Every finding on record at St Elizabeth Home Care Services, LLC

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102, for a home health agency. Survey dates: 2-10, 2-11, & 2-12-21 Facility: IN005272

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] 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 (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it had solicited volunteers for service during a disaster or emergency, to include their roles for integration with health care professionals during the disaster/emergency for 1 of 1 home health agency disaster preparedness plan. Findings included: Review of Agency's Emergency Preparedness plan, last reviewed on 12-30-2020, failed to evidence the use of volunteers in their emergency preparedness plan. On 2-12-21 at 2:00 p.m., Alternate Administrator, Employee B confirmed the lack of use of volunteers in their Emergency Preparedness program. At the time of survey exit on 2-12-21 at 2:51 p.m., when queried as to the lack of use of volunteers, the Administrator provided nothing further.

This visit was for a Federal Recertification and a State Licensure survey of a home health agency. One (1) complaint was investigated in conjunction with the recertification survey. This survey was announced as fully extended on 2-10-21 at 4:25 p.m. Complaint #: IN00347254-Substantiated with findings Survey dates: 2-10, 2-11, & 2-12-21 Facility: IN005272 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Dearborn County Hospital Home Health is precluded from conducting a home health aide training or competency evaluation program for a period of two years beginning February 12, 2021 through February 11, 2023 for being out of compliance with §484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients and §484.105 Condition of participation: Organization and administration of services. Quality Review completed on 3/5/2021 A4

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to disclose a change in Agency ownership and management (see G0850), failed to provide the names and addresses of the managing employees of the new owning entity (see G0856), failed to provide the names and business addresses of the new owning corporation including the chief executive officer and Governing Board Chairperson (see G0858), and failed to obtain an Indiana license for the new owning entity (see G0860). The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 42 CFR 484.100 Compliance with Federal, State, and local laws and regulations related to the health and safety of patients.

Disclosure of ownership and management info. CFR(s): 484.100(a) Standard: Disclosure of ownership and management information. The HHA must comply with the requirements of part 420 subpart C, of this chapter. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to disclose the change in ownership for 1 of 1 agency. Findings included: 1. Review of the ASPEN database indicated the Indiana Department of Health (IDOH) had previously been informed Employee H was the administrator/alternate clinical supervisor and Employee C was the alternate administrator/clinical supervisor. The database further indicated Employee H as a member/officer on the Governing Body along with eight (8) other members with the owner as Dearborn Home Health. 2. On 11-02-2020, the IDOH received an incomplete change in ownership (CHOW) notification from Other Entity A, effective 11-01-2020. Return communication was sent to Other Entity A, dated 11-9-2020, referring them to the home health agency website and specifically instructing them to follow the instructions provided to complete the CHOW. 3. On 1-4-21, IDOH had not received the Agency's license renewal application which expired on 12-31-2020. 4. On 1-29-21, IDOH attempted to contact licensed entity via the listed number in Aspen Central Office (ACO) and reached a switchboard in Kentucky identifying self as Other Entity A, that was unfamiliar with the number IDOH had listed. A second attempt was made to contact the Administrator listed in ACO with the phone being answered as Other Entity A (not reported to IDOH) with the specific request to speak with the Administrator listed in ACO, Employee H. Employee H answered the call and stated he was no longer associated with the home health agency and that he was aware the agency was actively seeing patients with a current patient census. Employee H further stated he was unaware IDOH was still awaiting appropriate paperwork for the supposed CHOW and expired license as of 12-31-2020 requesting an email with this information so that he may forward to the new owners. IDOH notified CMS. 5. On 2-9-21, the ACO listed Administrator returned a call to the IDOH and responded the owners of Dearborn Home Health were all dissolved as Other Entity A purchased the hospital and Other Entity A and another entity joined to purchase the HHA (home health agency). The listed Administrator confirmed awareness of the Agency still operating in Indiana. 6. On entrance to Agency on 2-10-21 at 1:00 p.m., Agency's Indiana license to operate a Home Health Agency was not visible. When queried as to availability or location, the Alternate Administrator, Employee B, of the new Entity (Other Entity A) stated: "Will look (as to location)". On 2-10-21 at 1:17 p.m., when queried as to the location of Agency's license to operate in the state of Indiana, the Administrator, Employee A of the new Entity (Other Entity A) reported it was with the attorney's as a change in ownership was being processed effective 11-1-20 for said Agency. On 2-10-21 at 3:18 p.m., the Administrator, Employee A of the new Entity (Other Entity A) stated the license application was submitted with the following copies provided: a) Other Entity A check request dated 2-10-21 for $250.00 to the IDOH; b) State form 48851, Renewal Application for license to operate a Home Health Agency identifying the date of license expiration of 12-31-2020 with the agency name listed with IDOH as the operating agency in section I and name of the new agency, Other Entity A in section II, signed by the Administrator, Employee A of Other Entity and dated 2-10-21; c) Two, one-page documents from the Ohio Bureau of Criminal Investigation to Other Entity B, with both for Employee B of Other Entity A, titled "Criminal History Record Check"; a one-page document for Entity A listing four (4) owners, Other Entity's C, D, E & F; a one-page document for Entity A, listing seven (7) board members, Other Entity's G, H, I, J, K, L, & M; a two-page resume for the Administrator, Employee A of Other Entity A; a two-page resume for the Alternate Administrator, Employee B of Other Entity A; a one-page organizational chart, last revised 2-10-21, titled Other Entity A/Lawrenceburg, IN/ Home Care with position titles and without individual names. On 2-11-21 at 11:15 a.m., the Alternate Administrator of Other Entity A, presented twenty (20) page document and stated: "(Called by name) Administrator of Other Entity A said the CMS agreement is in here (agreement with CMS to provide services)." This twenty-page packet of information contained the following: a) a five (5) page "Bill of Sale" between IDOH listed agency as the seller and Other Entity A as the buyer that included signatures with effective date of 11-01-2020; a seven (7) page "Membership Transaction Agreement" with effective date of 11-01-2020, listing acquisition of assets between the IDOH listed agency and Other Entity A that included signatures; and an eight (8) page document titled "Interim Billing Agreement" between IDOH listed agency and Other Entity A with an effective date of 11-01-2020 outlining billing of services and receipt of payment for said services that included signatures for both companies. The Indiana Department of Health had not been appropriately notified of these changes in administration/management or of a Change of Ownership (CHOW) in advance of the license renewal application. At the time of survey exit on 2-12-21 at 2:51 p.m., when queried as to the above findings and the lack of a current and active license to operate a home health agency in Indiana, no further information was provided. 17-10-1(d)

Officer, a director, agent, managing employee CFR(s): 484.100(a)(2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. This ELEMENT is not met as evidenced by: Based on document review and interview, the Agency failed to provide the names and addresses of each individual serving as a managing employee and/or officer prior to Agency license expiration and at the time of a change in ownership (CHOW) for 1 of 1 agency. Findings included: 1. Review of the ASPEN database indicated the Indiana Department of Health (IDOH) had previously been informed Employee H was the administrator/alternate clinical supervisor and Employee C was the alternate administrator/clinical supervisor. The database further indicated Employee H as a member/officer on the Governing Body along with eight (8) other members with the owner as Dearborn Home Health. 2. On 1-29-21, IDOH attempted to contact licensed entity via the listed number in Aspen Central Office (ACO) and reached a switchboard in Kentucky identifying self as Other Entity A, that was unfamiliar with the number IDOH had listed. A second attempt was made to contact the Administrator listed in ACO with the phone being answered as Other Entity A (not reported to IDOH) with the specific request to speak with the Administrator listed in ACO, Employee H. Employee H answered the call and stated he was no longer associated with the home health agency. 3. On 2-9-21, the ACO listed Administrator returned a call to the IDOH and responded the owners of Dearborn Home Health were all dissolved as Other Entity A purchased the hospital and Other Entity A and another entity joined to purchase the HHA. The listed Administrator confirmed awareness of the Agency still operating in Indiana. 4. During entrance conference on 2/10/21 at 1:17 p.m., the Administrator, Employee A, indicated via phone she was indeed the current administrator, Employee B was the current Alternate Administrator and Clinical Supervisor, and Employee C was the current Alternate Clinical Supervisor. 5. The agency failed to notify IDOH with changes of the names and addresses of each individual serving as managing employees. 17-10-1(d)(2)

Responsible for the management of the HHA CFR(s): 484.100(a)(3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This ELEMENT is not met as evidenced by: Based on document review and interview, the Agency failed to provide company management information that included the names and addresses of the chief executive officer, chairperson of the board of directors, and overall managers for 1 of 1 agency. Findings included: 1. Review of the ASPEN database indicated the Indiana Department of Health (IDOH) had previously been informed Employee H was the administrator/alternate clinical supervisor and Employee C was the alternate administrator/clinical supervisor. The database further indicated Employee H as a member/officer on the Governing Body along with eight (8) other members with the owner as Dearborn Home Health. 2. On 11-02-2020, the IDOH received an incomplete change in ownership (CHOW) notification from Other Entity A, effective 11-01-2020. Return communication was sent to Other Entity A on 11-9-2020, referring them to the home health agency website and specifically instructing them to follow the instructions provided to complete the CHOW. 3. On 1-4-21, IDOH had not received the Agency's license renewal application which expired on 12-31-2020. 4. On 1-29-21, IDOH attempted to contact licensed entity via the listed number in Aspen Central Office (ACO) and reached a switchboard in Kentucky identifying self as Other Entity A, that was unfamiliar with the number IDOH had listed. A second attempt was made to contact the Administrator listed in ACO with the phone being answered as Other Entity A (not reported to IDOH) with the specific request to speak with the Administrator listed in ACO, Employee H. Employee H answered the call and stated he was no longer associated with the home health agency and that he was aware the agency was actively seeing patients with a current patient census. Employee H further stated he was unaware IDOH was still awaiting appropriate paperwork for the supposed CHOW and expired license as of 12-31-2020 requesting an email with this information so that he may forward to the new owners. IDOH notified CMS. 5. On 2-9-21, the ACO listed Administrator returned a call to the IDOH and responded the owners of Dearborn Home Health were all dissolved as Other Entity A purchased the hospital and Other Entity A and another entity joined to purchase the HHA. The listed Administrator confirmed awareness of the Agency still operating in Indiana. 6. On entrance to Agency on 2-10-21 at 1:00 p.m., Agency's Indiana license to operate a Home Health Agency was not visible. When queried as to availability or location, the Alternate Administrator, Employee B, of the new Entity (Other Entity A) stated: "Will look (as to location)". On 2-10-21 at 1:17 p.m., when queried as to the location of Agency's license to operate in the state of Indiana, the Administrator, Employee A of the new Entity (Other Entity A) reported it was with the attorney's as a change in ownership was being processed effective 11-1-20 for said Agency. On 2-10-21 at 3:18 p.m., the Administrator, Employee A of the new Entity (Other Entity A) stated the license application was submitted with the following copies provided: a) Other Entity A check request dated 2-10-21 for $250.00 to the IDOH; b) State form 48851, Renewal Application for license to operate a Home Health Agency identifying the date of license expiration of 12-31-2020 with the agency name listed with IDOH as the operating agency in section I and name of the new agency, Other Entity A in section II, signed by the Administrator, Employee A of Other Entity and dated 2-10-21; c) Two, one-page documents from the Ohio Bureau of Criminal Investigation to Other Entity B, with both for Employee B of Other Entity A, titled "Criminal History Record Check"; a one-page document for Entity A listing four (4) owners, Other Entity's C, D, E & F; a one-page document for Entity A, listing seven (7) board members, Other Entity's G, H, I, J, K, L, & M; a two-page resume for the Administrator, Employee A of Other Entity A; a two-page resume for the Alternate Administrator, Employee B of Other Entity A; a one-page organizational chart, last revised 2-10-21, titled Other Entity A/Lawrenceburg, IN/ Home Care with position titles and without individual names. On 2-11-21 at 11:15 a.m., the Alternate Administrator of Other Entity A, presented twenty (20) page document and stated: "(Called by name) Administrator of Other Entity A said the CMS agreement is in here (agreement with CMS to provide services)." This twenty-page packet of information contained the following: a) a five (5) page "Bill of Sale" between IDOH listed agency as the seller and Other Entity A as the buyer that included signatures with effective date of 11-01-2020; a seven (7) page "Membership Transaction Agreement" with effective date of 11-01-2020, listing acquisition of assets between the IDOH listed agency and Other Entity A that included signatures; and an eight (8) page document titled "Interim Billing Agreement" between IDOH listed agency and Other Entity A with an effective date of 11-01-2020 outlining billing of services and receipt of payment for said services that included signatures for both companies. The Indiana Department of Health had not been appropriately notified of these changes in administration/management or of a Change of Ownership (CHOW) in advance of the license renewal application. At the time of survey exit on 2-12-21 at 2:51 p.m., when queried as to the above findings, the lack of a current and active license to operate a home health agency in Indiana, and the status of the CHOW, no further information was provided. 17-10-1(d)(4)

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the Agency failed to produce a current, active license to operate a home health agency in the state of Indiana for 1 of 1 agency. Findings included: On entrance to Agency on 2-10-21 at 1:00 p.m., Agency's Indiana license to operate a Home Health Agency was not visible. When queried as to availability or location of the license, the Alternate Administrator, Employee B, of the new Entity (Other Entity A) stated: "Will look (as to location)". On 2-10-21 at 1:17 p.m., when queried as to the location of Agency's license to operate in the state of Indiana, the Administrator, Employee A of the new Entity (Other Entity A) reported it was with the attorney's as a change in ownership was being processed effective 11-1-20 for said Agency. On 2-10-21 at 3:18 p.m., the Administrator, Employee A of the new Entity (Other Entity A) stated the license application was submitted with the following copies provided: a) Other Entity A check request dated 2-10-21 for $250.00 to the IDOH; b) State form 48851, Renewal Application for license to operate a Home Health Agency identifying the date of license expiration of 12-31-2020 with the agency name listed with IDOH as the operating agency in section I and name of the new agency, Other Entity A in section II, signed by the Administrator, Employee A of Other Entity and dated 2-10-21; c) Two, one-page documents from the Ohio Bureau of Criminal Investigation to Other Entity B, with both for Employee B of Other Entity A, titled "Criminal History Record Check"; a one-page document for Entity A listing four (4) owners, Other Entity's C, D, E & F; a one-page document for Entity A, listing seven (7) board members, Other Entity's G, H, I, J, K, L, & M; a two-page resume for the Administrator, Employee A of Other Entity A; a two-page resume for the Alternate Administrator, Employee B of Other Entity A; a one-page organizational chart, last revised 2-10-21, titled Other Entity A/Lawrenceburg, IN/ Home Care with position titles and without individual names. At the time of survey exit on 2-12-21 at 2:51 p.m., the Administrator failed to produce a current and active home health agency license and when queried as to the lack of a current and active license to operate a home health agency in Indiana, no further information was provided. 17-10-1(a)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the governing body failed to report changes in management and ownership; failed to ensure the agency did not operate without an active license, failed to appoint a qualified administrator, adopt written bylaws, and oversee the management, quality assurance and performance improvement (QAPI) and fiscal affairs of the Agency (See G0942), and failed to ensure the Governing Board approved the appointment of an Agency Administrator (See G0946). The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 484.105 Organization and administration of services.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to report changes in management and ownership; failed to ensure the agency did not operate without an active license, failed to appoint a qualified administrator, adopt written bylaws, and oversee the management, quality assurance and performance improvement (QAPI) and fiscal affairs of the Agency for 1 of 1 Agency. Findings included: 1. Regarding Change of Management & Ownership Review of the ASPEN database indicated the Indiana Department of Health (IDOH) had previously been informed Employee H was the Administrator/Alternate Nursing Supervisor and Employee C as the Alternate Administrator/Nursing Supervisor with Other Entity's, N, O, P, Q, R, S, T, U, V and Employee H listed as the Governing Board members. On 11-02-2020, the IDOH received an incomplete change in ownership (CHOW) notification from Other Entity A, effective 11-01-2020. Return communication was sent to Other Entity A referring them to the home health agency website and specifically instructing them to follow the instructions provided to complete the CHOW. On 1-4-21, IDOH had not received the Agency's license renewal application which expired on 12-31-2020 and had not received a completed CHOW application. On 1-29-21, IDOH attempted to contact licensed entity via the listed number in Aspen Central Office (ACO) and reached a switchboard in Kentucky identifying self as Other Entity A, that was unfamiliar with the number IDOH had listed. A second attempt was made to contact the Administrator listed in ACO with the phone being answered as Other Entity A (not reported to IDOH) with the specific request to speak with the Administrator listed in ACO, Employee H. Employee H answered the call and stated he was no longer associated with the home health agency and that he was aware the agency was actively seeing patients with a current patient census. Employee H further stated he was unaware IDOH was still awaiting appropriate paperwork for the supposed CHOW and expired license as of 12-31-2020 requesting an email with this information so that he may forward to the new owners. IDOH notified CMS. On 2-9-21, the ACO listed Administrator returned a call to the IDOH and responded the owners of Dearborn Home Health were all dissolved as Other Entity A purchased the hospital and Other Entity A and another entity joined to purchase the HHA. The listed Administrator confirmed awareness of the Agency still operating in Indiana. On entrance to Agency on 2-10-21 at 1:00 p.m., Agency's Indiana license to operate a Home Health Agency was not visible. When queried as to availability or location, the Alternate Administrator, Employee B, of the new Entity (Other Entity A) stated: "Will look (as to location)". On 2-10-21 at 3:18 p.m., the Administrator, Employee A of the new Entity (Other Entity A) stated the license application was submitted with the following copies provided: a) Other Entity A check request dated 2-10-21 for $250.00 to the IDOH; b) State form 48851, Renewal Application for license to operate a Home Health Agency identifying the date of license expiration of 12-31-2020 with the agency name listed with IDOH as the operating agency in section I and name of the new agency, Other Entity A in section II, signed by the Administrator, Employee A of Other Entity and dated 2-10-21; c) Two, one-page documents from the Ohio Bureau of Criminal Investigation to Other Entity B, with both for Employee B of Other Entity A, titled "Criminal History Record Check"; a one-page document for Entity A listing four (4) owners, Other Entity's C, D, E & F; a one-page document for Entity A, listing seven (7) board members, Other Entity's G, H, I, J, K, L, & M; a two-page resume for the Administrator, Employee A of Other Entity A; a two-page resume for the Alternate Administrator, Employee B of Other Entity A; a one-page organizational chart, last revised 2-10-21, titled Other Entity A/Lawrenceburg, IN/ Home Care with position titles and without individual names. On 2-11-21 at 11:15 a.m., the Alternate Administrator of Other Entity A, presented twenty (20) page document and stated: "(Called by name) Administrator of Other Entity A said the CMS agreement is in here (agreement with CMS to provide services)." This twenty-page packet of information contained the following: a) a five (5) page "Bill of Sale" between IDOH listed agency as the seller and Other Entity A as the buyer that included signatures with effective date of 11-01-2020; a seven (7) page "Membership Transaction Agreement" with effective date of 11-01-2020, listing acquisition of assets between IDOH listed agency and Other Entity A that included signatures; and an eight (8) page document titled "Interim Billing Agreement" between IDOH listed agency and Other Entity A with an effective date of 11-01-2020 outlining billing of services and receipt of payment for said services that included signatures for both companies. The Indiana Department of Health had not been appropriately notified of these changes in administration/management/operation of or of a Change of Ownership (CHOW) in advance of the license renewal application. 2. Regarding Timeliness of License Renewal and Operating Without an Active License On 1-4-21, IDOH had not received the Agency's license renewal application which expired on 12-31-2020 and had not received a completed CHOW application. Refer to the documented evidence listed in #1. 3. Regarding the appointment of a qualified Administrator, adoption of written bylaws, overseeing the management and fiscal affairs of the Agency. On 2-10-21 at 1:17 p.m., copies of the Agency's organizational chart, bylaws and governing board minutes were requested from the Agency Administrator, Employee A (Other Entity A). On 2-10-21 at 4:28 p.m., the Alternate Administrator, Employee B (Other Entity A) presented a policy from Other Entity F, titled "Bylaws", last revised 4-28-15 and a policy from Other Entity E, titled "Administrative Control", last revised 11-5-20. Request was made a second time for a copy of the Agency's actual bylaws and governing board minutes from Employee B (Other Entity A). On 2-11-21 at 11:15 p.m., the Alternate Administrator, Employee B (Other Entity A) presented a 3-page document stating "(Called by name-Administrator [Other Entity A]) says this is all she can give out, will this work?" which contained a list of Other Entity A's Board of Directors and the most current Board meeting date of 9-15-2020, the location of WebEx meeting and attendees and failed to evidence the content or meeting minutes. A request for minutes of the Agency Governing Board was made a third time. On 2-12-21 at 10:25 a.m., the Alternate Administrator, Employee B (Other Entity A) presented a two-page document with a handwritten note stating: "Board meeting minutes. 1st board meeting for Dearborn is March (2021)". The minutes were dated 9-15-2020 and failed to evidence any mention of this agency, purchase of this agency, license application, adoption of agency bylaws, QAPI, budget approval and/or approval of the administrator/alternate administrator for this Agency. On 2-12-21 at 10:25 a.m., the Alternate Administrator, Employee B (Other Entity A) presented an eleven (11) page document as the Agency's bylaws titled "Code of Regulations of Other Entity F known as "the Corporation", which contained eleven Articles for the corporation. At the time of survey exit on 2-12-21 at 2:51 p.m., when queried as to the above findings and the lack of a current and active license to operate a home health agency in Indiana, the oversight of management and fiscal affairs of the agency, QAPI and appointment of the Administrator/Management, no further information was provided. 17-12-1(b)

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Governing Board approved the appointment of an Agency Administrator for 1 of 1 Agency. Findings included: Review of the ASPEN database indicated the Indiana Department of Health (IDOH) had previously been informed Employee H was the Administrator/Alternate Nursing Supervisor and Employee C as the Alternate Administrator/Nursing Supervisor with Other Entity's, N, O, P, Q, R, S, T, U, V and Employee H listed as the Governing Board members. Upon entrance to the Agency on 2-10-21 at 1:00 p.m., Agency name now Other Entity A and with new ownership, management and leadership as reported by Other Entity's Alternate Administrator, Employee B. On 2-11-21 at 11:15 p.m., the Alternate Administrator, Employee B (Other Entity A) presented a 3-page document stating "(Called by name-Administrator [Other Entity A]) says this is all she can give out, will this work?" which contained a list of Other Entity A's Board of Directors and the most current Board meeting date of 9-15-2020, the location of WebEx meeting and attendees and failed to evidence the content or meeting minutes. On 2-12-21 at 10:25 a.m., the Alternate Administrator, Employee B (Other Entity A) presented a two-page document with a handwritten note stating: "Board meeting minutes. 1st board meeting for Dearborn is March (2021)". The minutes were dated 9-15-2020 and failed to evidence any mention of this agency, purchase of this agency, license application, adoption of agency bylaws, QAPI, budget approval and/or approval of the administrator/alternate administrator for this Agency. At the time of survey exit on 2-12-21 at 2:51 p.m., when queried as to the above findings and the lack of the Governing Board approval of an Administrator/Alternate Administrator, no further information was provided. 17-12-1(b)(1)