Every finding on record at Team Select Home Care of Indiana, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: March 4, 5, 6, 9, 10, and 11, 2026 Active Census: 95 At this Emergency Preparedness survey, Team Select was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. Abbreviations: EP Emergency Preparedness

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency’s communication plan failed to include contact information for emergency officials for all counties served for 1 of 1 agency. Findings include: 1. Review of the EP communication plan failed to include contact information for the following counties served by the agency: Cass, Fulton, Grant, Miami, Tipton, Wabash, Boone, Carroll, Clinton, Fountain, Jasper, Montgomery, Newton, Parke, Pulaski, and Putnam. 2. During an interview on 03/11/2026 at 1:27 PM, the Administrator indicated the EP communication plan for the parent location only included local emergency officials contact information for the city and county in which the parent location was located. 3. During an interview on 03/11/2026 at 2:06 PM, the Administrator indicated the EP communication plan for Branch B only included local emergency officials contact information for the city and county in which Branch B was located.

This visit was for an Initial Medicare Certification, Federal Recertification and State Re-Licensure survey of a Home Health Provider Survey Dates: 03/03, 03/04, 03/05, 03/06, 03/09, 03/10, 03/11/2026 12-Month Unduplicated Skilled Admissions: 3 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: CM-Clinical Manager, CNA-Certified Nurse’s Aide, EMR-Electronic Medical Record, RN-Registered Nurse, SOC-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 home health agency failed to conduct an initial assessment within 48 hours of referral for 5 of 5 active patients admitted after 01/11/2024 (Patient #2, 3, 4, 6, and 7). 6. Patient #7’s clinical record indicated a SOC date of 07/30/2024. The record failed to evidence a referral source and date. The clinical record failed to evidence an initial assessment was completed within 48 hours of referral. During an interview on 03/10/2026 beginning at 02:30 PM, the CM indicated there was no referral information for Patient #7. The CM indicated the agency only recorded referral information for physician referrals. The CM indicated they could not demonstrate the initial assessment occurred within 48 hours. IAC 17-14-1(a)(1)(A) Findings include: 1. Review of the Patient Admission Criteria/ Scope of Services policy, dated 07/01/2025, indicated “… If Agency receives a referral of a patient who requires care or services that are not available at the time of referral, Agency shall advise the patient’s primary care provider, if applicable, and the patient or authorized representative of that fact. The patient will be referred to another agency, if appropriate. Referral forms will reflect this… Patient referrals may be made by anyone including the family, physician, discharge planners, friends, relatives or the patient… Referrals may be received by phone, fax, in person, email, referral portals, or in the mail. When the agency accepts a referral, the following information is collected and documented in the system of record… referral source… A log of all referrals received is maintained by the agency…” 2. Review of Patient #2’s clinical record indicated a SOC date of 01/29/2025. The record failed to evidence a referral source and date. The clinical record failed to evidence an initial assessment was completed within 48 hours of referral. During an interview on 03/06/2026 at 3:24 PM, the CM indicated she believed Patient #2’s referral was from the family but relayed the agency didn’t consider it a referral until they had a physician order in place and did not keep a referral log so she could not tell me when the referral/inquiry came in. 3. Review of Patient #3’s clinical record indicated a SOC date of 11/05/2025. The record failed to evidence a referral source and date. The clinical record failed to evidence an initial assessment was completed within 48 hours of referral. During an interview on 03/06/2026 at 3:27 PM, the CM relayed Patient #3 was referred by family but indicated she wasn’t sure when the referral came in because the agency did not document referrals until the provider order was received. 4. Review of Patient #4’s clinical record indicated a SOC date of 07/26/2024. The record failed to evidence a referral source and date. The clinical record failed to evidence an initial assessment was completed within 48 hours of referral. During an interview on 03/09/2026 at 3:44 PM, the Alternate CM relayed Patient #4 was referred to the agency by another home health agency but could not give me that referral date. 5. Review of Patient #6’s clinical record indicated a SOC date of 04/09/2024. The record failed to evidence a referral source and date. The clinical record failed to evidence an initial assessment was completed within 48 hours of referral. During an interview on 03/11/2026 at 11:31 AM, the CM relayed she thought Patient #6’s referral was a family referral but could not provide the date the call was received by the agency for that referral. 7. During an interview on 03/06/2026 at 3:21 PM, the CM indicated the agency considered referrals to be inquiries until they determined the need for home health services and further relayed the agency considered the referral date to be the date they received the verbal order to admit to the agency. The CM further relayed the patient would then be admitted within 48 hours of that date or on the provider ordered SOC date.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure provider orders were obtained prior to providing services for 5 of 7 active patient records reviewed (Patient #2, 3, 4, 6, and 7). 6. Patient #7’s clinical record evidenced a POC for certification period 07/30/2024 – 09/27/2024 which was returned signed by the physician/ allowed practitioner on 08/19/2024. The record failed to include provider orders for 9 SN visits for a total of 92.6 hours. During an interview on 03/10/2026 beginning at 02:30 PM, the CM indicated care was provided without provider orders. IAC 17-13-1(a) Findings include: 1. Review of the Plan of Care policy, dated 07/01/2025, indicated “… Licensed professionals must immediately record and sign, date and time oral orders…” 2. Review of Patient #2’s clinical record included a POC for certification period 01/29/2025 to 03/29/2025 which was returned signed by the provider on 02/10/2025. The record failed to include provider orders for the SN visits on 02/02/2025, 02/03/2025, 02/04/2025, 02/05/2025, and 02/06/2025. During an interview on 03/11/2026 at 11:12 AM, RN 1 indicated the POC orders for the above SN visits for Patient #2 were on the POC for certification period from 01/29/2022 to 03/29/2025 and relayed the POC was signed by the physician on 02/06/2025 and was faxed to the agency on 02/10/2025. 3. Review of Patient #3’s clinical record included a POC for certification period 11/05/2025 to 01/03/2026 which was returned signed by the provider on 11/12/2025. The record failed to include provider orders for the HHA visits on 11/05/2025 and 11/08/2025. During an interview on 03/09/2026 at 3:24 PM, RN 4 relayed she gets a verbal order prior to the assessment and relayed after the assessment she reports findings and that the POC will be faxed for signature. RN 4 also indicated the only verbal order she had received regarding the SOC was received prior to the initial assessment. 4. Review of Patient #4’s clinical record included a SOC of 07/26/2024 and a POC for certification period 07/26/2024 to 09/23/2024 which was returned signed by the provider on 08/06/2024. The record failed to include provider orders for the SN visits on 07/29/2024, 07/30/2024, 07/31/2024, 08/01/2024, 08/02/2024, and 08/05/2024. During an interview on 03/09/2026 at 3:44 PM when asked where the orders were for the above SN visits, the CM relayed she received a verbal order for SOC for Patient #4 on 07/15/24, and then she called after the assessment to confirm the POC but could not show a verbal order for the POC. 5. Review of Patient #6’s clinical record included a POC 04/09/2024 to 06/07/2024 which was returned signed by the provider on 04/16/2024. The record failed to include provider orders for SN visits on 04/10/2024, 04/11/2024, 04/12/2024, and 04/15/2024. During an interview on 03/11/2026 at 11:31 AM when asked where the orders for the above SN visits could be found, the CM relayed she spoke with a medical assistant at the providers office to confirm the POC but could not show me a verbal order for the visits.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician (or allowed practitioner) of the likelihood of discharge for 2 of 2 patients discharged from agency branch locations (Patients #5 and 10). Findings include: 1. Patient #5’s clinical record indicated they started care on 07/29/2025 at Branch B. The record evidenced a discharge date of 09/26/2025 due to the agency’s inability to provide staff. The record evidenced a physician’s order to discharge Patient #5 on 09/26/2025. The record failed to evidence ongoing communication with the physician regarding the inability to provide staff to care for Patient #5. The record failed to evidence Branch B notified the physician of the potential discharge of Patient #5. During an interview on 03/09/2026 beginning at 03:30 PM, the CM indicated they did not notify the physician of Patient #5’s potential discharge. 2. Review of Patient #10’s clinical record indicated they started care on 07/21/2025 at Branch C. The record evidenced a discharge date of 09/04/2025 due to the agency’s inability to provide care because the agency felt Patient #10 wasn’t safe to be at home. The record evidenced a physician’s order to discharge Patient #10 effective 09/04/2025 was generated on 09/05/2025 by RN 4. The record failed to evidence communication with the physician regarding the inability to provide care for Patient #10 prior to the discharge date and failed to evidence the agency received an order for discharge from the physician prior to Patient #10’s discharge. During an interview on 03/10/2026 at 2:35 PM, RN 4 relayed she left a voicemail for the physician’s office on 09/04/2025 at 3:24 PM to notify the physician Patient #10 was being discharged from the agency. RN 4 relayed the physician signed the discharge order on 09/08/2025.

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 record review and interview, the agency failed to provide patients with medication instructions in plain, non- medical language for 4 of 7 active patient records reviewed (Patients #1, 2, 6, and 8). Findings include: 3. Patient #2’s clinical record included a POC medication list which included the medical abbreviations BID, QID, and PRN (as needed). During an interview on 03/11/2026 at 11:12 AM, RN 1 relayed Patient #2 got a POC with a medication list at SOC and after each recertification. RN 1 indicated it looked like the medication list had the abbreviation BID on it. 4. Patient #6’s clinical record included a medication list which included the medical abbreviations BID, TID, and PRN. During an interview on 03/10/2026 at 2:23 PM, RN 6 relayed she could print a medication list to give to Patient #6 and indicated it would have the same terminology as the POC medication list. 1. The agency policy, “Medication Profile,” dated 07/01/2025, indicated the medication profile should be “…updated whenever there is a change or discontinuation in medication.” The policy further indicated the medication profile should be “… in the patient’s home chart when extended hours of service are being provided.” The policy indicated medication profiles “…created through electronic point – of- care documentation systems will have a copy in the … patient’s home.” 2. Patient #1’s clinical record included a medication list which included the medical abbreviations BID (twice a day), QID (four times a day), and TID (three times a day). During an interview on 03/11/2026 beginning at 11:09 AM, RN 1 indicated BID, TID, and QID are medical abbreviations and not plain language. 5. Patient #8’s medication list included medical abbreviations BID (twice a day), SOB (short of breath), and Abd pad (a highly absorbent wound dressing). During an interview on 03/10/2026 beginning at 02:30 PM, the CM indicated BID, SOB, and Abd pad are medical abbreviations and not plain language.

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, record review, and interview, the home health agency failed to ensure staff followed hand hygiene policies and procedures for 3 of 3 home visit observations (RN 2, RN 3, and CNA 1). 4. During a home visit observation on 03/06/2026 beginning at 12 PM, CNA 1 provided care to Patient #8. During the visit, CNA 1 applied hand sanitizer and waved her hands in the air. While providing a bed bath, CNA 1 used a gloved finger to move hair off her face. CNA 1 failed to use hand sanitizer properly and failed to complete hand hygiene after touching her hair. During an interview at the end of the visit, CNA 1 indicated she knew she should allow the hand sanitizer to air dry. CNA 1 indicated she knew she should change gloves if she touches her face or hair. RN 1 indicated CNA 1 should have rubbed hands together until hand sanitizer dries. RN 1 indicated hand hygiene should be completed after touching hair or face. During an interview on 03/06/2026 beginning at 02:34 PM, the CM indicated hands should be rubbed together until hand sanitizer is dry. IAC 17-12-1(m) Findings include: 1. A home visit observation of RN 3 providing care for Patient #6 was conducted on 03/06/2026 at 10:10 AM. RN 3 dried the tracheostomy stoma site with gauze. RN 3 changed her left glove without performing hand hygiene and then placed the new tracheostomy strap. During an interview on 03/06/2026 at 10:29 AM, RN 3 relayed hand hygiene should be performed when changing gloves. 2. A home visit observation of RN 2 providing care for Patient #2 was conducted on 03/06/2026 at 9:00 AM. RN 2 washed her hands and scrubbed for 20 seconds then picked up her phone to look at the Patient’s medication list. RN 2 then washed her hands again and scrubbed for seven seconds. RN 2 then prepared Patient #2’s medications and tube feed. After preparing the medication, RN 2 then carried the prepared medications to Patient #2’s bedroom and donned gloves without first performing hand hygiene. RN 2 then got new tubing from the Patient’s supplies. RN 2 then changed gloves without performing hand hygiene and administered the tube feeding and medications. During an interview on 03/06/2026 at 9:18 AM, RN 2 relayed hand hygiene should be performed before and after patient care, any time hands are soiled, and after glove removal. RN 2 also relayed the scrubbing part of the handwashing process should be performed for 30 seconds. 4. During an interview on 03/06/2026 at 3:24 PM, the CM relayed hand hygiene should be performed before gloves and between glove changes. The CM also relayed sink handwashing should take 20 to 30 seconds of scrubbing of the hands, fingers, and wrists.

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 and interview, CNA 1 failed to follow her scope of practice by applying medicated products for 1 of 1 home observation of a bed bath (Patient #8). Findings include: During a home visit observation on 03/06/2026 beginning at 12 PM, CNA 1 performed a bed bath on Patient #8. When CNA 1 prepared the basin of water for the bath, she indicated she put chlorhexidine (an antiseptic to prevent or treat skin infections) into the water. After CNA 1 completed the bath, she applied nystatin (powder to prevent or treat fungal infections) to Patient #8’s abdomen and underarms. During an interview at the end of the home visit, CNA 1 indicated the chlorhexidine and nystatin were over the counter products, so she could use them. CNA 1 later indicated she could not apply medicated products as it was not in her scope of practice. RN 1 indicated a CNA should not apply medicated products. During an interview on 03/06/2026 beginning at 02:34 PM, the CM indicated CNA’s should not apply medicated products.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey dates: January 8, 9, 10, 11, 2024 Active Census: 16 At this Emergency Preparedness survey, Team Select Home Care was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the Emergency Preparedness Plan (EPP) included a process to engage in collaborative planning with local officials for an integrated emergency response for 1 of 1 agency. Findings Include: 1. The “Team Select Home Care Emergency Action Plan” dated 2023 was provided for review. The plan states the home health agency Director will join local EMS group and meet per groups schedule to ensure that EMS group knows the agencies needs and their abilities to provide assistance to authorities within their jurisdiction. The plan failed to include documentation of the Director joining any local group. 2. During an interview on 1/10/24 beginning at 3:50 PM, the Administrator confirmed the EPP failed to include any collaboration or documentation with local officials and they confirmed they have not joined any local emergency groups.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the Emergency Preparedness Plan (EPP) included procedures to inform state and local emergency officials about homebound patients in need of evacuation from their residences during an emergency for 1 of 1 agency. Findings Include: 1. The “Team Select Home Care Emergency Action Plan” dated 2023 was provided for review. The plan failed to include evacuation and transportation procedures during an emergency and failed to include an active patient list with appropriate medical and contact information. 2. During an interview on 1/10/24 beginning at 3:50 PM, the Administrator confirmed the EPP failed to mention how the home health agency would contact local officials and failed to include an active patient list.

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 record review and interview, the home health agency failed to ensure the communication plan included a list of all employees and phone numbers and failed to include a list of all active patients and phone numbers for 1 of 1 agency. Findings Include: 1. The “Team Select Home Care Emergency Action Plan” dated 2023 was provided for review. The plan mentioned a call tree will be utilized in an emergency. The plan failed to include an employee call tree list of names and phone numbers and failed to include an active patient list with names and phone numbers. 2. During an interview on 1/10/24 beginning at 3:50 PM, the Administrator confirmed the emergency action plan failed to include an active employee call tree list and failed to include an active patient list with contact information.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(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 facilities]. 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 home health agency failed to ensure the Emergency Preparedness Plan (EPP) included the use of volunteers or identified how other emergency personnel would be utilized in the emergency communication plan for 1 of 1 agency. Findings Include: 1. The “Team Select Home Care Emergency Action Plan” dated 2023 was provided for review. The plan failed to mention the use of volunteers or other emergency personnel during an emergency and failed to mention a policy and procedure to address surge needs during an emergency. 2. During an interview on 1/10/24 beginning at 3:50 PM, the Administrator confirmed the home health agency does not have a plan to utilize volunteers in an emergency and the emergency action plan failed to identify how other emergency personnel would be utilized in an emergency.

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 record review and interview, the home health agency failed to ensure the Emergency Preparedness Plan (EPP) included a procedure to release patient information in the event of an emergency for 1 of 1 agency. Findings Include: 1. The “Team Select Home Care Emergency Action Plan” dated 2023 was provided for review. The plan indicated an EMS coordination note will be entered upon admission to the home health agency and upon activation an episode summary will be sent to other medical providers using the HCHB fax system. The plan failed to include the current electronic medical record (EMR) system and failed to ensure the home health agency could provide current accurate information in the event the fax and/or EMR system is unavailable during an emergency. The plan also failed to include an active patient list with names and phone numbers. 2. During an interview on 1/10/24 beginning at 3:50 PM, the Administrator confirmed the home health agency does not have a back-up plan in the event the EMR system is unavailable and the plan failed to include an active patient list with contact information.

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 record review and interview, the home health agency failed to participate in a full-scale community-based exercise or a tabletop exercise in the past year for 1 of 1 agency. Findings Include: 1. The “Team Select Home Care Emergency Action Plan” dated 2023 was provided for review. The plan failed to include documentation of a full-scale community-based exercise or a tabletop exercise specific to this home health agency. 2. During an interview on 1/10/24 beginning at 3:50 PM, the Administrator confirmed the home health agency did not participate in a tabletop exercise and they have not participated in any community emergency exercises in the past year.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: January 8, 9, 10, 11, 2024 Facility ID: 016319 Provider/CCN Number: 15K189 Medicaid No: 300058717 12 Month Unduplicated Skilled Admissions: 34 Partially Extended on 01/08/2024 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR Completed on 01/19/2024 by A4

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined 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 ensure all services were provided as ordered in the plan of care (POC) for 2 of 5 active records reviewed (Patient’s #4 and #5) and 1 of 2 discharged records reviewed (Patient #6). Findings Include: 1. A review of agency policy “Plan of Care” indicated the written plan of care includes the frequency and duration of visits and consultation with the physician on any modification in the POC will be documented and the physician’s signature obtained within a timely manner, or according to state law. 2. A review of agency policy “Visit Schedule / Missed Visits” indicated if there is a missed visit, services shall be provided as agreed upon by the patient and the agency. The agency will coordinate with the patient or the patient’s authorized representative to reschedule a missed visit whenever possible. 3. The review of Patient #4’s active clinical record (start of care 8/22/23) included a POC for the certification period 12/20/23 to 2/17/24. The POC indicated the patient was to receive Home Health Aide (HHA) services 4 hours a day, 5 days a week for 60 days. The clinical record failed to evidence HHA visits were performed 5 days a week during the weeks of 11/19/23 and 12/31/23 and failed to evidence documentation the physician was notified in the change in visit frequencies. During an interview on 1/10/24 beginning at 10:08 AM, the Clinical Manager indicated the clinical record for Patient #4 failed to evidence documentation the physician was notified regarding the POC frequencies not being met. 4. The review of Patient #5’s active clinical record (start of care 8/09/22) included a POC for the certification period 12/02/23 to 1/30/24. The POC indicated the patient was to receive Home Health Aide (HHA) services 3 hours a day, 7 days a week for 60 days. The clinical record failed to evidence HHA visits were performed 7 days a week during the weeks of 11/12/23, 11/19/23, 12/24/23, 12/31/23 and 1/07/24 and failed to evidence documentation the physician was notified in the change in visit frequencies. During an interview on 1/10/24 beginning at 10:08 AM, the Clinical Manager indicated the clinical record for Patient #5 failed to evidence documentation the physician was notified regarding the POC frequencies not being met. 5. The review of Patient #6’s discharged clinical record (start of care 12/02/22) included a POC for the certification period 1/31/23 to 3/31/23. The POC indicated the patient was to receive Home Health Aide (HHA) services 8 hours a day, 7 days a week for 60 days. The clinical record failed to evidence HHA visits were performed 7 days a week during the weeks of 1/22/23 and 1/29/23 and failed to evidence documentation the physician was notified in the change in visit frequencies. During an interview on 1/10/24 beginning at 10:08 AM, the Clinical Manager indicated the clinical record for Patient #6 failed to evidence documentation the physician was notified regarding the POC frequencies not being met.

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 was completed by a registered nurse (RN) within 48 hours for 2 of 2 active patients reviewed with SOC in the last 7 months (Patient #3 and 4). Findings Include: 1. A review of agency policy “Initial Assessments / Comprehensive Assessments” indicated an RN must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician-ordered start of care date. 2. The review of Patient #3’s clinical record evidenced a referral for home health aide services was received on 5/30/23. The initial assessment by the Registered Nurse (RN) was performed on 6/15/23. The clinical record failed to evidence a physician order to perform the initial assessment greater than 48 hours after referral was received. During an interview on 1/10/24 beginning at 11:24 AM, the Administrator confirmed the initial assessment for Patient #3 was not performed by an RN within 48 hours of receiving the referral. 3. Review of Patient #4’s clinical record evidenced a referral for Skilled Nursing (SN) services was received on 7/12/23. The initial assessment by the Registered Nurse (RN) was performed on 8/22/23. The clinical record failed to evidence a physician order to perform the initial assessment greater than 48 hours after referral was received. During an interview on 1/10/24 beginning at 11:24 AM, the Administrator confirmed the initial assessment for Patient #4 was not performed by an RN within 48 hours of receiving the referral. 410 IAC 17-14-1(a)(1)(A)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interviews, the home health agency failed to ensure a complete and accurate medication review of all current as needed (PRN) medications for 1 of 5 active patient records reviewed (Patient #1). Findings Include: 1. A review of agency policy “Medication Orders” indicated specific PRN medication orders must specify dose, route, frequency and indication for use. 2. The clinical record for Patient #1 included a medication list which included but not limited to ipratropium bromide (a medication used to used to treat the symptoms of asthma) twice daily as needed with an indication of sick. The medication list failed to include an appropriate indication for use of the as needed medication. 3. During an interview on 1/10/24 beginning at 11:10 AM, the Clinical Manager confirmed the PRN indication of sick is not an appropriate indicator to administer PRN medications. 410 IAC 17-14-1(a)(1)(B)

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 home health agency failed to review the plan of care (POC) with the attending physician at least every 60 days for 1 of 2 active clinical records reviewed with a recertification in the last 30 days (Patient #3). Findings include: 1. A review of agency policy “Plan of Care” indicated the total plan of care will be reviewed and signed by the attending physician and agency personnel involved in the patient’s care as often as the severity of the patient’s condition requires, but at least once every sixty (60) days. 2. The review of Patient #3’s clinical record failed to evidence a POC was created for the re-certification period effective 12/12/23 to 2/09/23 and failed to evidence documentation the patient was reviewed with the attending physician at least every 60 days. 3. During an interview on 1/8/24 beginning at 4:00 PM, the Clinical Manager confirmed the clinical record for Patient #3 was missing a current POC and failed to include documentation the patient was reviewed with the physician. 410 IAC 17-13-1(a)(2)

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 home health agency failed to ensure that the recertification plan of care (POC) was created, reviewed and signed by the provider for 1 of 2 active clinical records reviewed with recertification in the last 30 days (Patient #3). Findings Include: 1. A review of agency policy “Plan of Care” indicated the total plan of care will be reviewed and signed by the attending physician and agency personnel involved in the patient’s care as often as the severity of the patient’s condition requires, but at least once every sixty (60) days. 2. The review of Patient #3’s clinical record evidenced a recertification comprehensive assessment was performed by the Clinical Manager on 12/08/23. The clinical record failed to evidence a POC was created for the re-certification period effective 12/12/23 to 2/09/23. 3. During an interview on 1/8/24 beginning at 4:00 PM, the Clinical Manager confirmed the clinical record for Patient #3 was missing a current POC. 410 IAC 17-13-1(a)(1)(A)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure frequency orders were received and recorded prior to staff providing services for 5 of 5 active records reviewed (Patients #1, 2, 3, 4 and 5). Findings Include: 1. A review of agency policy “Plan of Care” indicated the written plan of care includes the frequency and duration of visits and consultation with the physician on any modification in the POC will be documented and the physician’s signature obtained within a timely manner, or according to state law. The policy also indicated verbal orders are put in writing, signed and dated within the date of receipt by an RN or therapist responsible for furnishing or supervising ordered services. Licensed professionals must immediately record and sign, date, and time oral orders and obtain the physician’s countersignature. 2. The review of Patient #1’s clinical record included a POC for certification period 11/10/23 to 1/08/24 with orders for 1572 hours of Registered Nurse respite services for the period 3/01/23 to 2/29/24. The record evidenced SN visits were performed on 11/13/23, 11/14/23, 11/15/23 and 11/16/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed the agency did not have documentation of a signed verbal order or written orders for Patient #1’s recertification plan of care prior to 11/08/23. 3. The review of Patient #2’s clinical record included a POC for certification period 11/10/23 to 1/08/24 with orders for home health aide (HHA) 4 hours a day, 7 days a week for 60 days. The record evidenced HHA visits were performed on 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/20/23, 11/21/23 and 11/22/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed the agency did not have documentation of a signed verbal order or written orders for Patient #2’s recertification plan of care prior to 11/22/23. 4. The review of Patient #3’s clinical record included a POC for certification period 12/12/23 to 2/09/24 with orders for home health aide (HHA) 9 hours a day, 5 days a week for 60 days. The record evidenced HHA visits were performed on 12/12/23, 12/13/23, 12/15/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 1/02/24, 1/05/24 and a home visit observation on 1/08/24. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed the agency did not have documentation of a signed verbal order or written orders for Patient #3’s recertification plan of care that was created on 1/08/24. 5. The review of Patient #4’s clinical record included a POC for certification period 12/20/23 to 2/17/24 with orders for home health aide (HHA) 4 hours a day, 5 days a week for 60 days. The record evidenced HHA visits were performed on 12/20/23, 12/21/23, 12/22/23, 12/25/23 and 12/26/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed the agency did not have documentation of a signed verbal order or written orders for Patient #4’s recertification plan of care prior to 12/26/23. 6. The review of Patient #5’s clinical record included a POC for certification period 12/02/23 to 1/30/24 with orders for home health aide (HHA) 3 hours a day, 7 days a week for 60 days. The record evidenced HHA visits were performed on 12/02/23, 12/03/23 and 12/04/24. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed the agency did not have documentation of a signed verbal order or written orders for Patient #5’s recertification plan of care prior to 12/04/23. 410 IAC 17-13-1(a)(1)(iii)

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 home health agency failed to ensure all verbal orders were entered into the electronic medical record and sent to the physician for signature for 5 of 5 active charts reviewed (Patients #1, 2, 3, 4 and 5). Findings Include: 1. A review of agency policy “Plan of Care” indicated verbal orders are put in writing, signed and dated within the date of receipt by an RN or therapist responsible for furnishing or supervising ordered services. Licensed professionals must immediately record and sign, date, and time oral orders and obtain the physician’s countersignature. 2. The review of Patient #1’s clinical record included a comprehensive reassessment performed on 11/09/23 and a communication note stating a verbal order was received from Other Person B. The clinical record failed to evidence a written verbal order that was signed by the physician. During an interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed they did not create a verbal order for Patient #1’s recertification plan of care. 3. The review of Patient #2’s clinical record included a comprehensive reassessment performed on 11/09/23. The clinical record failed to evidence a verbal order that was signed by the physician. During an interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed they did not create a verbal order for Patient #2’s recertification plan of care. 4. The review of Patient #3’s clinical record included a comprehensive reassessment performed on 12/08/23 and a communication note dated 12/13/23 stating a verbal order was received from Other Person D. The clinical record failed to evidence a written verbal order that was signed by the attending practitioner. During an interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed they did not create a verbal order for Patient #3’s recertification plan of care. 5. The review of Patient #4’s clinical record included a comprehensive reassessment performed on 12/15/23 and a communication note stating a verbal order was received from Other Person F. The clinical record failed to evidence a verbal order that was signed by the physician. During an interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed they did not create a verbal order for Patient #4’s recertification plan of care. 6. The review of Patient #5’s clinical record included a comprehensive reassessment performed on 11/28/23 and a communication note stating a verbal order was received from Other Person H. The clinical record failed to evidence a verbal order that was signed by the physician. During an interview on 1/9/24 beginning at 3:42 PM, the Clinical Manager confirmed they did not create a verbal order for Patient #5’s recertification plan of care. 410 IAC 17-14-1(a)(H)

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the 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 that the recertification plan of care (POC) was reviewed by the physician at minimum of every 60 days for 1 of 2 active clinical records reviewed with recertification in the last 30 days (Patient #3). Findings Include: 1. A review of agency policy “Plan of Care” indicated the total plan of care will be reviewed and signed by the attending physician and agency personnel involved in the patient’s care as often as the severity of the patient’s condition requires, but at least once every sixty (60) days. 2. The review of Patient #3’s clinical record evidenced a recertification comprehensive assessment was performed by the Clinical Manager on 12/08/23. The clinical record failed to evidence a POC was created for the re-certification period effective 12/12/23 to 2/09/23. 3. During an interview on 1/8/24 beginning at 4:00 PM, the Clinical Manager confirmed the clinical record for Patient #3 was missing a current POC. 17-13-1(a)(2)

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, record review and interview, the home health agency failed to ensure all staff followed accepted standards of practice and agency policies and procedures to prevent the transmission of communicable diseases for 1 of 3 home health aide (HHA) home visits observed (Patient #3). Findings Include: 1. The review of an agency policy titled “Hand Hygiene / Hand Washing / Hand Cleansing” indicated staff are to perform hand hygiene before and after direct patient care, before and after each procedure, when hands are soiled, after any contact with contaminated materials and before entering patient’s clean supplies. The policy also indicated the proper procedure for hand washing when using soap and water should include the use of friction for a minimum of 20 seconds. 2. A home visit observation was conducted on 1/08/24 beginning at 3:00 PM with Patient #3. During the home visit, observed HHA 1 wearing gloves and providing peri care to Patient #3 when surveyor and Clinical Manager arrived. HHA 1 commented they forgot to obtain the proper supplies to provide the peri care. HHA 1 exited Patient #3’s room, walked into the bathroom to obtain washcloths and reentered Patient #3’s room. HHA 1 failed to remove their gloves and failed perform hand hygiene when exiting the room. HHA 1 resumed providing peri care to Patient #3. Once finished, HHA 1 exited the room again to obtain trash bags. HHA 1 returned to the room and proceeded to place the soiled trash and linens in the bags. HHA 1 then placed clean linens under Patient #3. HHA 1 failed to change their gloves and failed to perform hand hygiene before the clean linens were applied. HHA 1 adjusted Patient #3 in the bed and placed their phone and game control in Patient #3’s hands while wearing the soiled gloves. HHA 1 exited the room, walked to the kitchen to throw the trash away, removed their gloves and performed hand hygiene using soap and hot water for 14 seconds. HHA 1 commented that the water was too hot. HHA 1 failed to perform hand hygiene for at least 20 seconds. 3. During an interview with HHA 1 on 1/8/24 beginning 3:25 PM, HHA 1 stated gloves should have been changed after care, when they left the room and after peri care. They also stated hands should have been washed for 20 seconds. 4. During an interview on 1/10/24 beginning at 11:10 AM, the Clinical Manager confirmed hand hygiene should be performed upon entering the home, before, during and after patient care, in between glove changes, after gloves, anytime hands are soiled, and before preparing and serving food and they also confirmed hands should be washed at least 20 seconds. 410 IAC 17-12-1(m)