The cumulative effect of these systemic issues evidenced the agency failed to maintain an effective, ongoing, HHA-wide, data-drive QAPI program, which resulted in Servant's Heart Home Health Services being found out of compliance with 42 CFR 484.65 Condition of participation: Quality assessment and performance improvement.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on QAPI document review, governing body document review, and interview, the home health agency failed to conduct QAPI meetings at the pre-determined frequency and failed to evidence analysis of quality indicators, with the potential to affect all patients. Findings include: 1. The agency policy “Performance Improvement” indicated quality indicator data would be “assessed and analyzed to … Identify current level of performance … Identify areas and trends that need to be improved … Identify strategies and action plans to stabilize or improve processes … Evaluate whether outcomes were achieved … Compare results with self and others … standards, and best practices ….” 2. QAPI documentation failed to evidence QAPI meetings were held after 1/03/2023. 3. Governing body meeting minutes dated 10/2023 and 10/2024 indicated QAPI quality indicators, collected over the past year, were reported during the meeting. The meeting minutes failed to evidence analysis of the quality indicators. 4. During an interview on 7/16/2025 beginning at 5:28 PM, Administrator and Alternate Administrator reported QAPI meetings should be held quarterly, however the last documented QAPI meeting was held 1/03/2023. The administrative staff reported yearly quality indicator data was reported to the governing body during an annual meeting. When asked how the indicator data was analyzed, the administrative staff reported the data was “totaled up.” 410 IAC 17-12-2(a)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on QAPI document review, governing body document review, and interview, the home health agency failed to conduct and document performance improvement projects (PIP) as part of its QAPI program, which had the potential to affect all active patients. Findings include: 1. QAPI documentation failed to evidence a PIP had been conducted on or after 1/03/2023. 2. Governing body meeting minutes dated 10/2023 and 10/2024 failed to evidence a PIP had been conducted in 2023 or 2024. 3. During an interview on 7/16/2025 beginning at 5:28 PM, Administrator reported the agency’s current PIPs included conducting chart audits to ensure POCs and supervisory visits are completed timely. Administrator reported the agency did not have documentation of these PIPs.

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 ensure all staff followed infection control policies and best practice for 3 of 4 home visit observations (Patient #1, 2, 4). 5. A home visit observation with Patient #1 occurred on 7/8/2025 beginning at 9:58 AM. The CM placed the nursing bag on a chair, without a barrier. The CM washed their hands and began to set up a work area. During the dressing change for a PICC line (catheter inserted into a large vein for long-term medication administration) the CM completed hand washing and glove change at the beginning and end of the dressing change. During the procedure itself, the CM touched potentially contaminated objects with gloved hands. The CM failed to perform hand hygiene between glove changes. During an interview on 7/10/2025 beginning at 10:46 AM, the CM indicated hand hygiene is required after touching potentially contaminated items. The CM indicated they should have used hand sanitizer between glove changes. They indicated they had a barrier to use when they put the nursing bag down, but they did not use it. 410 IAC 17-12-1(m) Findings include: 1. The undated agency policy “Handwashing/Hand Hygiene” indicated staff should perform hand hygiene through either handwashing or using hand sanitizer “… When there is prolonged or intense contact with the patient (bathing the patient.) … Between tasks on the same patient … Before touching a wound … After removing gloves … After touching objects that are potentially contaminated … After assisting patient to use the bathroom … After contact with non intact skin ….” Staff should wash their hands with soap and water “When hands are visibly dirty or contaminated with proteinaceous material [body fluids] ….” The policy indicated when washing hands with soap and water, staff should apply the soap, “rub hands together vigorously for at least 15 seconds,” then rinse hands with water. 2. Manufacturer’s instructions for Clorox Scentiva disinfecting wipes, obtained from www.clorox.com, indicated after using the wipe, surfaces should be “visibly wet” with the disinfectant for four minutes to ensure disinfection. 3. A home visit observation with Patient #2 occurred on 7/08/2025 beginning at 4:02 PM. During the visit, RN 1 washed her hands on six occasions under running water with no soap visible. During one of the handwashing observations, RN 1 scrubbed her hands for 10 seconds. RN 1 failed to perform hand hygiene in between glove changes on one occasion and failed to perform hand hygiene after removing gloves on one occasion. After obtaining Patient’s vital signs, RN 1 wiped her stethoscope, blood pressure cuff, and thermometer with a Clorox Scentiva disinfectant wipe, then returned the equipment immediately to her nursing bag, failing to allow the disinfectant to dry. During an interview on 7/09/2025 beginning at 3:48 PM, RN 1 reported when washing her hands, she would scrub “mostly outside” of running water for 30 seconds. The nurse stated the dry time for the disinfectant wipes used was 10 seconds. When asked if she would perform hand hygiene in between glove changes, RN 1 stated it depended on what task she was doing prior to changing gloves. The nurse stated she would perform hand hygiene after removing gloves. 4. A home visit observation with Patient #4 occurred on 7/09/2025 beginning at 1:04 PM. During the visit, HHA 2 failed to perform hand hygiene prior to donning gloves on one occasion, failed to perform hand hygiene in between glove changes on one occasion, and performed a five second hand wash on one occasion. While assisting Patient with a shower, HHA 2 cleaned Patient’s Stage 2 pressure ulcer (an open wound caused by prolonged pressure to a bony area) with a dirty washcloth. After cleaning stool off Patient’s buttocks, HHA 2 continued to assist Patient with the shower, including applying a barrier cream to redness on Patient’s groin, failing to change gloves and perform hand hygiene after contact with Patient’s stool. After applying barrier cream to Patient’s Stage 2 pressure ulcer, HHA 2 removed her gloves and applied a foam dressing to the wound without gloves. The aide failed to perform hand hygiene after removing her gloves nor after applying the dressing. The aide failed to wear gloves while changing Patient’s trash. During an interview on 7/09/2025 beginning at 1:53 PM, HHA 2 reported she would perform hand hygiene before donning gloves, after showering Patient, after performing wound care, after applying creams or powders, after cleaning stool off Patient, and after taking Patient’s trash out. HHA 2 stated she would perform hand hygiene in between glove changes if she had time, as Patient was often in a hurry to get dressed. 410 IAC 17-12-1(m)

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the skilled professional failed to conduct and document a complete wound assessment (See G706) and failed to provide services as indicated in the POC (See G710). The cumulative effect of these systemic issues evidenced the agency failed to provide skilled nursing services which adhered to agency policy and best practice, which resulted in the agency being found out of compliance with 42 CFR 484.75 Skilled professional services.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the skilled professional failed to conduct and document a complete wound assessment for 2 of 2 records reviewed of patient with a wound that worsened (Patient #4, 5). Findings include: 1. Patient #5’s clinical record indicated a SOC date of 1/14/2025. A POC for the recertification period of 5/14/2025 – 7/12/2025 included orders for SN visits three times a week “for wound care. SN to assess wounds for infection, healing status and complications.” Patient was noted to have a venous leg ulcer (VLU, type of wound caused by decreased blood flow back to the heart) to the right lower leg which required wound care to be performed daily. Patient resided at Entity H, an assisted living facility (ALF). A recertification comprehensive assessment dated 5/13/2025 indicated Patient’s wound measured 12 centimeters (cm) in length by 21 cm in width by 0.1 cm in depth (12 cm x 21 cm x 0.1 cm) with a “moderate” amount of serous drainage (clear to yellow drainage from a wound). The assessment failed to evidence a further assessment of the wound, including wound bed tissue description, presence or absence of signs and symptoms of infection, etc. SN visit notes dated 5/14/2025, 5/15/2025, 5/20/2025, 5/21/2025, 5/22/2025, 5/27/2025, and 5/29/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurements, presence or absence of signs and symptoms of infection, etc. A wound clinic note from Entity C dated 5/29/2025 evidenced Patient’s wound measured 21 cm x 24.5 cm x 0.1 cm, an increase from the last noted measurement of 9 cm in length and 3.5 cm in width. The wound bed included over 50% of “nonviable slough/fibrin” (dead tissue which can impede wound healing) with serous drainage. SN visit notes dated 6/03/2025, 6/04/2025, and 6/05/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurements, presence or absence of signs and symptoms of infection, etc. A wound clinic note from Entity C dated 6/09/2025 evidenced Patient’s wound measured 21 cm x 26 cm x 0.1 cm, an increase from the last noted measurement of 1.5 cm in width. The wound bed included over 50% of “nonviable slough/fibrin” with serous drainage. SN visit notes dated 6/10/2025 and 6/11/2025 noted Patient had “heavy” drainage but failed to evidence a description of the drainage. The record failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. A SN visit note dated 6/12/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. No SN visits were conducted between 6/13/2025 – 6/16/2025. A SN visit note dated 6/17/2025 indicated Patient had been started on Keflex and Doxycycline, two antibiotics, on 6/13/2025 after developing “an odor and greenish drainage” to their wound. After beginning the antibiotics, Patient developed “small blisters” and redness to the right leg, and the antibiotics were discontinued on 6/14/2025. Two different antibiotics, Zyvox and Rocephin, were started on 6/17/2025. CM noted Patient’s leg “looked better with no blisters.” The record failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, drainage description, presence or absence of signs and symptoms of infection, etc. SN visit notes dated 6/18/2025 and 6/19/2025 failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. CM noted Patient had “heavy” drainage on 6/18/2025 and the wound was “constantly moist” on 6/19/2025. The record failed to evidence a further description of the drainage, such as color, presence or absence of odor, etc. A wound clinic visit note from Entity C evidenced Patient was seen on 6/23/2025. Patient’s wound was noted to have “worsened.” The wound measured 21 cm x 25 cm x 0.1 cm. A SN visit dated 6/24/2025 failed to evidence CM obtained Patient’s vital signs or pain rating. The record failed to evidence an assessment of Patient’s wound, including wound bed tissue description, wound measurement, presence or absence of signs and symptoms of infection, etc. Records from Entity F, an emergency department (ED), evidenced Patient was taken to the ED on 6/24/2025 for “right leg pain with increasing weakness and difficulty getting around” for three days. Patient’s VLU was noted to be “overtly infected.” Patient’s blood pressure on arrival to the ED was 99/53. Patient was admitted to Entity G, an acute care hospital. Records from Entity G evidenced Patient was admitted to the hospital on 6/25/2025 with diagnoses including sepsis (an infection in the bloodstream) and cellulitis (infection of the skin) with wound infection. During the Entrance Conference conducted on 7/07/2025 beginning at 9:43 AM, Alternate Administrator reported wounds should be assessed and measured at least weekly. During an interview on 7/10/2025 beginning at 3:51 PM, CM reported prior to Patient beginning antibiotics, the wound’s drainage increased and turned green. CM stated her assessment of the wound included “mainly the amount of drainage.” She was unable to measure the wounds, and stated this was the responsibility of Entity C. CM reported she did receive visit notes from Entity C, however the record failed to evidence visit notes between 5/05/2025 – 6/23/2025. The nurse described Patient’s wound bed as “white … looks like the … surface of the moon.” When asked if there was any eschar or slough, CM reported there was occasionally dry skin. CM stated on 6/24/2025, prior to Patient being taken to Entity F, Patient’s wound “looked about the same,” and the nurse did not note any changes in Patient. Staff of Entity H reportedly became concerned on Patient’s condition later in the day on 6/24/2025 and took Patient to be evaluated in an ED. During an interview on 7/11/2025 beginning at 3:04 PM, Person I reported Patient was started on antibiotics after Person J reported the wound was “red and soiling.” During an interview on 7/14/2025 beginning at 10:28 AM, Person J reported Patient began having green drainage and an odor to the wound approximately two weeks before Patient was hospitalized. Person J reported they requested Patient be started on antibiotics due to concerns the caregiver had for a possible infection. The caregiver stated on 6/24/2025, Person I reported Patient was “looking really bad,” was confused, incontinent of bowel and bladder (unable to control their stool and urine), and had fallen repeatedly. 2. Patient #4’s clinical record indicated a SOC date of 2/24/2025 with orders for home health aide visits five days a week. Patient resided at Entity A, an ALF. An HHA visit note dated 5/27/2025 evidenced HHA 3 noted “an open area that was bleeding.” The aide documented she notified CM of the wound. An HHA visit note dated 5/30/2025 evidenced Patient had an “open area on [his/her] inner thigh.” Patient reportedly told CM that he/she had the area evaluated by the doctor and the doctor “didn’t see anything.” An HHA supervisory visit note dated 5/30/25, documented by CM, failed to evidence Patient’s wound was assessed during the visit. An HHA visit note dated 6/13/2025 evidenced HHA 3 “contacted [the] nurse about [an] open area.” A recertification comprehensive assessment dated 6/26/2025 evidenced Patient had a Stage 2 pressure ulcer (type of wound caused by prolonged pressure to a bony area, graded by “stages” from 1 to 4 and unstageable) to the left buttock measuring 2 cm x 2 cm x 0.1 cm. This was the first documented nurse assessment of the wound. The record failed to evidence a complete wound assessment was completed, including wound bed tissue, surrounding skin appearance, wound edges, presence or absence of signs and symptoms of infection, etc. A POC for the recertification period of 6/26/2025 – 8/24/2025 included orders for both SN and HHA visits. SN visits were to be done twice a week with interventions to include SN “assessment of the wound for [signs and symptoms] of infection, healing status, wound deterioration and any complications.” The POC was signed by Patient’s ordering provider on 6/30/2025. The record failed to evidence a SN visit was conducted the week of 6/28/2025 – 7/04/2025. A SN visit dated 7/08/2025 by CM evidenced Patient’s wound measured 3.4 cm x 2.0 cm x 0.1 cm, an increase by 1.4 cm in length. This was the first documented wound assessment since the recertification assessment on 6/26/2025. The record failed to evidence a complete wound assessment was completed, including wound bed tissue, surrounding skin appearance, wound edges, presence or absence of signs and symptoms of infection, etc. A home visit observation was conducted on 7/09/2025 beginning at 1:04 PM. An approximate dime-sized Stage II pressure ulcer was observed on Patient's left lower buttock/upper thigh. During an interview on 7/09/2025 beginning at 1:53 PM, HHA 2 reported Patient had the pressure ulcer wound for approximately three weeks. The aide reported Patient's wound did not start "as big" as it currently was and first appeared as "peeled skin." HHA 2 reported HHA 3 had notified CM of the wound. During an interview on 7/10/2025 beginning at 10:09 AM, CM stated she was first notified of the wound on 6/26/25 by HHA 2. CM reported when she assessed the wound, it was "one big area." CM sent an order to Patient's PCP to add SN services, and signed orders were received from the PCP on 6/30/2025. CM reported the agency had to wait for Patient’s insurance to approve the addition of SN services before SN visits could begin. CM reported while waiting for insurance approval, she instructed HHA 2 and HHA 3 to apply barrier cream only to the wound as it was "better than nothing." During a follow-up interview on 7/11/2025 beginning at 10:42 AM, CM reported she was informed on 6/13/25 by HHA 3 of a wound to Patient's left buttock, and stated it was reported as "red ... a little open," but was not a Stage II pressure ulcer. CM reported she advised HHA 3 to "keep an eye" on the area and she did not assess the wound until the recertification visit on 6/26/25. CM reported the wound did get worse. During a follow-up interview on 7/15/2025 beginning at 4:24 PM, CM reported her assessment of Patient’s wound included type of wound, measurement, and the “best treatment for it.” During an interview on 7/15/2025 beginning at 12:13 PM, HHA 3 reported she was unsure how long Patient had the left buttocks wound. The aide reported the wound to CM and the nurse had come to visit Patient shortly afterwards. Patient reportedly “lied” to CM during the visit, saying he/she had seen the doctor and the doctor did not find any wounds. HHA reported after CM left, the aide assisted Patient with a shower, and found the wound was still present. HHA 3 notified CM of the wound again, and CM reportedly stated she would have to come back and assess the wound, and would also work on getting Patient approved for SN services.

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 LPN failed to provide services as indicated in the POC for 1 of 2 records reviewed of a pediatric patient receiving tube feeding (Patient #9). Findings include: 1. Patient #9’s clinical record included a POC for the recertification period of 8/10/2024 – 10/08/2024. Patient was to receive SN visits “up to” 12 hours per day, seven days a week “per availability of staff and parental need.” SN interventions included but were not limited to administering tube feeding every four hours. SN visits documented 8/10/2024 – 9/27/2024 evidenced for 17 of 18 visits, the nurse administered Patient’s tube feeding every two hours. The record failed to evidence the feeding was not administered as ordered in the POC. During an interview on 7/15/2025 beginning at 3:55 PM, Administrator reported she was Patient’s RN case manager. The nurse was unsure of the reason Patient’s tube feeding was not administered as indicated on the POC. 410 IAC 17-14-l (a)(2)(F)

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on observation, personnel file review, and interview, the home health agency failed to ensure all home health aides had successfully completed a competency evaluation prior to furnishing home health services (see G768), the RN failed to create and maintain an aide care plan with detailed instructions to apply non-medicated creams (see G798), and the home health agency failed to ensure HHAs performed tasks only within their scope of practice (see G800). The cumulative effect of these systemic issues evidence the home health agency failed to provide home health aide services according to its policies and best practice, which resulted in Servant's Heart Home Health Services being found out of compliance with 42 CFR 484.80 Condition of Participation: Home health aide services.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on observation, personnel file review, and interview, the home health agency failed to ensure all home health aides had successfully completed a competency evaluation prior to furnishing home health services for 1 of 2 HHAs observed performing care during a home visit (HHA 1). Findings include: 1. A home visit observation with Patient #3 was conducted on 7/08/2025 beginning at 12:40 PM. During the visit, HHA 1 was observed performing HHA tasks. 2. HHA 1’s personnel file evidenced a hire date of 6/20/2025. The aide completed a competency evaluation with Administrator on 6/26/2025. The competency evaluation form failed to evidence HHA 1 was evaluated through observation with a patient or pseudo-patient for the following skills: a. Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; b. Bed bath c. Sponge and tub bath d. Hair shampooing in sink and tub e. Nail care f. Safe transfer techniques g. Normal range of motion (ROM) 3. During an interview on 7/16/2025 beginning at 12:33 PM, HHA 1 reported she was evaluated for skills through the following methods: a. For communication skills, she was given a written case scenario. b. For bed bath, sponge bath, and tub bath, she was advised “step-by-step” how to perform the tasks by Administrator and HHA 4. c. For hair shampoo, she performed the task during a bed bath. d. For normal ROM, Administrator reviewed the different types of ROM and HHA 1 performed the tasks on Administrator. 4. During an interview on 7/16/2025 beginning at 3:40 PM, Administrator reported HHA 1 was evaluated for skills through the following methods: a. For communication skills, HHA 1 was given a written case scenario. b. For bed bath, sponge bath, and tub bath, HHA 1 performed the skills on a non-computer-based mannequin. c. For hair shampoo, HHA performed the skills on a non-computer-based mannequin. d. For nail care, Administrator reported she advised HHA 1 not to trim nails. The aide was not observed performing nail care. e. For normal ROM, HHA 1 performed the skills on a non-computer-based mannequin. 410 IAC 17-14-1(l)(1)(A)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the RN failed to create and maintain an aide care plan with detailed instructions to apply non-medicated creams for 2 of 2 records reviewed of a patient receiving HHA services who required the aide to apply a non-medicated cream (Patient #4, 11). Findings include: 1. Patient #4’s clinical record indicated Patient was to receive home health aide visits five days a week. A home visit observation with Patient #4 was conducted on 7/09/2025 beginning at 1:04 PM. Patient was noted to have redness to bilateral (both sides) of the anterior (front) groin and pelvic area. HHA 2 applied Desitin (a barrier cream) to the area. During an interview on 7/09/2025 beginning at 1:53 PM, HHA 2 reported Patient had intermittent redness to his/her groin and the aide applied Desitin to the area at the previous direction of CM. During an interview on 7/10/2025 beginning at 10:09 AM, CM reported she had advised the home health aides to apply Nystatin (an antifungal medication) to Patient’s groin when red. She was unsure if this was indicated on the aide care plan. Patient’s aide care plan failed to evidence directions for the aides to apply a barrier cream to the groin redness. 2. Patient #11’s clinical record indicated Patient was to receive HHA visits five hours per visit, three days per week. The POC for the recertification period of 6/21/2025 – 8/19/2025 indicated Patient’s DME and supplies included “wound care” which consisted of applying barrier cream as needed. An HHA care plan failed to evidence directions for the aide to apply barrier cream. During an interview on 7/16/2025 beginning at 3:22 PM, Administrator reported Patient’s HHAs applied barrier cream as needed. Administrator reported this task was not indicated on the aide care plan.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure HHAs performed tasks only within their scope of practice for 1 of 2 home visit observations of an HHA visit (Patient #4). Findings include: 1. Patient #4’s clinical record indicated a SOC date of 2/24/2025 with orders for home health aide visits five days a week. An HHA care plan included tasks to “check Pressure areas for skin break downs.” An HHA visit note dated 5/27/2025 indicated HHA 3 noted an “open area that was bleeding” and Patient’s groin area was “very red and sore.” An HHA visit note dated 5/30/2025 indicated HHA 3 noted an “open area” on Patient’s inner thigh and Patient’s groin area was red. An HHA supervisory visit dated 5/30/2025, documented by CM, indicated Patient had a “yeasty rash” to [his/her] groin area.” The nurse noted the HHAs were applying Nystatin (an antifungal medication) powder and cream to the rash. A recertification comprehensive assessment dated 6/26/2025 evidenced Patient had a Stage 2 pressure ulcer (type of wound caused by prolonged pressure to a bony area, graded by “stages” from 1 to 4 and unstageable) to the left buttock measuring 2 centimeters (cm) in length by 2 cm in width by 0.1 cm in depth (2 cm x 2 cm x 0.1 cm). A POC for the recertification period of 6/26/2025 – 8/24/2025 included orders for both SN and HHA visits. SN visits were to be done twice a week with interventions to include applying Calmoseptine (a barrier cream) and a foam dressing to Patient’s wound. A home visit observation was conducted on 7/09/2025 beginning at 1:04 PM. An approximate dime-sized Stage 2 pressure ulcer was observed on Patient's left lower buttock/upper thigh. Patient reported they had a foam dressing on the area, but it had fallen off, and the wound was open-to-air. HHA 2 performed wound care by applying Desitin (a barrier cream) to the wound and covering it with a foam dressing. During an interview on 7/09/2025 beginning at 1:53 PM, HHA 2 reported Patient had the pressure ulcer wound for approximately three weeks. The aide reported during previous visits, she had been applying Desitin to the wound and leaving it open-to-air. During her visit on 7/08/2025, HHA 2 reported she was directed by CM to apply Desitin and cover the wound with a foam dressing. HHA 2 reported Patient had intermittent redness to his/her groin and the aide had previously applied Nystatin powder and Solosite wound gel (a medicated wound treatment) to the area at the direction of CM. During an interview on 7/09/2025 beginning at 2:12 PM, Patient reported the home health aides had been applying Nystatin powder to the rash in his/her groin. During an interview on 7/10/2025 beginning at 10:09 AM, CM reported she had instructed HHA 2 and HHA 3 to apply barrier cream to the wound while the agency waited for insurance to approve the addition of SN services as it was "better than nothing." CM reported she did not inform HHA 3 to apply a foam dressing to the wound. CM also reported she had instructed Patient’s aides to apply Nystatin powder to the yeasty rash in Patient’s groin after showering Patient. During a follow-up interview on 7/11/2025 beginning at 10:42 AM, CM reported she was informed on 6/13/25 by HHA 3 of a wound to Patient's left buttock, and stated it was reported as "red ... a little open," but was not a Stage II pressure ulcer. CM reported she advised HHA 3 to "keep an eye" on the area and she did not assess the wound until the recertification visit on 6/26/2025. CM reported the wound did get worse. During an interview on 7/15/2025 beginning at 12:13 PM, HHA 3 reported she was unsure how long Patient had the left buttocks wound. HHA 3 reported she did not perform any treatment to the wound, as she could not find anything that was “appropriate.” HHA 3 also reported she had previously applied Nystatin powder to a rash in Patient’s groin at the direction of CM.

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 observation, record review, and interview, the agency failed to keep clinical records secured when not in use for 2 of 2 locations with paper clinical records and failed to protect patient information while in patients’ homes for 2 of 4 home visit observations (Patients #1 ,2). Findings include: 4. During an observation at the agency parent office on 7/08/2025 beginning at 9:12 AM, the agency was observed sharing office space with Entity Q, a physician office. Entity Q staff and patients were observed within the agency’s office space. In Administrator’s office, paper clinical records were observed unsecured in an unlocked filing cabinet and sitting next to Administrator’s desk. Administrator was not working in the office that day. During an interview on 7/08/2025 beginning at 9:17 AM, Alternate Administrator reported paper clinical records were secured by locking the entryway door to the agency, however Entity Q staff and patients were allowed entryway behind the locked door. The agency did not keep Administrator’s office nor the filing cabinet locked. 5. During a home visit observation with Patient #2, conducted on 7/08/2025 beginning at 4:02 PM, RN 1 was observed documenting Patient’s vital signs and assessment in a notebook. The notebook was left unattended on Patient’s dresser during the visit. RN 1 reported she documented assessment findings for two patients within the notebook. During an interview on 7/09/2025 beginning at 3:48 PM, RN 1 reported she ensured protection of Patient’s records by keeping her notebook in her nursing bag during the visit. 1. An undated agency policy, “Clinical Records/ Medical Record Retention” indicated clinical records would be stored in a locked cabinet when not in use. 2. During a home visit observation on 7/8/2025 with Patient #1 and the CM. Observed a small notebook in which the CM wrote notes about the visit. During an interview on 7/8/2025 beginning at 11:20 AM, the CM indicated the book was to put visit notes until they could document in the EMR. The notebook contained information for multiple patients. The CM did not realize there was a confidentiality issue with this practice. 3. During an observation visit at the agency branch office on 7/8/2025, the surveyor noted a large stack of papers on the CM’s desk. The office had an entry door from the outside and a Dutch door (the top half of the door opens while the bottom half of the door remains closed) leading to the building corridor. During an interview on 7/8/2025 beginning at 11:20 AM, the CM indicated the papers were patient records. The CM said they preferred to keep hard copies rather than rely on the EMR. The CM indicated they faxed the records to the parent office and kept hard copies of key documents (assessments, POCs). When asked, the CM looked around the office and said the records could go into a metal filing cabinet, but the cabinet didn’t lock. When asked, the CM indicated the Dutch door was open to improve airflow. The CM indicated they were not aware if the bottom half of the door could be opened from the hallway by reaching in and opening the bottom half of the door.