Every finding on record at Tesmac LLC

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 had the correct SOC dates, discipline, and duration of services to be provided for 3 of 3 active clinical records reviewed (Patients: #1, 5, and 6). Findings Include: 1. A review of a dated 6/2025 agency policy titled “Plan of Care (POC)” indicated but was not limited to, “Each patient of Haven of Care Home Health will receive home health services that are written in an individualized plan of care … (b) The nursing plan of care must contain the following: … (3) Services to be provided. (4) The frequency and duration of visits … ” 2. A review of the clinical record for Patient #1, SOC date of 08/04/2025, contained a POC for the recertification period 10/03/2025 through 12/01/2025. The POC section titled “Start of Care Date” listed the incorrect date of 10/02/2025. The POC indicated, but was not limited to, the following diagnoses: Cognitive Deficits following Cerebral Infarction (problems with memory and thinking after having a stroke), and the Patient’s other noncompliance with the Meds Regimen. The POC section titled “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” indicated Patient #1 had orders for Skilled Nursing one (1) time a week for medication education with the caregiver, and medication set up for Patient #1, but failed to provide the duration of the Skilled Nursing frequency. A review of a physician-signed and dated 10/08/2025 order titled “Re-Certification of Care” indicated Patient #1 had orders for a recertification for skilled nursing visits 1 times a week for medication management, and the patient’s diagnosis remained the same. A review of a POC for the initial certification period 08/04/2025 through 10/02/2025. The POC indicated, but was not limited to, the following diagnoses: Cognitive Deficits following Cerebral Infarction (problems with memory and thinking after having a stroke), and the Patient’s other noncompliance with the Meds Regimen. Review of an agency document titled “OASIS Assessment” electronically signed by the Administrator/Clinical Manager and dated 10/02/2025, noted the reason for the assessment “4. Recertification(follow-up) reassessment. The OASIS noted Patient #1’s SOC date 08/04/2025. 3. A review of the clinical record for Patient #5, SOC date of 08/01/2025, contained a POC for the recertification period 09/30/2025 through 11/28/2025. The POC section titled “Start of Care Date” listed the incorrect date of 09/29/2025. The POC indicated but was not limited to the following diagnoses: Vascular Dementia, Unspecified, Severity, Without Behavior (condition where damage to the brain from impaired blood flow caused problems with thinking, and reasoning), Age Related Physical Debility, and Alzheimer’s disease (condition of buildup of proteins forming plaque in the brain causing cells to die over time and the brain the shrink). The POC section titled” Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” indicated Patient #5 had orders for Skilled Nursing 1 visit every 30 days (2 as needed (PRN), but and discipline had been left blank for 7 days per week, 18-30 hours per week for daily skin care, hygiene, and grooming. The POC failed to identify the discipline for 7 days per week, duration, and failed to provide the duration of the Skilled Nursing frequency. A review of a physician-signed and dated 10/08/2025 order titled “Re-Certification of Care” indicated Patient #5 had orders for a recertification for skilled nursing visits 1-2 times per 30 days and 2PRN per month, Home Health Aide visits 7 days a week, 18-30 hours a week. A review of a POC for the initial certification period 08/01/2025 through 09/29/2025. The POC indicated but was not limited to the following diagnoses: Vascular Dementia, Unspecified, Severity, Without Behavior ( condition where damage to the brain from impaired blood flow caused problems with thinking, and reasoning), Age Related Physical Debility, and Alzheimer’s disease (condition of buildup of proteins forming plaque in the brain causing cells to die over time and the brain the shrink). Review of an agency document titled “OASIS Assessment” electronically signed by the Administrator/Clinical Manager and dated 09/29/2025, noted the reason for the assessment “4. Recertification(follow-up) reassessment. The OASIS noted Patient #6’s SOC incorrect date 09/29/2025. 4. A review of the clinical record for Patient #6, SOC date of 07/23/2025, contained a POC for the recertification period 09/20/2025 through 11/18/2025. The POC section titled “Start of Care Date” listed the incorrect date of 09/20/2025 and incorrect certification period dates. The POC indicated, but was not limited to, the following diagnoses: Peripheral Vascular Disease (a condition in which narrowed arteries reduce blood flow to the arms and legs), Unspecified Macular Degeneration (a condition of the eye causing blurred vision or reduced central vision caused by breakdown of the retina), and Hypertension (high blood pressure). The POC section titled “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” indicated Patient #6 had orders for Skilled Nursing one (1) time a week for medication management, but failed to provide the duration for the Skilled Nursing frequency. A review of a POC for the initial certification period 07/23/2025 through 09/20/2025. The POC indicated, but was not limited to, the following diagnoses: Peripheral Vascular Disease (a condition in which narrowed arteries reduce blood flow to the arms and legs), Unspecified Macular Degeneration (a condition of the eye causing blurred vision or reduced central vision caused by breakdown of the retina), and Hypertension (high blood pressure). Review of an agency document titled “OASIS Assessment” electronically signed by the Administrator/Clinical Manager and dated 09/20/2025, noted the reason for the assessment “4. Recertification(follow-up) reassessment. The OASIS noted Patient #6’s SOC incorrect date 09/20/2025. During an interview on 10/20/2025 at 1:07 PM, when questioned regarding the Clinical records for Patients #1, 5, and 6 having incorrect start of care dates on the POCS, and review of the disciplines ordered with frequency and duration, the Administrator/Clinical Manager stated, “The start of care dates are wrong. I don’t know why it changes them.” The Administrator/Clinical Manager further communicated the certification period as the duration of the dates. When reviewing the POC section titled “Orders for Discipline and Treatment (Specify Amount/Frequency/Duration),” the Administrator/Clinical Manager indicated that the duration needs to be located there. 410 IAC 17-13-1(a)(1)(D)(ii, iii, xiii)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 08/25/2025, 08/26/2025, 08/27/2025, and 08/28/2025 Active Census: 8 At this Emergency Preparedness survey, Haven of Care Home Health was found to be in compliance with Emergency Preparedness Requirements for Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 3 on 9/5/2025.

This visit was for an Initial Federal Medicaid and State Licensure survey of a home health agency. Survey dates: 08/25/2025, 08/26/2025, 08/27/2025, and 08/28/2025 Facility Number: 018200 12-month unduplicated census: 10 During this Federal Initial Survey, Haven of Care Homehealth was found to be out of compliance with 42 CFR 484 and out of compliance with 410 IAC 17 for a home health provider at Condition of Participation 42 CFR 484.80 Home Health Aide Services. Haven of Care is precluded from providing its own home health aide training and competency evaluation program for a period of 2 years beginning 08/28/2025 through 08/27/2027 for being found out of compliance with the Condition of Participation 42 CFR 484.80 Home Health Aide Services. Abbreviations used: HHA - Home Health Aide RN - Registered Nurse POC - Plan of Care SOC - Start of Care QR by Area 3 on 9/5/2025.

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 observation, record review and interview, the agency failed to ensure the documentation of home health aide services was completed and documented, as ordered in the Plan of Care, for 1 of 3 active patients receiving HHA services. (Patient #6) Findings include: 1. A review of an agency policy titled 'Interruption of Services/Missed Visits' stated, "… a. Complete the 'Missed Visit form, including an explanation why visit did not occur per the POC … c. All documentation will be filed in the patient chart …" 2. A review of an agency policy titled 'Records: Clinical' stated, "… All record entries into the clinical record, by all disciplines, for care/services rendered, are written at the time the service was rendered, by the primary person providing the care/service and will be incorporated into the patient's clinical record within 7 days of the delivery of service …" 3. A review of the clinical record for Patient #6 with a SOC date of 07/23/2025 for the initial certification period of 07/23/2025 to 09/20/2025 indicated home health aide visits were ordered 4 times per week for 2 hours per day to provide assistance with personal cares and activities of daily living (or ADLs, basic self-care tasks that individuals perform to maintain their daily lives) and skilled nursing 1 time per week for medication management. The record failed to evidence HHA visit notes or documentation visits had been completed. 4. On 08/26/2025 at 3:30 PM, during a home visit for Patient #6, the patient indicated their home health aide had not missed any visits. 5. On 08/25/2025 at 3:14 PM, when queried as to the clinical record of Patient #6 and the lack of HHA visit notes, or missed visit notes the Administrator/Clinical Supervisor indicated the HHA visits had been completed and explained the HHA visit note documentation remained in the home until he collected it during supervisory visits every 14 days, at which time the HHA notes were brought to the office and added to the clinical record and indicated was unaware the documentation was missing from the chart.

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 timely SOCs and failed to ensure documentation as to cause of delay, in 2 of 7 active records reviewed. (Patient #1 and #7) Findings include: 1. A review of an agency policy titled 'Admission Policy/Approved Treatments' stated, "… 1. Once the determination is made that the patient is suitable for admission, an initial assessment visit is scheduled within 48 hours of the referral unless patient and/or family or other circumstances (i.e. postponed discharge from a facility) dictate otherwise. If this occurs the clinician will document the reasons why the visit is delayed and be in communication with the medical provider about the same …" 2. A review of an agency policy titled 'Acceptance of Patients/Medical Supervision' stated, "… If patient is not assessed with the 48 hours then a new order must be obtained for a late start of care …" 3. A review of the clinical record for Patient #1 with a SOC date of 08/04/2025, evidenced physician orders for home health services were signed by the patient's provider on 07/29/2025, 6 days earlier, and failed to evidence documentation for a delay in services. 4. A review of the clinical record for Patient #7 with a SOC date of 08/15/2025, evidenced physician orders for home health services were signed by the patient's provider on 08/06/2025, 9 days earlier, and failed to evidence documentation for why there had been a delay in services. 5. On 08/24/2025 at 3:46 PM, in an interview, when queried as to the delay in patients SOCs, the Administrator/Clinical Supervisor indicated the agency makes sure they have signed orders before they see the patient and this can cause a delay. "Sometimes I leave messages for orders, sometimes the doctors' offices tell me to put what I want on the order and send it", and indicated they do as requested, and the agency goes out to complete the admission as soon as they receive the signed order back from the provider. The Administrator/Clinical Supervisor indicated they failed to document the communication in the clinical record. 6. On 08/28/2025 at 1:23 PM, in an interview, when queried as to the delay in the SOC for Patient #1 the Administrator/Clinical Supervisor indicated the patient had been out of town with family, and the family had called to inform they wanted to be there for the Admission visit and requested the SOC to be 08/04/2025. The Administrator/Clinical Supervisor indicated had failed to document the communications and failed to obtain physician orders to delay the care at the patient/family's request. 7. On 08/28/2025 at 1:37 PM, in an interview, when queried as to the delay in the SOC for Patient #7, the Administrator/Clinical Supervisor indicated the patient lived with family members, had additional family members visiting from out of town and the patient requested to wait until they had left. The Administrator/Clinical Supervisor indicated had failed to document the communications and failed to obtain physician orders to delay the care at the patient/family's request. 410 IAC 17-14-1(a)(1)(A)

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 a transfer summary had been completed and sent to appropriate parties, for 1 of 1 transferred patient reviewed. (Patient #3) Findings include: 1. A review of an agency policy titled 'OASIS-E Policy' stated, "… 3. The OASIS-E is completed at the following time points: … d. Transfer to an inpatient facility …" 2. A review of an agency policy titled 'Transfers' stated, "… Unplanned Transfer: completed & sent within 2 business days of becoming aware of the unplanned transfer if the patient is still receiving care in the health care facility at the time when the Agency becomes aware of the transfer …" 3. A review of an agency policy titled 'Records: Clinical' stated, "… o. Transfer … summaries … p. Evidence of coordination of care/services provided by the Agency with others who may be providing care/services …" 4. A review of the clinical record for Patient #3 with a SOC date of 07/29/2025 and an initial certification period of 07/29/2025 to 09/26/2025 contained an incident report dated 08/15/2025 which indicated the patient had been hospitalized with Covid and the agency had notified the ordering physician the same day. The clinical record failed to evidence a Transfer OASIS had been completed and failed to evidence a Transfer Summary had been completed and sent to the ordering physician or to the receiving facility. 5. On 08/27/2025 at 11:25 AM, in an interview, the Administrator/Clinical Manager was queried as to the lack of a Transfer OASIS or Transfer summary in the clinical record for Patient #3, after they had admitted to the hospital. The Administrator/Clinical Manager indicated they had questions about the transfer process and how this should be done, and indicated had informed all staff and the patient's physician, yet had not completed a Transfer OASIS or Transfer summary, and had not sent same to the ordering provider, nor to the receiving facility. 410 IAC 17-13-2(a)(b)(9)

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure direct care staff followed appropriate infection control practices per agency policy while providing patient care, in 2 of 2 RN home visits observed. (Administrator/Director of Nursing, who was also the visiting RN) Findings include: 1. A review of agency policy titled 'Bag Technique: Nursing' stated, "… 12. Wash your hands again if you need to re-enter the bag for additional supplies during patient care …" 2. On 08/26/2025 at 10:35 AM, during a home visit for Patient #10, the Administrator/Clinical Manager (who was also the RN providing care) was observed performing a blood pressure reading for the patient. Afterwards, the RN reached into their nursing bag with gloved hands to retrieve a notebook, contaminating the interior of the bag, and proceeded to record their findings in the notebook. The RN had failed to doff their gloves and perform hand hygiene before re-entering their bag. 3. On 08/27/2025 at 2:55 PM, during a home visit for Patient #5, the Administrator/Clinical Supervisor (who was also the RN providing care) was observed preparing to take vital signs on the patient. With gloved hands, the RN re-entered the nursing bag to retrieve a thermometer, contaminating the interior of the bag, and failed to doff their gloves and perform hand hygiene, before re-entering their bag. 4. On 08/28/2025 at 1:13 PM, in an interview, when queried as to the breaches in infection prevention during the home visits, the Administrator/Clinical Supervisor stated, "I have to take my gloves off" and indicated needed to perform hand hygiene in between tasks.

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 home health aides were appropriately trained prior to providing aide services to patients; failed to ensure home health aides had completed appropriate home health aide competency training (see G0754), Based on record review and interview the agency failed to ensure it retained documented evidence of completed home health aide competency evaluation program (see G0766), failed to document evidence home health aides had successfully completed a competency evaluation program before furnishing direct care to agency clients (see G0768), and failed to ensure home health aide supervisory visits were conducted (see G0808). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services. These practices had the potential to impact all 8 active skilled patients serviced by the agency. *

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure home health aides were qualified to provide services by failing to ensure they had completed appropriate home health aide competency training, in 2 of 2 HHA personnel files reviewed. (HHAs 1 and 2) Findings include: 1. A review of an agency policy titled 'Competency Testing: Clinical Staff' stated, "… Paraprofessional's competency testing is completed after hire and before unsupervised direct patient service … Skills competency testing will be performed by a 'like' discipline as follows: … Registered Nurses (including Clinical Manager) will perform skills competency testing for employees that perform home health aide duties … Competency testing includes a combination of: a written exam, demonstration of core competency skills, verbal presentation as appropriate to the skill being evaluated. The Agency will also utilize: … Use of knowledge-based tests … Situational analysis/case studies … Self-assessment …" 2. A review of untitled agency policy stated, "… 12. HOME HEALTH AIDE (HHA) … Will have successfully completed an Aide training program of no less than 75 hours which meets state and federal standards and have a certificate of completion … Will have successfully completed competency testing …" 3. On 08/25/2025, a review of the personnel file for HHA 1 with a date of hire of 04/14/2025 and a first patient contact date of 8/18/2025, indicated an HHA license had been issued 04/01/202. The record failed to evidence home health aide training/education, a written competency exam, or a skills check-off had been completed. 4. On 08/25/2025, a review of the personnel file for HHA 2 with a date of hire of 03/15/2025 and a first patient contact date of 07/28/2025, indicated an HHA license had been issued 04/01/2025. The record failed to evidence home health aide training/education, a written competency exam, or a skills check-off had been completed. 5. On 08/28/2025, a review of a document from Entity 1, an online-based home health aide training platform, titled 'Home Health Aide Skills' for 'Competency Evaluation Checklist for Hands-On skills Demonstration' which failed to evidence the aide was competencied for "bed bath", "sponge bath", or "shampooing … in bed … sink … tub or shower …" and was signed and dated by HHA 1 and the Administrator/Clinical Supervisor on 03/21/2025. The document contained an attached form titled 'HOME HEALTH AIDE REGISTRY APPLICATION' which had been completed and signed by HHA 1 and the Administrator/Clinical Supervisor on 03/26/2025, no additional documentation was included. 6. On 08/28/2025, a review of a document from Entity 1, an online-based home health aide training platform, titled 'Home Health Aide Skills' for 'Competency Evaluation Checklist for Hands-On skills Demonstration' which failed to evidence the aide was competencied for "bed bath", "sponge bath", or "shampooing in bed", and was signed and dated by HHA 2 and the Administrator/Clinical Supervisor on 03/21/2025 and 03/27/2025. The document contained an attached form titled 'HOME HEALTH AIDE REGISTRY APPLICATION' which had been completed and signed by HHA 2 and the Administrator/Clinical Supervisor on 03/27/2025, no additional documentation was included. 7. On 08/25/2025 at 10:33 AM, in an interview, the Administrator/Clinical Supervisor indicated the agency had a program to train Home Health Aides and explained the trainees completed 76 hours of online training with modules which contained videos and exams completed, were completed via Entity 1, an on-line based home health aide training platform. "Then I do 16 hours of competency myself" and indicated there was a checklist that was completed with the trainees, after which the trainees were placed on the State Aide Registry. 8. On 08/28/2025 at 2:50 PM, in an interview, a request was made of the Administrator/Clinical Supervisor (as the agency was unable to provide documentation of the HHA's skills training/competency and written competency exam) to provide the writer with the same information submitted to the Indiana State Aide Registry, used to place the aides on the registry. The Administrator provided Home Health Aide Registry applications, attached were skills check-off forms (as above), and failed to evidence a written competency exam, or other documentation of the agency's Home Health Aide training. The Administrator indicated the written competency exams were conducted via Entity 1, an online-based home health aide training platform, which had been 'uploaded' to the State Aide Registry, and they could not reproduce this nor provide evidence of same, such as certificates of completion. When queried as to a location where the skills competency testing and training were conducted, the Administrator/Clinical Supervisor indicated in the agency's office, and they had utilized a rolling walker, chair, and gait belt to demonstrate and 'return demonstrate' appropriate transfers and appropriate use of gait belt. Vital sign equipment was also used during training, and return demonstrations of obtaining vital sign measurements had been completed by the trainees. When queried as to the lack of a bed, mannequin, or hoyer lift for training purposes, the Administrator/Clinical Supervisor confirmed none of this equipment was on-site, and only one current patient possessed a hoyer lift, this hoyer lift would not be utilized by either HHA, as neither aide would be assigned to the patient in the future. The Administrator/Clinical Manager indicated the checklist presented to the State Aide Registry was what had been utilized to teach specific item to the trainees. The Administrator/Clinical Supervisor stated had spent excessive time reviewing and explaining each, and afterwards ensured the trainees verbalized back what had been taught. When queried as to how bed bath training and competency had been conducted, the Administrator/Clinical Supervisor stated since there was no bed to utilize for practice, HHA 1, who was the paid caregiver and family member for Patient #7, was trained in the patient's home. The Administrator explained the bathing procedure to HHA 1, the patient was clothed and laying in their in own bed, HHA 1 verbalized understanding and explained and motioned through the process of giving a bed bath, but had not 'return demonstrated' an actual bed bath. The Administrator indicated foot care training and competency had been conducted, and both aides had proficiently return demonstrated the task on each other utilizing basins with water. When queried as to how perineal care (the process of cleaning the external genital and anal areas to maintain hygiene, prevent infections, reduce odor, and provide comfort) training and competency had been conducted, the Administrator indicated they had explained the technique for both male and female perineal care, and afterwards had the trainees verbalize understanding of same, confirmed there was no mannequin or pseudo patient utilized for demonstration, and there was not a 'return demonstration' performed by either aide. 410 IAC 17-14-19(l)(1)(A)

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure it retained documented evidence of completed home health aide competency evaluation program, for 2 of 2 HHAs. (HHA 1 and 2) Findings include: 1. A review of an unnamed agency policy titled '13. EMPLOYEE PERSONNEL FILE ORGANIZATION' stated, " … RED FILE … Competency Skills Checklist … HHA training certificate/Competency Certificate …" 2. A review of the personnel file for HHA 1 with a date of hire of 04/14/2025 and a first patient contact date of 8/18/2025, failed to evidence completion of a competency evaluation program. 3. A review of the personnel file for HHA 2 with a date of hire of 03/15/2025 and a first patient contact date of 07/28/2025, failed to evidence completion of a competency evaluation program. 4. On 08/28/2025 at 2:50 PM, in an interview, when queried as to the lack of written competency exams and skills competency in the personnel files of HHA 1 and 2, the Administrator/Clinical Supervisor indicated the written competency exams were conducted via Entity 1, an online-based home health aide training platform, which had been 'uploaded' to the State Aide Registry, and they could not reproduce a copy nor provide evidence of same, such as certificates of completion. When queried as to how the HHAs would be able to obtain a copy of their completed written competency exams, the Administrator/Clinical Supervisor indicated the aides were able to download their own copies from Entity 1. 410 IAC 17-14-1(l)(2)

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 document evidence home health aides had successfully completed a competency evaluation program before furnishing direct care to agency clients, in 2 of 2 HHA personnel records reviewed. (HHA 1 and 2) Findings include: 1. A review of an agency policy titled 'Competency Testing: Clinical Staff' stated, "… All direct care patient employees … Paraprofessional's competency testing is completed after hire and before unsupervised direct patient service … Competency testing includes a combination of: a written exam, demonstration of core competency skills, verbal presentation as appropriate to the skill being evaluated …" 2. A review of the personnel file for HHA 1 with a date of hire of 04/14/2025 and a first patient contact date of 8/18/2025, failed to evidence completion of a competency evaluation program. 3. A review of the personnel file for HHA 2 with a date of hire of 03/15/2025 and a first patient contact date of 07/28/2025, failed to evidence completion of a competency evaluation program. 4. On 08/25/2025 at 10:33 AM, in an interview, the Administrator/Clinical Supervisor indicated the agency had a program to train Home Health Aides and explained the trainees completed 76 hours of online training with modules which contained videos and exams completed via Entity 1, an on-line based home health aide training platform. "Then I do 16 hours of competency myself" and indicated there was a checklist that was completed with the trainees, after which the trainees were placed on the State Aide Registry. 5. On 08/28/2025 at 2:50 PM, in an interview, when queried for the HHAs written competency exams, the Administrator indicated was unable to provide a copy of the aide's completed and graded exams for surveyor review, to determine date(s) completed, grade/result, who conducted and graded the exams, along with their qualifications. 410 IAC 17-14-1(l)(1)(A)

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 supervisory visits were conducted, in 1 of 3 active patients receiving HHA services. (Patient #6) Findings include: 1. A review of an agency policy titled, 'Supervision: Clinical Staff' stated, "… 3. AIDE STAFF: a. If Aide services are provided to a patient who is receiving skilled nursing … an RN … must perform the onsite supervision every 14 days … 8. The Clinical Manager/ Administrator will have primary accountability to assure this supervisory policy is being adhered to and that timely documentation exists …" 2. A review of the clinical record for Patient #6 with a SOC date of 07/23/2025 for the initial certification period of 07/23/2025 to 09/20/2025 indicated home health aide visits were ordered 4 times per week for 2 hours per day to provide assistance with personal cares and activities of daily living (or ADLs, basic self-care tasks that individuals perform to maintain their daily lives) and skilled nursing 1 time per week for medication management. The record failed to evidence the nurse had completed a supervisory visit. 3. On 08/25/2025 at 2:40 PM, in an interview, the Administrator/Clinical Supervisor (who was also the visiting RN) was queried as to the lack of supervisory visits for Patient #6, stated, "let me look" and indicated they were not in the chart, verbalized it had been greater than 14 days, and would see the patient the following day as scheduled to complete their HHA supervisory visit.