Every finding on record at Staffed for Perfection Healthcare Staffing

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 494.62 Survey Dates: 02/02/2026 to 02/06/2026 Facility ID: 018943 12-month unduplicated skilled admissions: 40 At this Emergency Preparedness Survey, Staffed For Perfection Home Health was found to be out of compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 494.62.

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 and interview, the agency failed to maintain compliance with the condition of Emergency Preparedness at 42 CFR 494.62. The requirement was not met as evidenced by: the agency failed to complete a community based hazard risk assessment (E0006); the agency failed to include a process for cooperation and collaboration with local, state, and federal emergency preparedness officials to maintain an integrated response during a disaster or emergency situation (E0009); the agency failed to implement policies and procedures based on the emergency preparedness plan (E00013); the agency failed to include a communication plan of how the agency would inform state and local emergency preparedness officials of a patient required evacuation (E0019); the agency failed to include a procedure to follow up with on duty staff and patients and inform the state and local officials of any on duty staff or patients they were unable to contact (E0021); the agency’s emergency plan failed to include a system to preserve medical documentation (E0023); the agency failed to have a communication plan related to the use of volunteers during an emergency (E0024); the agency failed to have a communication plan that included primary and alternate means of communications (E0032); the agency failed to have a communication plan that included a method for sharing medical information with emergency officials (E0033); the agency failed to develop an emergency preparedness training and testing program based on the emergency preparedness plan (E0036); and the agency failed to evidence that exercises were conducted to test the emergency plan (E0038). Findings include: An undated policy, titled “Emergency Preparedness and Response,” indicated the agency would conduct a risk assessment to identify potential emergencies that could affect operations, and would establish a communication plan to ensure effective communication with employees, patients and local emergency management agencies during an emergency. The policy indicated the agency would conduct drills periodically to test the effectiveness of the emergency preparedness plan. The policy indicated the agency would outline specific procedures for safe evacuation of patients and staff. The policy indicated the agency would coordinate planning efforts with local health departments and emergency management agencies. The policy indicated the agency would use an emergency reserve roster for staffing. During an interview on 02/05/2026, beginning at 2:00 PM, the Administrator indicated the agency’s emergency preparedness policies and procedures have not been implemented. The Administrator indicated a hazard risk assessment had not been completed, the agency had not conducted emergency table top or community wide exercises with the staff, did not have a policy if a patient required evacuation, the agency did not have an emergency staffing plan, and the agency had not coordinated with the local emergency preparedness officials. The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment and resulted in the agency being found out of compliance with condition 42 CfC 494.62 Emergency Preparedness.

This visit was for an Initial Medicaid Certification and State licensure survey of a Home Health Provider. Survey Dates: 02/02/2026 to 02/06/2026 Facility ID: 028943 Unduplicated 12 month skilled admissions: 40 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. During this initial certification and state licensing survey, Staffed For Perfection Home Health was found to be out of compliance with Condition of Participation 42 CFR 484.80 Home Health Aide Services, 494.110 Quality Assessment and Performance Improvement, and 42 CFR 494.62 Emergency Preparedness. Abbreviations used in this survey include RN for Registered Nurse, HHA for Home Health Aide, LPN for Licensed Practical Nurse, POC for Plan of Care, and SOC for Start of Care.

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 agency failed to ensure an RN performed an initial assessment within 48 hours of a referral in 1 of 1 active clinical records reviewed with a diagnosis of guillain-barre syndrome (condition that causes weakness and paralysis) (Patient #4). Findings include: An undated policy, titled, "Comprehensive Assessment at Start of Care [SOC]," indicated an initial assessment visit would occur within 48 hours of the patients' referral to home care. A referral from a skilled nursing facility, dated 01/05/2026, faxed to the agency on 01/06/2026, indicated Patient #4 to be discharged home with skilled nurse, HHA, physical and occupational therapy. A SOC Comprehensive Assessment, was completed on 01/09/2026 by the Clinical Manager. A clinical record review failed to evidence a physician order for SOC to be on 01/09/2026. During an interview on 02/02/2026, beginning at 11:00 AM, the Administrator indicated the agency attempted to complete a patient within 48 hours of a referral but may take up to 72 hours. 410 IAC 17-14-1(a)(1)(A)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency’s comprehensive assessment failed to reflect patients’ current health status in 1 of 1 active clinical record reviewed with a port a catheter (Patient #2), in 2 of 2 active clinical records reviewed with a foley catheter (Patient #1 and Patient #3). in 1 of 1 active clinical record reviewed with a colostomy (Patient #1), and in 1 of 1 active clinical record reviewed with a percutaneous endoscopic gastrostomy tube (Patient #7). Findings include: 1.An undated policy titled, “Comprehensive Assessment at Start of Care,” indicated the comprehensive assessment would accurately reflect the patient’s current health status. 2.An Order Summary Report from Entity B, a skilled nursing facility, dated 01/18/2026bfor Patient #2, indicated a start date of 01/04/2026 for RN to change the Huber needle monthly to the right chest port a catheter [PAC] (medical device implanted under the skin for administration of medications and fluids) and flush with heparin for non-use and saline if used every 4 weeks. A Start of Care [SOC] Comprehensive Assessment, dated 01/23/2026, failed to evidence documentation of a PAC. During an interview on 02/04/2026, beginning at 1:40 PM, the Administrator indicated she was not aware Patient had a PAC until after Patient’s hospitalization and resumption of care on 02/02/2026. 3.A SOC Comprehensive Assessment, dated 12/11/2026, indicated Patient #1 had a foley catheter (tube into the bladder to drain urine), and failed to evidence documentation of urine assessment or size of catheter. The assessment indicated Patient had an ostomy (artificial opening in an organ of the body) for bowel elimination, and failed to evidence documentation of stoma (surgical opening to abdomen to pass bodily waste) assessment, or surrounding stoma skin assessment. During an interview on 02/04/2026, beginning at 10:30 AM, the CM indicated he would check the comprehensive assessment for the stoma site documentation, the stoma site should be documented on the comprehensive assessment, no further information was provided upon exit on 02/06/2026. 4. A SOC Comprehensive Assessment, dated 01/13/2026, indicated Patient #3 had a foley catheter, and failed to evidence documentation of urine assessment or size of catheter. During an interview, on 02/05/2026, beginning at 1:15 PM, the Administrator indicated there should have been documentation on the comprehensive assessment to include if there was sediment in the urine, but the electronic medical record system limited what documentation could be included for an assessment for a foley catheter. 5.A SOC Comprehensive Assessment, dated 12/15/2025, indicated Patient #7 had a percutaneous endoscopic gastrostomy [PEG] tube (feeding tube inserted into stomach), and failed to evidence documentation of a skin assessment or placement site of the peg tube. During an interview on 02/03/2026, beginning at 12:45 PM, the Administration indicated a peg tube site assessment should include the surrounding skin and quadrant site. 410 IAC 17-14-1(a)(1)(B)

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all necessary medical information pertaining to the patient’s course of illness and treatment was sent to the receiving facility or health care practitioner to ensure the safe and effective transition of care in 1 of 2 active clinical records reviewed of a patient hospitalization (Patient #2); and in 1 of 1 discharge clinical records reviewed of a patient discharged to a hospital (Patient #8); and in 1 of 1 discharge clinical records reviewed due to goals met (Patient #9). Findings include: 1.An undated policy, titled, “Discharge Planning,” indicated the agency would coordinate with other healthcare providers or facilities to ensure a smooth transition and continuity of post discharge care. 2.A Transfer Form, dated 01/26/2026, indicated Patient #2 was admitted to a hospital. The Transfer Form was left blank under section of notification if transfer summary was sent to the inpatient facility or the physician. During an interview, on 02/04/2026, beginning at 10:45 AM, the Clinical Manager [CM] indicated he was not sure if the transfer summary was sent to the receiving hospital. 3. A Transfer Form, dated 11/10/2025, indicated Patient #8 was admitted to a hospital. The Transfer Form was left blank under section of notification if the transfer summary was sent to the inpatient facility or the physician. During an interview, on 02/04/2026, beginning at 10:45 AM, the CM indicated there was no documentation that the transfer form was sent to the hospital. 4. A Discharge Non-Visit Note by the CM, dated 12/31/2025, indicated Patient #9 was discharged from the agency due to goals met and failed to include documentation the discharge summary was sent to the POC physician. During an interview, on 02/04/2026, beginning at 10:50 AM, the Administrator indicated the discharge summary should include documentation the summary was sent to the physician and would check for documentation. Upon exit on 02/06/2026 no further documentation was received. 410 IAC 17-13-2(a)(b)(9)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received services as ordered in the plan of care in 1 of 2 active clinical records reviewed with a foley catheter (catheter into the bladder to drain urine)(Patient #1), in 3 of 5 active clinical records reviewed with wound care (Patient #3, Patient #5, and Patient #6). Findings include: 1. An undated policy, titled, “Development and Management of Medical Plan of Care,” indicated the RN would oversee the implementation of the nursing POC to ensure that care delivery aligned with the plan. 2.A POC, for certification period 12/11/2025 to 02/08/2026, indicated Patient #1’s skilled nurse was to change foley indwelling catheter every 30 days and as needed for malfunction of the catheter. The POC indicated skilled nursing visits 2 times per week for 8 weeks. The clinical record review indicated one RN visit during the week of January 4th, a visit on 01/06/2026. A RN Visit Note, dated 01/13/2026, indicated date of last foley indwelling catheter change was 12/08/2025. The visit note failed to evidence documentation of the foley catheter change being completed or offered. During an interview, on 02/04/2026, beginning at 10:30 AM, the CM indicated Patient refused to have the foley catheter changed on 01/18/2026. Requests for documentation of refusal prior to 01/18/2026 were unmet upon exit on 02/06/2026. 3.A POC, for certification period 01/07/2026 to 03/07/2026, indicated Patient #3 a referral for a medical social worker to "facilitate session with the primary care physician for covered services for care planning". A review of the clinical record, on 02/03/2026, failed to evidence a social worker had visited Patient. During an interview, on 02/04/2026, beginning at 11:00 AM, the Administrator indicated the social worker referral should not be on the POC and Patient did not see a social worker, and the agency's employee was assisting Patient with community resources and the employee was not a social worker. 4. A POC, for certification period 12/05/2025 to 02/02/2026, indicated Patient #5 was to have skilled nursing visits 2 times per week for 8 weeks. A review of the clinical record indicated a skilled nurse visit on 12/17/2026 and failed to evidence a 2nd skilled nurse visit for the clinical work week of 12/14/2025. During an interview, on 02/04/2026, beginning at 10:30 AM, the Administrator indicated Patient did not receive a 2nd skilled nurse visit for the week of 12/14/2025 and did not have documentation of a missed skilled nurse visit. 5.A POC, for certification period 12/26/2025 to 02/23/2026, indicated Patient #6 was to receive HHA visits 2 times per week for 8 weeks. A review of the clinical record failed to evidence a HHA visit for the week of 01/18/2026. During an interview, on 02/03/2026 beginning at 12:30 PM and on 02/04/2026 beginning at 10:30 AM, the Administrator indicated she would check for documentation of HHA visits completed for the week of 01/18/2026 and upon exit on 02/06/2026, no further information was provided. The POC indicated a medical social worker to assess psychosocial issues that would impact healthcare, need for counseling, need for access to community resources and the master’s prepared social worker [MSW] would establish a plan discussed with the case manager and approved by the physician. A review of the clinical record failed to evidence that MSW had seen Patient. During an interview, on 02/03/2026, beginning at 12:30 PM, the Administrator indicated the MSW referral should not have been on the POC. 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 record review and interview, the agency failed to ensure the POC included all medications and treatments to include diabetes testing frequency in 4 of 4 active skilled clinical records reviewed with a diagnosis of diabetes (body’s impaired ability to regular insulin resulting in elevated levels of glucose in the blood), (Patient #1, Patient #5, Patient #6, Patient #7); in 1 of 1 active skilled clinical records reviewed that received hemodialysis (a process to filter the blood of a patient whose kidneys do not work normally)(Patient #1); and in 1 of 2 skilled nurse home visits observed (Patient #3). Findings include: 1.An undated policy, titled, “Development and Management of Medical Plan of Care,” indicated the plan of care would include but not limited to medications and treatments. 2.A POC, for certification period 12/11/2025 to 02/08/2026, indicated Patient #1 was on Lispro Insulin per sliding scale coverage 3 times per day, had a diagnosis to include but not limited to type 2 diabetes mellitus (inability for body to control blood sugar), and had parameters to notify the physician of fasting blood sugar greater than 180 or less than 70 and random blood sugar of greater than 200 or less than 70. The POC indicated skilled nurse visits 2 times per week for 8 weeks to assess diabetic status, and monitor blood sugar levels to assess efficacy of medication therapy. The POC failed to evidence the frequency of blood sugar testing. During an interview, on 02/04/2026, beginning at 10:30 AM, the Clinical Manager [CM] indicated the skilled nurse checked Patient’s blood sugar levels 2 to 3 times per week and Patient did not check own blood sugar. The CM confirmed the frequency of blood sugar testing was not on the POC. 3.A SOC Comprehensive Assessment, dated 12/11/2025, indicated Patient #1 had hemodialysis treatments. A Plan of Care, for certification period 12/11/2025 to 02/08/2026, for Patient #1 indicated a diagnosis to include but not limited to end stage renal disease and failed to evidence Patient was receiving hemodialysis nor site of hemodialysis treatments. During an interview, on 02/03/2026, beginning at 11:40 PM, Entity A, an outpatient hemodialysis clinic, facility administrator indicated Patient had been receiving hemodialysis at the outpatient clinic 2 days per week and was discharged due to noncompliance on 01/30/2026. During an interview on 02/04/2026, beginning at 10:30 AM, the CM indicated there was no documentation of Patient receiving hemodialysis on the POC. 4.A POC, for certification period 12/05/2025 to 02/02/2026, indicated Patient #5 was on Glargine insulin twice daily, had a diagnosis to include but not limited to type 2 diabetes mellitus with other circulatory complications, had parameters to notify physician for fasting blood sugar greater than 180 or less than 70 and random blood sugar greater than 200 or less than 70. The POC indicated skilled nurse to assess diabetic status, instruct patient on self-management program to include blood sugar monitoring and to monitor blood sugar levels. The POC failed to evidence the frequency of blood sugar testing. During an interview on 02/03/2026, beginning at 1:00 PM, the Administrator indicated there was not a frequency for blood sugar testing on the POC. 5. A POC, for certification period 12/26/2025 to 02/23/2026, indicated Patient #6 was on glipizide (oral blood sugar lowering medication), had a diagnosis to include but not limited to type 2 diabetes mellitus, had parameters to notify physician for fasting blood sugar greater than 180 or less than 70 and random blood sugar greater than 200 or less than 70. The POC indicated skilled nurse to perform finger stick for blood sugar analysis, and may obtain blood sugar levels as needed for hyperglycemia or hypoglycemia. The POC failed to evidence the frequency of blood sugar testing. During an interview on 02/03/2026, beginning at 12:30 PM, the Administrator indicated Patient did not check their own blood sugars and blood sugars were only checked at skilled nursing visits. 6.A POC, for certification period 12/15/2025 to 02/12/2026, indicated Patient #7 was on Lispro and Lantus insulin, and metformin (oral blood sugar lowering medication); and had a diagnosis to include but not limited to diabetes due to underlying condition with hyperglycemia (elevated blood sugar). The POC indicated the skilled nurse was to monitor blood sugar levels to assess efficacy of medication via fingerstick as needed for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia. The POC failed to evidence the frequency of blood sugar testing. During an interview, on 02/03/2026, beginning at 12:45 PM, the Administrator indicated Patient tested blood sugars twice per day and the POC did not contain the frequency of blood sugar testing. 7.During an observation of a home visit on 02/05/2026, beginning at 11:00 AM, Patient #3 indicated medications included but not limited to Entresto (heart failure medication) 24/26 milligrams [mgs] one tablet twice a day, Keppra (seizure medication) 500 mgs one tablet daily, Aldactone (diuretic) 25mg one tablet daily, and Hydrocodone (pain relieving medication) 5/325mg one tablet every 4 hours as needed. A POC, for certification period 01/07/2026 to 03/07/2026, failed to evidence Entresto, Keppra, Aldactone, and Hydrocodone. During an interview on 02/05/2026, beginning at 11:00 AM, Patient indicated he/she had been taking Entresto, Keppra, Aldactone and Hydrocodone since discharge from the hospital in the beginning of January 2026. During an interview on 02/06/2026, beginning at 10:30 AM, CM indicated Patient was on Hydrocodone, Keppra and Aldactone at the start of care and should have been included on the POC. 410 IAC 17-13-1(a)(1)D(ix)

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to obtain physician verbal orders to continue care at recertification in 1 of 1 active clinical records reviewed with a start of care prior to 12/05/2025 (Patient #6). Findings include: An undated policy, titled, “Physician Verbal Orders,” indicated verbal orders must include date, time of order, details of the order, physician giving the order and signature and titled of clinical that received the order. A POC, for certification period 12/25/2025 to 02/23/2026, indicated Patient #5’s start of care date was 08/28/2025. The POC was signed by the physician on 01/02/2026. A clinical record review failed to evidence verbal orders were obtained at recertification to continue Patient’s care. During an interview, on 02/04/2026, beginning at 10:30 AM, the CM indicated he would call the physician for verbal orders at recertification, however, documentation of verbal orders to continue care requested was not received upon exit on 02/06/2026. 410 IAC 17-14-1(a)(F)

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 record review and interview, the agency failed to measure or track quality indicators that would enable the agency to assess the agency operations (G0642); the agency failed to utilize data to identify opportunities for improvement (G0644); the agency’s governing body failed to approve the frequency and detail of data collection (G0644); the agency failed to implement performance improvement activities on high risk or problem prone areas (G0648); the agency failed to identify problems that would lead to a performance improvement activity (G0652); the agency failed to analyze adverse patient events and implement preventative action (G0654); the agency failed to implement performance improvement activities and sustain improvement (G0656); and the agency failed to implement a performance improvement project (G0658). An undated policy, titled, “Quality Assessment and Performance Improvement [QAPI],” indicated the governing body was responsible for the QAPI problem and would ensure the QAPI program was implemented and maintained. The policy indicated the agency would track and analyze adverse patient events to identify causes and implement preventative action. The policy indicated improvement activities would focus on high risk, high volume, or problem prone areas. The policy indicated the agency would conduct improvement projects annually, would implement interventions that measured progress achieved and identify problems that directly affected the health and safety and patients to correct immediately. A Hospitalization Log indicated 38% (15 patients were hospitalized with an unduplicated skilled admission from last 12 months of 40 patients) of patients had been hospitalized from 08/20/2025 to 01/26/2026. During an interview, 02/03/2026, beginning at 1:20 PM, the Administrator indicated the agency did not have QAPI meetings, did not have governing body meeting minute notes, did not implement a performance improvement project, was able to track hospitalizations through the agency’s electronic medical records system but did not analyze or implement performance improvement activities based on findings. The cumulative effect of the systemic problems had resulted in the agency's inability to ensure the provision of quality of health care in a safe environment for the condition of participation 494.110 Quality Assessment and Performance Improvement. 410 IAC 17-12-2(a)

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, interview, and record review, the agency failed to ensure they adopted and implemented standard infection control practices and precautions to include bag technique and failed to ensure hand hygiene practices were maintained to prevent the transmission of infections and communicable diseases in 2 of 2 skilled nursing visits observed (Patient #2 and Patient #3). Findings include: 1.A Center for Disease Control website indicated hand hygiene should be completed after contact with body fluids, before moving from work on a soiled body site to a clean body site, and immediately after glove removal. 2.A Center for Disease Control website indicated a bag technique was essential for home health nurses to prevent infection. The website indicated nurses should maintain aseptic conditions while using their bags to prevent cross contamination and indicated a clean surface should be used to place items needed for the visit. 3.An undated policy, titled, “Infection Control and Prevention,” indicated staff would perform hand hygiene using soap and water or an alcohol-based hand sanitizer before and after all patient contacts, after removing gloves, and after contact with surfaces potentially contaminated by infectious materials. 4.During an observation of a home visit, on 02/05/2026 beginning at 5:00 PM, the Clinical Manager [CM] removed Patient #2’s wound dressing and packing to the right hip and changed the dressing, removed his gloves, failed to perform hand hygiene, and donned new gloves. The CM then changed the left hip dressing, then removed his gloves, failed to perform hand hygiene, donned new gloves, then removed and changed the dressing to left buttocks wound. The CM then removed his gloves, failed to perform hand hygiene, donned new gloves, and changed the dressing to the suprapubic catheter (tube into bladder to drain urine) site. During an interview, on 02/05/2026 beginning at 6:00 PM, the CM indicated he did not complete hand hygiene between donning new gloves when performing wound dressing changes of the right hip, left hip, left buttocks, and the suprapubic catheter site. The CM indicated hand hygiene should have been completed with each glove change and when moving from one wound site to another. 5. During an observation of a home visit, on 02/05/2026 beginning at 11:00 AM, LPN 1 entered Patient #3’s home and placed his bag directly onto a fabric couch without a barrier. LPN 1 then removed vital sign equipment from the bag. During an interview, on 02/05/2026, beginning at 12:15 PM, LPN 1 indicated he was unaware if the agency had a bag technique policy or if the bag should be placed directly on a surface without a barrier. During an interview, on 02/05/2026, beginning at 1:15 PM, the Administrator indicated the agency did not have a bag technique policy, however, a barrier should have been utilized when LPN 1 placed his bag on Patient’s couch. 410 IAC 17-12-1(m)

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 record review and interview, the Director of Nursing failed to provide ongoing interdisciplinary assessment of Home Health Aide services in 2 of 2 patients with home health aide services (Patient #6, Patient #7) from HHA 1 out of a sample of 1 HHA. Findings include: 1.An undated policy, titled, "Home Health Aide Plan of Care," indicated the Aide's assignment would verify that the aide was competent to perform the assigned tasks and include personal care tasks, ambulation and transfer techniques, nutritional support, vital signs to be monitored to include frequency and parameters for report, and infection control precautions. The policy indicated the Home Health Aide [HHA] would only be assigned tasks for which they demonstrated competency. 2.An undated policy titled, "Home Health Aide Supervisory Visits," would verify the HHA was following the plan of care, maintaining infection control standards, and providing safe patient care. The policy indicated patients that received skilled care would have an on-site supervisory visit every 14 days completed by a Registered Nurse [RN], and the supervisory visit would be documented in the clinical record. 3.An undated job description titled, "Director of Nursing and Backup Administrator indicated the Director of Nursing would conduct mandatory supervisory visits for HHAs, would provide HHA oversight by conducting supervisory visits for HHAs every 14 days to ensure the aide care plan was being followed and the patient's needs were met, and would ensure that all care provided aligned with physician orders and current standards of practice. 4. Patient #6’s POC, for certification period 12/26/2025 to 02/23/2026, indicated Skilled Nursing and HHA 2 times per week for 8 weeks. The Plan of Care indicated Patient had a diagnosis to include but not limited to primary hypertension (high blood pressure) and was on Lisinopril (blood pressure lowering medication) daily. An HHA Care Plan, for 12/26/2025 to 02/23/2026, indicated HHA was to complete temperature, pulse rate, respirations, and blood pressure at every visit; complete personal care to include shower, assist with dressing, shampoo hair, perform oral care, and perform incontinent care at every visit. The HHA Care Plan did not include vital sign parameters to notify RN. HHA 1 Visit Notes indicated on 12/26/2025, 12/30/2025, 01/02/2026, 01/06/2026, 01/08/2026, 01/13/2026, 01/15/2026, 01/27/2026, and 01/29/2026 HHA 1 completed shower, oral care, shampooing of hair, assisted with dressing and provided incontinent care. HHA 1 Vital Sign Documentation were as follows: 12/30/2025: blood pressure 236/86 recheck 202/99 (normal blood pressure 120/80), respirations 96 (normal respirations 12-20). 01/02/2026: blood pressure 178/69, respirations 92 01/06/2026: blood pressure 209/119, respirations 93 01/08/2026: blood pressure 161/151, respirations 93 01/13/2026: blood pressure 229/182, respirations 94 01/15/2026: blood pressure 195/124, respirations 95 01/19/2026: blood pressure 176/106, respirations 96 5.Patient #7’s POC, for certification period 12/15/2025 to 02/12/2026, indicated Skilled Nursing 1 time per week for 9 weeks and HHA was to provide care 2 times a week for 9 weeks. An HHA Care Plan, for 12/15/2025 to 02/12/2026, indicated HHA was to complete temperature, pulse rate, respirations, and blood pressure at every visit; complete personal care to include bed bath, assist with dressing, shampoo hair, perform oral care, perform incontinent care, assist with transfer using Hoyer lift (mechanical device to assist with transfers) at every visit. 6. A Personnel Record Review for HHA 1 indicated a date of hire of 12/01/2025. An HHA 1 Clinical Self-Assessment Skills Checklist, dated 12/04/2025, indicated no experience with taking blood pressure, pulse rate or respirations, and required assistance for completing a bath on a patient. 7.During an interview, on 02/03/2026 beginning at 10:30 AM, the Director of Nursing indicated HHA 1 had skills validation checklist completed in the office and was not on a patient or pseudo patient. The Director of Nursing indicated LPN 1 was to evaluate HHA 1’s competencies with patients during visits but did not have documentation of a competency evaluation. 8.During an interview, on 02/04/2026, beginning at 2:20 PM, the Director of Nursing indicated an RN did not evaluate competency skills evaluation with patients during home visits with HHA 1, and he did not verify HHA 1's ability to take a blood pressure. The Director of Nursing indicated he completed HHA supervisory visits by making sure the patient looked clean, asking the patient about the care that was provided by the HHA, and he did not review the HHA's visit notes. The Director of Nursing indicated he did not document HHA supervisory visits. 410 IAC 17-12-2(g)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide home health aide services per the physician referral in 1 of 1 active clinical record reviewed with a diagnosis of Guillain-Barre syndrome (body’s immune system attacks the nerves causing weakness, numbness or paralysis) (Patient #4). Findings include: A Referral dated, 01/05/2026, indicated Patient #4 was to be discharged home from a skilled nursing facility with skilled nursing, physical [PT] and occupational therapy [OT], and home health aide services. A SOC Comprehensive Assessment, dated 01/09/2026, indicated Patient had impaired functional mobility, was able to bath self with intermittent assistance of another person for intermittent supervision. The Assessment indicated Patient refused OT and failed to include documentation Patient was offered Home Health Aide Services. A PT, dated 01/12/2026, indicated Patient had compromised mobility with the use of an assistive device and expressed fear of falling due to unsteady gait and general weakness. During an interview, on 02/05/2026 beginning at 1:30 PM, the Administrator indicated Patient refused Home Health Aide Services, however there was no documentation Patient refused. During an observation of a home visit on 02/04/2026, beginning at 1:00 PM, Patient #4 indicated he/she was not aware what OT was and was not offered OT by the agency. 410 IAC 17-14-1(a)(1)(H)-RN

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 record review and interview, the agency failed to ensure: the home health aide [HHA] was evaluated for competency before providing patient care (see tag G0768); the home health aide provide services that were consistent with the HHA's training (see tag G0800); the HHA notified the RN of patient's abnormal vital signs (see tag G0804); and HHA supervision was provided every 14 days for skilled patients (see tag G0808). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation 42 CFR 484.80 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 record review and interview, the agency failed to ensure the Home Health Aide [HHA] provided services after a competency evaluation was completed by an RN with a patient or pseudo patient in 1 of 1 agency HHA (HHA 1). Findings include: 1.An undated policy, titled, “Home Health Aide Plan of Care (Written Assignment),” indicated the HHA would be assigned tasks for which they have demonstrated competency during their initial orientation and evaluations. 2.Patient #6’s POC, for certification period 12/26/2025 to 02/23/2026, indicated HHA 2 times per week for 8 weeks. The Plan of Care indicated Patient had diagnosis to include but not limited to primary hypertension (high blood pressure) and was on Lisinopril (blood pressure lowering medication) daily. An HHA Care Plan, for 12/26/2025 to 02/23/2026, indicated HHA was to complete temperature, pulse rate, respirations, and blood pressure at every visit; complete personal care to include shower, assist with dressing, shampoo hair, perform oral care, and perform incontinent care at every visit. The HHA Care Plan did not include vital sign parameters to notify RN. HHA 1 Visit Notes indicated on 12/26/2025, 12/30/2025, 01/02/2026, 01/06/2026, 01/08/2026, 01/13/2026, 01/15/2026, 01/27/2026, and 01/29/2026 HHA 1 completed shower, oral care, shampooing of hair, assisted with dressing and provided incontinent care. HHA 1 Vital Sign Documentation were as follows: 12/30/2025: blood pressure 236/86 recheck 202/99 (normal blood pressure 120/80), respirations 96 (normal respirations 12-20). 01/02/2026: blood pressure 178/69, respirations 92 01/06/2026: blood pressure 209/119, respirations 93 01/08/2026: blood pressure 161/151, respirations 93 01/13/2026: blood pressure 229/182, respirations 94 01/15/2026: blood pressure 195/124, respirations 95 01/19/2026: blood pressure 176/106, respirations 96 3.Patient #7’s POC, for certification period 12/15/2025 to 02/12/2026, indicated HHA was to provide care 2 times a week for 9 weeks. An HHA Care Plan, for 12/15/2025 to 02/12/2026, indicated HHA was to complete temperature, pulse rate, respirations, and blood pressure at every visit; complete personal care to include bed bath, assist with dressing, shampoo hair, perform oral care, perform incontinent care, assist with transfer using Hoyer lift (mechanical device to assist with transfers) at every visit. 4. A Personnel Record Review for HHA 1 indicated a date of hire of 12/01/2025. An HHA 1 Clinical Self-Assessment Skills Checklist, dated 12/04/2025, indicated no experience with taking blood pressure, pulse rate or respirations; and required assistance for completing a bath on a patient. An HHA 1 Skills Validation Checklist, dated 12/05/2025, validated by the Clinical Manager [CM] indicated HHA 1 passed bed bath technique, oral care, dressing assistance, and accurately measured and documented pulse rate and respirations and failed to evidence Hoyer lift skills evaluation. 5.During an interview, on 02/03/2026, beginning at 10:30 AM, the CM indicated HHA 1 had skills validation checklist completed in the office with return demonstration and was not on a patient or pseudo patient. The CM indicated LPN 1 was to evaluate HHA 1’s competencies with patients during visits but did not have documentation of a competency evaluation. 6.During an interview, on 02/04/2026, beginning at 2:20 PM, the CM indicated an RN did not evaluate competency skills evaluation with patients during home visits with HHA 1, and he did not verify HHA 1's ability to take a blood pressure. The CM indicated HHA 1 care to be provided to patients was to be discussed with by LPN 1 during patient visits. The CM indicated HHA 1 did not use a Hoyer lift when transferring Patient #7. 7. Attempts to contact HHA 1 on 02/04/2026, 02/05/2026, and 02/06/2026 via phone and text message went unreturned and unable to leave voicemail. Attempts by the Administrator to reach HHA 1 on 02/05/2026 did not result in contact with HHA 1. 410 IAC 17-14-1(l)(1)(A)

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 record review and interview, the agency failed to ensure the agency ensured home health aide services assigned and provided were consistent with the HHA training and ability in 1 of 1 HHA personnel record reviewed (HHA 1) out of a sample of 1 HHA employed. Findings include: An undated policy, titled, “Home Health Aide Plan of Care (Written Assignment),” indicated the HHA would be assigned tasks for which they have demonstrated competency during their initial orientation and evaluations. An HHA Care Plan for Patient #6, for 12/26/2025 to 02/23/2026, indicated HHA was to complete temperature, pulse rate, respirations, and blood pressure at every visit. HHA 1 Visit Notes for Patient #6 were as follows: 12/30/2025: blood pressure 236/86 recheck 202/99 (normal blood pressure 120/80), respirations 96 (normal respirations 12-20). 01/02/2026: blood pressure 178/69, respirations 92 01/06/2026: blood pressure 209/119, respirations 93 01/08/2026: blood pressure 161/151, respirations 93 01/13/2026: blood pressure 229/182, respirations 94 01/15/2026: blood pressure 195/124, respirations 95 01/19/2026: blood pressure 176/106, respirations 96 An HHA 1 Clinical Self-Assessment Skills Checklist, dated 12/04/2025, indicated no experience with taking blood pressure, pulse rate or respirations. An HHA 1 Skills Validation Checklist, dated 12/05/2025, validated by the Clinical Manager [CM] indicated taking pulse rate and respirations skills were completed. During an interview, on 02/04/2026, beginning at 2:20 PM, the CM indicated an RN did not complete competency skills evaluation for HHA 1 on / with a real or pseudo patient, and he did not evaluate HHA 1’s ability to obtain a blood pressure.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, HHA 1 failed to ensure abnormal vital signs were reported to the RN in 1 of 2 active clinical records reviewed with HHA 1 (Patient #6). Findings include: HHA 1 Visit Notes for Patient #6 were as follows: 12/30/2025: blood pressure 236/86 recheck 202/99 (normal blood pressure 120/80), respirations 96 (normal respirations 12-20). 01/02/2026: blood pressure 178/69, respirations 92 01/06/2026: blood pressure 209/119, respirations 93 01/08/2026: blood pressure 161/151, respirations 93 01/13/2026: blood pressure 229/182, respirations 94 01/15/2026: blood pressure 195/124, respirations 95 01/19/2026: blood pressure 176/106, respirations 96 HHA 1 Visit Notes failed to evidence documentation the CM was notified of the abnormal blood pressures and respirations readings. During an interview, on 02/03/2026, beginning at 12:30 PM, the Administrator indicated she would expect the HHA to notify the RN of abnormal blood pressures.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure Home Health Aide [HHA] supervisory visits were conducted every 14 days for 2 of 2 active skilled patients with an HHA (Patient #6, Patient #7). Findings include: 1.An undated policy, titled, “Home Health Aide Supervisory Visits,” indicated skilled care patients receiving nursing or therapy and home health aide services would have an on-site RN supervisory visit every 14 days. 2. A POC, for certification period 12/26/2025 to 02/23/2026, indicated Patient #6 was to receive skilled nursing and HHA services 2 times per week for 8 weeks. HHA 1 Visit Notes were completed for 12/26/2025, 12/30/2025, 01/02/2026, 01/06/2026, 01/08/2026, 01/13/2026, 01/15/2026, 01/20/2026, 01/22/2026, 01/27/2026, 01/29/2026, and 02/03/2026. A review of the clinical record, on 02/03/2026, failed to evidence documentation of RN supervisory visits being completed. 3.A POC, for certification period 12/15/2025 to 02/12/2026, indicated Patient #7 was to receive skilled nursing 1 time per week for 9 weeks and HHA visits 2 times per week for 9 weeks. HHA 1 Visit Notes were completed for 12/18/2025, 12/23/2025, 12/26/2025, 12/30/2025, 01/02/2026, 01/06/2026, 01/08/2026, 01/13/2026, 01/15/2026, 01/20/2026, 01/22/2026, 01/27/2026, 01/29/2026, and 02/03/2026. A review of the clinical record, on 02/03/2026, failed to evidence documentation of RN supervisory visits being completed. 4.During an interview, on 02/03/2026, beginning at 12:30 PM, the Administrator indicated HHA supervisory visits should be completed during the RN visit every 30 days by asking the patient about HHA’s care. 5.During an interview, on 02/04/2026, beginning at 10:30 AM, the Clinical Manager [CM] indicated he would check HHA care during visits to ensure patients hygiene was completed by the HHA but did not complete supervisory visit documentation.