Every finding on record at The Frazier Health Group LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 03/24/2025, 03/25/2025, and 03/26/2025. Active Census: 7 At this Emergency Preparedness survey, The Right Touch Home Health Care, LLC was found to be out of compliance with Conditions of Participation Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102 QR complete by Area 3 on 4/02/2025.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive emergency preparedness program met all requirements to ensure the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to include documented attempts to contact officials in an effort to collaborate and maintain an integrated response during a disaster (E0009); failed to include an individualized emergency plan was documented for 5 of 7 (Patients: #1, 3, 4, 7, and 8) active records reviewed (E00017); failed to include the use of volunteers in an emergency or other emergency staffing (E0024); failed to ensure that an emergency preparedness communication plan included all staffing addresses and phone numbers, entities providing services under arrangements, and patient physicians for all districts/ territories that the agency provided services to (E0030); and failed to include contact information for Federal, State, tribal, regional, and local emergency preparedness officials (E00031). The cumulative effect of these systemic problems resulted in the agency being found out of compliance with the condition, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies. at 42 CFR 484.102. Findings include: 1. A review of an agency policy titled ‘Emergency Preparedness Plan' dated 2024, indicated the following but not limited to “… complies with the Centers for Medicare and Medicaid Services (CMS) Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers … Establish coordination with local, regional, state, and federal emergency preparedness entities … Patients will be classified as high-risk, moderate risk, or low risk based on medical needs … Identify hospitals, shelters, and partner agencies for care continuation … Maintain an updated emergency contact list for staff, clients, and emergency services …” 2. A review of an agency policy titled ‘Emergency Preparedness Communication Plan’ undated, indicated the following but not limited to “ … Liaises with emergency responders, local/state agencies … Maintain active collaboration with local EMS, fire, and police departments … Maintain detailed records of all emergency communications including … external agency interactions … Maintain updated staff contact information and emergency roles …” 3. During an interview on 03/25/2025 at 2:25 PM, the Administrator indicated there was no collaboration with Federal, State, tribal, regional, and local emergency officials. Administrator indicated there was no contact list of officials. 4. In an interview on 03/25/2025 at 2:40 PM, the Administrator indicated not all active records had a 'disaster preparedness form' and risk levels were not documented on the patients' plan of care. When queried regarding the agency's use of volunteers and/or other emergency staff, she indicated the information was not included in the policy. When queried regarding contact information for staff, patients' physicians, volunteers, and other entities providing services under arrangement, Administrator indicated the information was not included in the agency's communication plan.

This visit was for a Federal Medicaid initial home health agency survey. On 03/25/2025 at 3:08 PM, the survey was announced fully extended. Survey dates: 03/24/2025, 03/25/2025, and 03/26/2025 Facility Number: 017740 Active Census: 7 During this Federal Initial Survey, The Right Touch Home Health Care was found to be out of compliance with Conditions of Participation 484.55 Comprehensive Assessment of Patients; and 484.60 Care Planning, Coordination of services, and Quality of Care, and 484.102 Emergency Preparedness. Based on the Condition-level deficiencies during the 03/26/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 03/25/2025. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation program for a period of two years beginning 03/26/2025 and continuing through 03/25/2025. QR completed by Area 3 on 4/02/2025.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure comprehensive assessments accurately reflected patients' health status, psychosocial status, functional limitations, and cognition (see G528), failed to ensure comprehensive assessments accurately reflected patients' goals (see G530), failed to ensure a comprehensive assessment had been completed for recertification thereby failing to document the patient's need for continuing care (see G532), failed to ensure comprehensive assessments reflected a drug regimen review had been conducted (see G536), and failed to ensure the comprehensive assessment for a recertification occurred during the last 5 days of the certification period (see G546). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. These practices had the potential to impact all 7 active patients, in a total of 7 active home health patients serviced by the agency. *

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure comprehensive assessments accurately reflected patients' health status, psychosocial status, functional limitations, and/or cognition for 7 of 7 active clinical record reviewed. (Patients #1, 2, 3, 4, 5, 7 and 8) Findings include: 4. A review of the clinical record for Patient #2 evidenced an Comprehensive Adult Nursing Assessment dated 03/12/2025 completed by the Administrator indicated but not limited to Risk Factors/Hospital Admission/Emergency Room indicated Patient #2 was a quadriplegic. Patient #2's neurological status was within normal limits and had a suprapubic catheter. The record failed to evidence how Patient's #2 neurological status was affected with the diagnosis of a quadriplegic and failed to ensure the size of the suprapubic catheter. 5. A review of the clinical record for Patient #3 evidenced an Comprehensive Adult Nursing Assessment dated 02/22/2025 completed by the Administrator indicated by not limited to: primary diagnoses are but not limited to left below knee amputation (BKA) and diabetes, gender and date of birth was left blank, diabetic foot examine was left blank, Nutritional was marked no problem, Patient #3 was to receive wound care to the Left BKA with a wound vac (a medical device that uses negative pressure to promote wound healing), and the durable medical equipment (DME) listed were 2x2's and saline. The record failed to evidence gender and their date of birth, failed to evidence a right foot diabetic exam, nutritional status failed to evidence a diabetic diet, and failed to evidence wound care DME required to care for Patient #3. 6. A review of the clinical record for Patient #4 evidenced a Recertification/Follow-Up Assessment dated 03/06/2025 completed by the Administrator indicated Patient #4 was receiving total parenteral nutrition (TPN, a medical treatment that provides all the necessary nutrients directly into the bloodstream through a catheter), and peripherally inserted central catheter (PICC line is a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein in the chest), PICC line in left upper arm that was managed by Entity 2 a home infusion therapy company. On 03/26/2025 at 1:12 PM during a phone interview with Person 3 from Entity 2, a home infusion agency, indicated Patient #4 was discharged from their agency on 01/22/2025 with the PICC line removed the same day. 7. A review of the clinical record for Patient #7 evidenced a Comprehensive Adult Nursing Assessment dated 02/12/2025 completed by the Administrator. The Assessment indicated Patient #7 had no problems with Bowel Elimination then indicated Bowel incontinence Frequency was 2-3 times a week and the Nutritional assessment was blank. The record failed to accurately assess Patient's #7 Bowel elimination and nutritional needs. 8. A review of the clinical record of Patient #8 evidenced discharge paperwork from Entity 1, an acute care hospital indicated the patient was to receive wound care for wound vac changes to the left groin, change M-W-F with supplies required: mastisol (to secure dressings, tapes, and certain medical devices to the skin, ensuring secure placement over an extended period), stoma powder (application on broken skin around the opening to protect it from irritation), medium vac sponge, and duoderm (a hydrocolloid, moisture-retentive wound dressing used for partial and full-thickness wounds with exudate). The Clinical Record of Patient #8 evidenced an Comprehensive Adult Nursing Assessment dated 02/22/2025 completed by the Administrator for Patient #8 indicated the following were not addressed when the assessment was conducted: Bowel Elimination, Active Diagnoses, Endocrine/Hematology, Risk for Hospitalization, Pain, Cardiopulmonary, Nutritional Status, Skin Conditions, and Medications. Current DME/Medical Supplies list was 2 x2's and saline. The record failed to contain a completed assessment and failed to evidence all wound care DME supplies required for Patient #8. 9. On 03/26/2025 at 1:35 PM, the Administrator indicated they expected all assessments should be complete and accurate. 410 IAC 17-14-1(a)(1)(A) 1. A review of an undated agency policy titled 'COMPREHENSIVE CLIENT ASSESSMENT C-145' stated, "… The Comprehensive Assessment must accurately reflect the client's status, and must include at a minimum, the following information: The client's current health, psychosocial, functional, and cognitive status …" 2. A review of the clinical record for Patient #1 with a start of care date of 12/02/2024 for the initial certification period of 12/02/2024 to 01/30/2025, with diagnoses which included, but were not limited to: Chronic obstructive pulmonary disease (COPD) (lung disease causing ongoing inflammation and narrowing of the airways, making it difficult to breathe). The record contained an initial comprehensive assessment dated 12/02/2025 completed by the Administrator, failed to evidence 'dyspnea (shortness of breath or difficulty breathing) with minimal exertion' had been documented as a functional limitation. 3. A review of the clinical record for Patient #5 with a start of care date of 01/18/2025 for the initial certification period of 01/18/2025 to 03/18/2025, with diagnoses which included, but were not limited to: Arteriosclerotic Heart Disease (ASHD) (condition where the arteries that supply blood to the heart become narrowed and hardened due to the buildup of fatty deposits on their walls causing chest pain, shortness of breath, and fatigue). The record contained an initial comprehensive assessment dated 01/18/2025 completed by the Administrator, which failed to evidence the patient's height and weight. The record also contained a comprehensive reassessment for the recertification period of 03/19/2025 to 05/17/2025 dated 03/13/2025 completed by the Administrator, which failed to evidence date of patient's last bowel movement, failed to evidence the nurse had assessed bowel sounds, failed to evidence patient's height and weight, and whether there had been a change in weight in the previous 60-day period.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure comprehensive assessments accurately reflected patients' goals for 6 of 7 active clinical record reviewed. (Patients #1, 2, 3, 5, 7 and 8) Findings include: 6. The Clinical Record of Patient #1 evidenced a Comprehensive Adult Nursing Assessment dated 12/02/2024 completed by the Administrator, which failed to evidence patient stated goals. 7. The Clinical Record of Patient #5 evidenced a Comprehensive Adult Nursing Assessment dated 01/18/2025 completed by the Administrator, which failed to evidence patient stated goals. 8. On 03/24/2025 at 2:50 PM, while discussing findings related to absence of goals in the clinical records, the Administrator was asked if the patients had voiced their goals, or if she had inquired what their goals might be, stated there were, "none really". 1. A review of an undated agency policy titled 'COMPREHENSIVE CLIENT ASSESSMENT C-145' stated, "… The Comprehensive Assessment must accurately reflect the client's status, and must include at a minimum, the following information: … c. The client's strengths, goals … information … demonstrate the client's progress toward achievement of the goals …" 2. The clinical record of Patient #2 evidenced an Comprehensive Adult Nursing Assessment dated 03/12/2025 completed by the Administrator for Patient #2 failed to evidence patient stated or agency goals. 3. The clinical record of Patient #3 evidenced an Comprehensive Adult Nursing Assessment dated 02/22/2025 completed by the Administrator for Patient #3 failed to evidence patient stated or agency goals. 4. The Clinical Record of Patient #7 evidenced an Comprehensive Adult Nursing Assessment dated 02/12/2025 completed by the Administrator for Patient #7 failed to evidence patient stated or agency goals. 5. The Clinical Record of Patient #8 evidenced an Comprehensive Adult Nursing Assessment dated 02/22/2025 completed by the Administrator for Patient #8 failed to evidence patient stated or agency goals.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a comprehensive assessment had been completed for recertification, thereby failing to document the patient's need for continuing care, in 1 of 1 active record without a comprehensive assessment for recertification. (Patient #1) Findings include: 1. A review of an undated agency policy titled 'CLIENT REASSESSMENT/UPDATE TO COMPREHENSIVE ASSESSMENT C-155' stated, "… 8. The assessment will identify the problems, needs … of the client … ongoing assessments include consideration of the following: a. Specific individualized client needs pertinent to the care or service being provided … g. Need for continuing home care services …" 2. A review of the clinical record for Patient #1 with a start of care date of 12/02/2024 for the initial certification period of 12/02/2024 to 01/30/2025. The record contained an initial comprehensive assessment dated 12/02/2025 completed by the Administrator, but failed to contain a comprehensive reassessment for the recertification period of 1/31/2025 to 03/31/2025. 3. On 03/25/2025 at 10:25 AM, when queried as to the Recertification assessment documentation for Patient #1, the Administrator indicated this had not been completed, and cited a recent failed attempt to adopt an electronic medical record (EMR) system, stated the reassessment visit had indeed occurred on 01/28/2025, but there was no documentation.

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 interview the agency failed to ensure comprehensive assessments reflected a drug regimen review had been conducted, for 3 of 7 active clinical records reviewed. (Patients #1, 4, and 8) Findings include: 4. A review of the Clinical Record for Patient #1 evidenced a Comprehensive Adult Nursing Assessment dated 12/02/2024 completed by the Administrator, and failed to evidence a drug regimen review had been completed. Further review of the record evidenced a Recertification/Follow-up Assessment dated 03/13/2025 completed by the Administrator, which failed to indicate a date when the drug regimen had been reviewed. 5. On 3/26/2025 at 1:40 PM, the Administrator indicated understood drug regimen reviews needed to be addressed and documented in patients' comprehensive assessments. 410 IAC 17-14-1(a)(1)(B) 1. A review of an undated agency policy titled 'COMPREHENSIVE CLIENT ASSESSMENT C-145' stated, "… The Comprehensive Assessment must accurately reflect the client's status, and must include at a minimum, the following information: … f. A review of all medications including over the counter medications the client is taking 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. 2. A Review of the Clinical Record for Patient #4 evidenced an Recertification/Follow-Up Assessment dated 03/06/2025 completed by the Administrator failed to indicate when the drug regimen had been reviewed. 3. A review of the Clinical Record for Patient #8 evidenced an Comprehensive Adult Nursing Assessment dated 02/22/2025 completed by the Administrator indicated a drug regime was not completed.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the comprehensive assessment for a recertification occurred during the last 5 days of the certification period, for 2 of 7 active records reviewed. (Patients #1 and 5) Findings include: 1. A review of an undated agency policy titled 'CLIENT REASSESSMENT/UPDATE OF COMPREHENSIVE ASSESSMENT C-155' stated, "… Reassessments must be done at least: 1. Every second calendar month beginning with start of care {within last five (5) days of the episode, including day sixty (60)} …" 2. A review of the clinical record for Patient #1 with a start of care date of 12/02/2024, contained an initial comprehensive assessment for the initial certification period of 12/02/2024 to 01/30/2025. The record failed to contain a comprehensive assessment for the recertification period of 01/31/2025 to 03/31/2025, but instead contained a signed Plan of Care for a recertification period of 01/28/2025 through 03/28/2025, completed by the Administrator on 01/28/2025. 3. A review of the clinical record for Patient #5 with a start of care date of 01/18/2025, contained an initial comprehensive assessment for the initial certification period of 01/18/2025 to 03/18/2025. The record also contained a comprehensive assessment for the recertification period of 03/19/2025 to 05/17/2025, completed by the Administrator on 03/13/2025. 4. On 03/24/2025 at 2:50 PM, when queried as to their understanding of home health certification periods, the Administrator indicated a recertification was to be completed five (5) days before the end of the certification period. Indicated did not realize Patient #5's recert and reassessment had been completed too early. 5. On 03/25/2025 at 10:25 AM, when queried as to the location of the Recertification assessment documentation for Patient #1, the Administrator indicated this had not been completed, and cited a recent failed attempt to adopt an electronic medical record (EMR) system, stated the reassessment visit had indeed occurred on 01/28/2025, but there was no documentation. IAC 410 17-14-1(a)(1)(B)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure skilled nursing visits were conducted and documented as ordered, and failed to ensure patient- specific, measurable goals were documented (see G572), failed to include all elements required in the Plan of Care (see G574), failed to assure all communication with patients' providers involved in the plan of care was documented (see G602). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. These practices had the potential to impact all 7 active home health patients serviced by the agency. *

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing visits were conducted and documented as ordered in 6 of 7 active records reviewed (Patients #1, 3, 4, 5, 7, and 8). Findings include: 7. A review of the clinical record for Patient #1 evidenced a Plan of Care with a start of care date of 01/28/2025 for the recertification period of 01/28/2025 to 03/28/2025. Patient #1 was to receive skilled nursing services 1 time per week for medication management and teaching for 8 weeks. Further review of the clinical record failed to evidence skilled nursing visits had been documented for the weeks of: 02/02/2025, 02/09/2025, 02/16/2025, 02/23/2025, 03/02/2025, 03/09/2025, and 03/16/2025. 8. A review of the clinical record for Patient #5 evidenced Plans of Care with a start of care date of 01/18/2025 for the initial certification period of 01/18/2025 to 03/18/2025, the plan of care indicated Patient #5 was to receive skilled nursing services 1 time per week for medication management for 8 weeks. Further review of the clinical record failed to evidence a skilled nursing visit note had been documented for the week of: 01/19/2025. 9. On 03/25/2025 at 8:56 AM, when queried as to the visit note for Patient #5 the week of 01/19/2025, the Administrator indicated the skilled nursing visit note wasn't documented. 410 IAC 17-13-1(a) 1. A review of an undated policy titled 'CLINICAL DOCUMENTATION C-680' stated, "… POLICY Agency will document each direct contact with the client … PURPOSE To ensure that there is an accurate record of the services provided … SPECIAL INSTRUCTIONS All skilled services provided by Nursing … will be documented in the clinical record …" 2. A review of the clinical record for Patient #3 evidenced a Home Health Certification and Plan of Care with 02/22/2025 for a start of date for the certification period of 02/22/2025 through 04/22/2025. Patient #3 was to receive skilled nursing services 3 times a week for wound care. Further review of the clinical record failed to evidence skilled nursing visit notes for the current certification period. 3. A review of the clinical record for Patient #4 evidenced a Home Health Certification and Plan of Care with 01/07/2025 for a start of date for the certification period of 01/07/2025 through 03/07/2025. Patient #4 was to receive skilled nursing services 1 time a week for wound care. Further review of the record evidenced a Home Health Certification and Plan of Care with 03/08/2025 for a start of date for the certification period of 03/08/2025 through 05/06/2025. Patient #4 was to receive skilled nursing services 1 time a month for wound care. The record evidenced skilled visit notes for 01/09/2025, 01/16/2025, 01/23/2025, 01/20/2025, 02/06/2025, 02/13/2025, 02/20/2025 which were not completed or signed by the Administrator and failed to evidence skilled nursing visit notes from 02/21/2025 through 03/26/2025. 4. A review of the clinical record for Patient #7 evidenced a Home Health Certification and Plan of Care with 02/12/2025 for a start of date. Patient #4 was to receive skilled nursing services 1 time a week for medication management and teaching for 8 weeks. Further review of the clinical record failed to evidence skilled nursing visit notes. 5. A review of the clinical record for Patient #8 evidenced a Home Health Certification and Plan of Care with 02/22/2025 for a start of date for the certification period of 02/22/2025 through 04/22/2025. Patient #8 was to receive skilled nursing services 3 time a week for wound care. Further review of the clinical record failed to evidence completed skilled nursing visit notes for the following dates: 02/28/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/10/2025, 03/12/2025, 03/14/2025, 03/17/2025, 03/19/2025, and 03/21/2025. 6. On 03/27/2025 at 2:33 PM, the Administrator indicated they had initiated training with Entity 4, an electronic medical record system (EMR), had hoped to utilize the EMR for documentation purposes but it failed to work out, and they got behind in their documentation, insisted all the visits were completed, and when they submitted their letter of readiness they hoped for a couple of weeks to get caught up before surveyors initiated the survey.

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 include all durable medical equipment (DME) in use 2 of 7 active records review (Patients #1 and 5), failed to evidence complete treatment/wound orders in 2 of 3 wound care patients (Patients #3 and 8), and failed to evidence all applicable functional limitations in 2 of 7 active patients (Patients #1 and #5), and failed to evidence patient goals in the Plan of Care, in 7 of 7 active patients (Patients #1, 2, 3, 4, 5, 7, 8) Findings include: 7. A review of the clinical record for Patient #1 failed to evidence a Home Health Recertification, but contained a Plan of care with a start of care date of 01/28/2025 for the recertification period of 01/31/2025 through 03/31/2025 and contained diagnoses which included, but were not limited to: Chronic obstructive pulmonary disease (COPD) (lung disease causing ongoing inflammation and narrowing of the airways, making it difficult to breathe). The medication list included, but was not limited to: Oxygen, continuous at 3 liters per minute via nasal cannula. The patient required a shower chair for bathing. The plan of care failed to evidence nasal cannula(s), oxygen tubing, and the shower chair were included as required medical supplies, failed to evidence 'oxygen precautions' had been included as a safety risk, and failed to evidence patient-stated goals. 8. A review of the clinical record for Patient #5 evidenced a Home Health Certification and Plan of care with a start of care date of 03/19/2025 for the certification period of 03/19/2025 through 05/17/2025 and contained a medication list which included, but was not limited to: Clopidogrel (a blood thinning drug, which can increase chances of bleeding) 75mg by mouth once per day. The record further indicated the patient required a cane to assist with ambulation. The plan of care failed to evidence ‘bleeding precautions’ had been included as safety risk, failed to evidence ‘ambulation’ as a functional limitation, and failed to evidence patient-stated goals. 9. On 03/26/2025 at 1:42 PM, while discussing missing components of the plan of care and discrepancies between plans of care and comprehensive assessments in the clinical records, the Administrator acknowledged the concern and indicated going forward would be utilizing the alternate clinical manager to conduct chart reviews together to prevent future occurrences. 410 IAC 17-13-1(a)(1)(D)(i-xiii) 1. A review of an undated agency policy titled ‘PLAN OF CARE C-580’ stated, “… 2. The Plan of Care shall be completed in full to include: … j. Functional limitations and precautions … m. … treatments, and procedures … n. Medical supplies and equipment required … q. Treatment goals … v. All of the above items must always be addressed on the Plan of Care …” 2. A review of the clinical record for Patient #2 evidenced a Home Health Certification and Plan of Care with 03/12/2025 as a start of care date for the certification period of 03/12/2025 through 05/10/2025. The record failed to evidence patient stated goals. 3. A review of the clinical record for Patient #3 evidenced a Home Health Certification and Plan of Care with 02/22/2025 for a start of date for the certification period of 02/22/2025 through 04/22/2025. Patient #3 was to receive wound care 3 times a week "to be treated with negative pressure wound therapy. Vac (a medical device that uses negative pressure to promote wound healing) settings 125mmHG continuous therapy ( a type of negative pressure wound therapy (NPWT) that uses a device to apply a continuous negative pressure of -125 mmHg to a wound site, often used for wound healing and management)". A review of a discharge document from Entity 1, an acute care hospital indicated Patient #3 was to receive negative pressure wound treatment, to remove previous dressing, cleanse by choice. Periwound cleansed with skin prep, wound margins lined with duoderm, 2 pieces, placed in wound bed, secured with drape, TRAC (continuously monitors negative pressure at the wound site and compensates for any changes, maintaining a consistent environment for fluid removal) pad placed. Apply ace wrap to Left below knee amputation for edema management and to assist with seal maintenance. Settings 125 mmHG . The record failed to evidence patient stated goals and failed to have a complete wound care order as to how to clean and what to apply. 4. A review of the clinical record for Patient #4 evidenced a Home Health Certification and Plan of Care with 03/08/2025 for a start of date for the certification period of 03/08/2025 through 05/06/2025. The record failed to evidence patient stated goals. 5. A review of the clinical record for Patient #7 evidenced a Home Health Certification and Plan of Care with 02/12/2025 for a start of date. The record failed to evidence patient stated goals. 6. A review of the clinical record for Patient #8 evidenced a Home Health Certification and Plan of Care with 02/22/2025 for a start of date for the certification period of 02/22/2025 through 04/22/2025. Patient #8 was to receive skilled nursing visits 3 times a week for wound care, Wound care orders for the left inner thigh cutaneous abscess "treated with negative pressure wound therapy. Vac settings 125mmHG continuous therapy" Further review of the clinical record of Patient #8 evidenced discharge documents from Entity 1, an acute care hospital indicated the patient was to receive wound care for wound vac changes to the left groin, change M-W-F with supplies required: mastisol (to secure dressings, tapes, and certain medical devices to the skin, ensuring secure placement over an extended period), stoma powder (application on broken skin around the opening to protect it from irritation), medium vac sponge, and duoderm (a hydrocolloid, moisture-retentive wound dressing used for partial and full-thickness wounds with exudate). The record failed to evidence patient stated goals and failed to have a complete wound care order as to how to clean and what to apply.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to assure all communication with patients' providers involved in the plan of care was documented, in 3 of 7 active records reviewed. (Patients #3, 7, and 8) Findings include: 2. A review of the clinical record for Patient #3 evidenced an Initial Comprehensive Adult Nursing Assessment dated 02/22/2025 which was completed by the Administrator. The Care Coordination the Assessment indicated care was coordinated with the Patient, additional care coordination and communication with the certifying physician was left blank. The record failed to have communication notes with the certifying physician. 3. A review of the clinical record for Patient #7 evidenced an Initial Comprehensive Adult Nursing Assessment dated 02/12/2025 which was completed by the Administrator. For Care Coordination the Assessment indicated care was coordinated with the Patient, additional care coordination and communication with the certifying physician was left blank. The record failed to have communication notes with the certifying physician. 4. A review of the clinical record for Patient #8 evidenced an Initial Comprehensive Adult Nursing Assessment dated 02/22/2025 which was completed by the Administrator. The Care Coordination the Assessment indicated care was coordinated with the Patient, additional care coordination and communication with the certifying physician was left blank. The record failed to have communication notes with the certifying physician. 5. On 03/24/2025 at 3 PM, the Administrator indicated they had communicated with the patient's physicians but failed to document in the patient clinical records. 410 IAC 17-14-1(a)(1)(G) 1. A review of an undated agency policy titled 'CLINICAL DOCUMENTATION C-680' stated, "… 4. Telephone or other communication with … physicians/allowed nonphysician practitioner (NPP) … or other members of the health care team will be documented in clinical progress notes or other interagency communication form …" A review of an undated agency policy titled 'SKILLED PROFESSIONAL SERVICES C-200' stated, "… 1. Skilled professionals must assume responsibility for … the following: … g. Communication with all physicians/allowed non-physician practitioner (NPP) involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care …"

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide and document patient education and documentation of the patient response to the education in 6 of 7 active records reviewed. (Patients #1, 3, 4, 5, 7, and 8) Findings include: 6. A review of the clinical record for Patient #1 evidenced a Plan of Care for the certification period of 01/31/2025 through 03/31/2025. Patient #1 was to receive skilled nursing services 1 time per week for medication management and teaching for 8 weeks. The clinical record failed to evidence medication education and response to the education. 7. A review of the clinical record for Patient #5 evidenced a Home Health Certification and Plan of Care with a start of care of 03/19/2025 for the recertification period of 03/19/2025 to 05/17/2025. Patient #5 was to receive skilled nursing services 1 time per week for medication management for 8 weeks. The clinical record failed to evidence medication education and response to the education. 8. On 03/26/2025 at 2:21 PM, when queried about education provided to patients/caregivers, the Administrator acknowledge there was no documentation to this effect but she had indeed provided education. 6. On 03/27/2025 at 2:33 PM, the Administrator indicated they had initiated training with Entity 4, an electronic medical record system (EMR), and had hoped to utilize the EMR for documentation purposes but it failed to work out, and they got behind in their documentation and had hoped when they submitted their letter of readiness they hoped for a couple of weeks to get caught up before surveyors initiated the survey. The Administrator indicated they had patient's notes on their personal secure phone. IAC 410 17-14-1(A0(1)(G) 1. A review of an undated policy titled 'SKILLED PROFESSIONAL SERVICES POLICY C-200' stated, "… Skilled professional services Include skilled nursing services … 1. Skilled professionals must assume responsibility for, but not be restricted to the following: … e. Client and caregiver education …" A review of an undated policy titled 'Clinical' 'Subject: Care Planning' stated, "… Policy … E. The following documents will collectively be known as the care planning process, including but not limited to: … 7. Teaching guides … 8. Patient education should always be evident during skilled visits …" A review of an undated policy titled 'MEDICATION SET UP POLICY' stated, " … To document compliance in taking medications as set up by agency nurse … 9. The nurse will document all education provided and the consumers response to the education …" 2. A review of the clinical record for Patient #3 evidenced a Home Health Certification and Plan of Care with 02/22/2025 for a start of date for the certification period of 02/22/2025 through 04/22/2025. Patient #3 was to receive skilled nursing services 3 times a week for wound care. The clinical record failed to evidence wound care education, training, and response to training. 3. A review of the clinical record for Patient #4 evidenced a Home Health Certification and Plan of Care with 03/08/2025 for a start of date for the certification period of 03/08/2025 through 05/06/2025. Patient #4 was to receive skilled nursing services 1 time a month for wound care. The clinical record failed to evidence wound care education, training, and response to education and training. 4. A review of the clinical record for Patient #7 evidenced a Home Health Certification and Plan of Care with 02/12/2025 for a start of date. Patient #4 was to receive skilled nursing services 1 time a week for medication management and teaching for 8 weeks. The clinical record failed to evidence medication education and response to education. 5. A review of the clinical record for Patient #8 evidenced a Home Health Certification and Plan of Care with 02/22/2025 for a start of date for the certification period of 02/22/2025 through 04/22/2025. Patient #8 was to receive skilled nursing services 3 times a week for wound care. The clinical record failed to evidence wound care education, training, and response to education and training.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Administrator was responsible for the day-to-day operations: failed to ensure comprehensive assessments accurately reflected patients' health status, psychosocial status, functional limitations, and cognition, failed to ensure comprehensive assessments accurately reflected patients' goals, failed to ensure a comprehensive assessment had been completed for recertification thereby failing to document the patient's need for continuing care, failed to ensure comprehensive assessments reflected a drug regimen review had been conducted, failed to ensure the comprehensive assessment for a recertification occurred during the last 5 days of the certification period, failed to ensure comprehensive assessments were completed, timely and accurate, failed to ensure skilled nursing visits were conducted and documented as ordered, and failed to ensure patient- specific, measurable goals were documented, failed to include all elements required in the Plan of Care, and failed to assure communication with all patients' providers in 1 of 1 agency. Findings include: 1. A review of the agency's job description for the Administrator stated, "Administrator/Alternate - The Right Touch Home Health Care LLC Position Summary: The Home Health Administrator is responsible for overseeing the overall operations of the home health agency. The Administrator ensures compliance with regulatory requirements, manages staff, and drives the agency's strategic initiatives to provide high-quality care to patients. Key Responsibilities: Oversee the daily operations of the home health agency, including clinical and administrative functions … Ensure compliance with state, federal, and accreditation standards and regulations …" 2. On 03/27/2025 at 2:33 PM, the Administrator indicated they had initiated training with Entity 4, an electronic medical record system (EMR), had hoped to utilize the EMR for documentation purposes but it failed to work out, and they got behind in their documentation, insisted all the visits were completed, and when they submitted their letter of readiness they hoped for a couple of weeks to get caught up before surveyors initiated the survey. The Administrator indicated this was all their fault and they take full responsibility. 410 IAC 17-12-1(c)(1)