Every finding on record at Tiffco Care2 LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 04/13, 04/14, 04/15, and 04/16/2026. Active Census: 29 At this Emergency Preparedness survey, Visiting Angels Home Healthcare was found to be out of compliance with Conditions of Participation Emergency Preparedness Requirements for Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 4/22/2026.

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 develop and maintain an emergency preparedness plan and review and update it every 2 years (E-0004), complete a facility and community-based All-hazards approach document and the plan to address the identified emergency (E-0006), address the patient at-risk population and how they maintained services during an emergency (E-0007), demonstrate how the agency collaborated with local, state, regional, tribal, and federal officials and their attempts to contact the officials (E-0009), ensure the emergency plan, risk assessment, and communication plan was reviewed and updated every 2 years (E0013), include the plan individualized for each patient in their comprehensive assessment (E-0017), describe the procedure of contacting emergency officials regarding the patients’ needing evacuation (E-0019), develop the plan to follow-up with staff and patients and inform emergency officials of those they were unable to contact (E-0021), develop the procedure to protect medical information and maintain confidentiality of patient information (E-0023), include how they would use volunteers (E-0024), review and update their communication plan every 2 years (E-0029), include the name and contact information for staff, entities providing services under arrangement, patient’s physicians, other facilities, and volunteers (E-0030), include name and contact information for federal, state, tribal, regional, and local emergency officials (E-0031), how the agency shared information securely to ensure continuation of care (E-0034), ensure the emergency preparedness training and testing program was reviewed and updated every 2 years (E-0036), and participated in a full-scale exercise every 2 years and an additional exercise on the year opposite of the full-scale exercise and analyzed their response to the exercises (E-0039) for 1 of 1 Home Health Agency. The cumulative effect of these systematic problems resulted in the agency being 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 undated policy titled “Emergency Preparedness Management Policy” indicated but was not limited to, “ … Agency will have an identified plan in place to ensure the safety and well-being of clients and employees during periods of an emergency of disaster that disrupts agency services. … 2. All staff members will be oriented to the emergency management plan and their associated responsibilities. Reviews will be held at least annually. 3. The Agency Plan identifies who is responsible for certain activities and when they are to assume responsibilities. … 5. A listing of all staff members and telephone numbers will be included in the agency’s on-call book … 8. Clients and staff should use local radio station to listen for updates, closures, etc. … 12. In the event the agency’s telephone service or utilities are interrupted: a. A designated staff member will contact the repair company … b. Telephone calls will be forwarded to the answering service … the Director/Administrator will make arrangements for an alternate location to conduct business activities. … A defined plan will be established to allow for safe, confidential transfer of client and personnel records. … 15. The emergency plan will identify the links to local community organizations that may be needed to assist the agency in responding to client needs or who may need to utilize agency staff and resources to respond to community needs. 16. All administrative emergency or disaster activities will be documented by the Director of Clinical Services and/or the Administrator. … 17. If the emergency management plan is implemented, it will be evaluated for effectiveness and documentation will be on file. Effectiveness of processes and systems will be reviewed regularly, but at least annually to assure safety is assured. …” 2. An undated policy titled “Communication Plan For Emergency Preparedness” indicated but was not limited to, “ … 3. The Incident Commander Team/designee (sic blank space) is responsible for responding to requests for information by the local health department, emergency management and other emergency responders in emergency situations. 4. The (sic blank space) will maintain responsibility for all clinical communication, responses and decisions. 5. The agency will maintain a Staff Notification Tree which will list all personnel, including volunteers … 7. The (sic blank space) will maintain communication within the agency and also with local officials via the chain of command. 8. The (sic blank space) will be responsible for cooperation, collaboration and maintaining communication with local officials … and Federal emergency preparedness officials and community health coalitions. … 10. The (sic blank space) will verify contact information for local, State, Federal officials, community partners and resources on a quarterly basis. … 11. A current roster with contact information for clients and their emergency contact will be maintained. 12. The staff emergency organizational chart and the client roster will include primary and (sic blank space). Alternate method is (sic blank space) … If cellular phone systems are not adequately functioning, the agency will utilize backup communication system that include: organized messenger services … Walkie-Talkies … radio systems, satellite phone … This communication plan will be reviewed and updated and updated at least annually. …” 3. A review of the Emergency Preparedness (EP) binder failed to evidence the agency developed an emergency preparedness plan, ensured the emergency policy, risk assessment, and communication plan was reviewed and updated every 2 years, and completed a facility and community-based risk assessment, included a plan to continue services and the delegation of authority, the contact information and attempt to contact federal, local, state, regional, and tribal emergency officials to discuss collaboration, a procedure to contact emergency officials for patients needing to vacate their residence, a way to follow-up with staff and patients and contact emergency officials for those staff and patients the agency was unable to reach, a system to preserve patient information, maintained record confidentiality and availability, and releasing patient information in the event of an evacuation to continue care, how the agency utilized volunteers, name and contact information for staff, entities providing services under arrangement, patient physicians, other facilities, and volunteers, how the agency shared necessary information to continue care, reviewed and updated their emergency preparedness training every 2 years, and completed a full-scale exercise every 2 years and a mock drill or tabletop exercise on the opposite year of the full-scale exercise. 4. During an interview with the Alternate Administrator on 04/14/2026 at 12:00 PM, they indicated the emergency preparedness binder had not included an all-hazards assessment, employee and patient list, and no dates were included in the policy or emergency preparedness binder. 5. During an interview with the Administrator on 04/14/2026 at 2:34 PM, they explained they were aware of the concerns with emergency preparedness and there were no further documents provided. They explained there was no all-hazards approach, drills, tabletops, patient communication, plan review, and policy review. They stated they were unaware of the needs of emergency preparedness and thought the Alternate Administrator and DON took care of EP due to their prior survey experience.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 04/13, 04/14, 04/15, and 04/16/2026. 12 Month Unduplicated Skilled Admissions: 0 On 04/14/2025 at 2:34 PM, a partially extended survey was announced to the Administrator. On 04/15/2026 at 11:47 AM, a fully extended survey was announced to the Administrator and Alternate Administrator. During this Federal Recertification Survey, Visiting Angels Home Healthcare was found to be out of compliance with Conditions of Participation 42 CFR §484.55 Comprehensive Assessment of patient, 42 CFR §484.60 Care planning, coordination of services, and quality of care, 42 CFR §484.65 Quality assessment and performance improvement, 42 CFR §484.102 Emergency Preparedness, and 42 CFR §484.105 Organization and administration of services. Based on the Condition-level deficiencies during the 04/16/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 04/15/2026. 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 programs for a period of two years beginning 04/16/2026 and continuing through 04/15/2028. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: CNA Certified Nursing Assistant HHA Home Health Aide RN Registered Nurse DON Director of Nursing POC Plan of Care SOC Start of Care SN Skilled Nursing EP Emergency Preparedness DME Durable Medical Equipment ADLs Activities of Daily Living QAPI Quality Assessment and Performance Improvement OASIS Outcome and Assessment Information Set QR completed by Area 3 on 4/22/2026.

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 to evidence the comprehensive assessments were complete and accurately reflected the patient’s status, including current health, psychosocial, functional, and cognitive status (See G528), failed to ensure a complete and accurate assessment of the patient's strengths, goals, and care preferences (See G530), and failed to ensure a complete and accurate assessment of the patient's medical, nursing, rehabilitative, social, and discharge planning needs (See G534). The cumulative effect of these problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment, as required by the Condition of Participation 42 CFR § 484.55, Comprehensive Assessment of Patients. *

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 evidence the comprehensive assessments were complete and accurately reflected the patient’s status, including current health, and psychosocial status in 4 of 8 active records reviewed. (Patient #5, 6, 7, and 8) Findings Include: 4. A review of Patient #6’s clinical record evidenced a recertification comprehensive assessment dated 04/08/2026 by RN 1. The comprehensive assessment failed to include the patient’s psychosocial status. 5. A review of Patient #8’s active clinical record evidenced a recertification comprehensive assessment dated 02/17/2026 by the DON. The comprehensive assessment failed to include the patient’s psychosocial status. 6. During an interview with the DON and RN1 on 04/16/2026 at 1:45 PM, they indicated the comprehensive assessment had not contained a psychosocial assessment for the RNs to complete. 410 IAC 17-14-1(a)(1)(B) 3. Review of the clinical record for Patient #5 revealed a recertification assessment dated 03/06/2026. The recertification assessment failed to evidence the psychosocial status. 1. Review of an undated agency policy titled “Client Reassessment/Update of Comprehensive Assessment” indicated, but was not limited to, “ … Assessments will include OASIS data collection for all Medicare and Medicaid skilled clients. Clients who are not receiving skilled services under the Medicare or Medicaid program are assessed using the OASIS tool or an alternative form identified by the agency … The assessment will identify the client's problems, needs, and strengths, as well as the care the family can provide. The initial and ongoing assessments include consideration of the following: Specific individualized client needs ... Description of any applicable strengths the client has, including physical, psychosocial, and of spiritual resources ... Involvement of family, friends, and other individuals or organizations; Appropriateness of the level of care provided by the family or support system ... Condition of the home ... and identified safety needs ... ” 2. A review of the clinical record for Patient #7, SOC date of 03/19/2024, contained a comprehensive reassessment dated 03/04/2026, signed by RN 1. The comprehensive reassessment failed to address Patient #7’s health history of seizures, seizure diagnosis, and seizure precautions needed. A review of the medication list for Patient #7 dated 03/04/2026, indicated but was not limited to “Topiramate (an anticonvulsant medication used to treat epilepsy) 100 milligrams (mg) one oral two times a day for migraines. During an interview on 04/16/2026 at 1:16 PM, when asked about the medication Patient #7 had been taking for seizures and migraines, and if they were diagnosed with seizures, Patient #7 stated, “Yes, Topiramate doubles as my migraine and seizure medication. My seizures could happen anytime, the doctor said. I haven’t had one in a while, though, thanks to the medication.” 3. During an interview on 04/14/2026 at 11:30 AM, when asked about Patient #7 having seizures and seizure precautions on their SOC POC and now not listed, the DON and RN 1 indicated they were unaware, and it should be on the current POC. 4. Review of the clinical record for Patient #5 revealed a recertification assessment dated 03/06/2026. The recertification assessment failed to evidence the psychosocial status. 5. A review of Patient #6’s clinical record evidenced a recertification comprehensive assessment dated 04/08/2026 by RN 1. The comprehensive assessment failed to include the patient’s psychosocial status. 6. A review of Patient #8’s active clinical record evidenced a recertification comprehensive assessment dated 02/17/2026 by the DON. The comprehensive assessment failed to include the patient’s psychosocial status. During an interview with the DON and RN1 on 04/16/2026 at 1:45 PM, they indicated the comprehensive assessment had not contained a psychosocial assessment for the RNs to complete. 410 IAC 17-14-1(a)(1)(B)

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 a complete and accurate assessment of the patient's strengths, goals, and care preferences in 1 of 1 (Patient: #1) active clinical records reviewed of patients receiving SN and HHA services. Findings Include: 1. A review of an undated agency policy titled “Client Reassessment/ Update of Comprehensive Assessment” indicated but was not limited to “Assessment will include OASIS data collection for all Medicare and Medicaid skilled clients. Clients who are not receiving skilled services under the Medicare or Medicaid program will be assessed using the OASIS tool or an alternative .... Special attention will be paid to client-centered goal setting, clarifying the client's personal goals and his/her expectations of the home care services … The assessment will identify the problems, needs, and strengths of the client and the care the family can provide … The initial and ongoing assessments include consideration of the following: Specific individualized client needs … Description of any applicable strength the client has including physical, psychosocial, and or spiritual … Progress toward goals since previous assessment .... ” 2. A review of the clinical record for Patient #2, SOC date of 03/30/2026, contained an OASIS SOC comprehensive assessment signed by the DON and dated 03/30/2026. The initial comprehensive assessment sections, care management, and sources of assistance had been left blank; care preferences and personal goals had been left blank; and strengths and limitations had been left blank. During an interview on 04/13/2026 at 2:53 PM, when asked about the OASIS SOC assessment having blanks and not being completed, and leaving sections blank, such as the patient strengths and goals and care preferences, the DON confirmed they had not completed the comprehensive assessment and did not know why those areas were incomplete and left blank. When asked whether all comprehensive assessments should be completed, the DON indicated they should be completed without leaving any blank sections.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review, the agency failed to ensure a complete and accurate assessment of the patient's medical, nursing, rehabilitation potential, and discharge planning needs in 4 of 8 active clinical records reviewed. (Patients #2, 6, 7, and 8) Findings included: A review of Patient #6’s active clinical record evidenced a recertification comprehensive assessment dated 04/08/2026 by RN 1. The comprehensive assessment failed to include the patient’s rehabilitation potential and social needs. A review of Patient #8’s active clinical record evidenced a recertification comprehensive assessment dated 02/17/2026 by the DON. The comprehensive assessment failed to include the patient’s social needs. During an interview with RN 1 and the DON on 04/14/2026 at 10:10 AM, they indicated the rehabilitation potential was supposed to be completed. 410 IAC 17-14-1(a)(1)(B) 1. A review of an undated policy titled "Client Reassessment/Update of Comprehensive Assessment" evidenced "Assessment will include OASIS data collection for all Medicare and Medicaid skilled clients. Clients who are not receiving skilled services under the Medicare or Medicaid program will be assessed using the OASIS tool or an alternative ... The assessment will identify the problems, needs, and strengths of the client and the care the family can provide. The initial and ongoing assessments include consideration of the following: Specific individualized client needs pertinent to the care or service being provided; Description of any applicable strength ... including physical, psychosocial, and/or spiritual resources ... Involvement of family friends, and other individuals or organizations; Appropriateness of the level of care provided by the family or support system ... Condition of the home and surrounding environment and identified safety needs ... Progress toward goals since previous assessment and clarify the problems that require continuing home care services; Need for continuing home care services; Ability/willingness of the client/family to assume responsibility for healthcare needs … ” 2. Review of an undated agency policy titled “Discharge Process” indicated but was not limited to, “Discharge Planning is initiated for every home care client at the time of the client's admission for home care. When clients are admitted for home health services, the expectation is that the client will be discharged to self-care or care of family when goals are met ... Discharge Procedure: 1. Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected outcomes. The client/ family will participate in this process beginning with the initial assessment visit .... ” 3. A review of the clinical record for Patient #2, SOC date of 03/30/2026, contained an OASIS SOC comprehensive assessment signed by the DON and dated 03/30/2026. The initial comprehensive assessment sections care management and types of sources of assistance had been left blank, living arrangements and fall risk safety plans had been left blank safety measures had been left blank, home safety had been left blank, emergency preparedness and planning had been left blank, patient/caregiver /representative/family education and training for care planning had been left blank, rehab potential and discharge plan had been left blank, and care coordination had been left blank. During an interview on 04/13/2026 at 2:53 PM, when asked about the OASIS SOC assessment having blanks and not being completed and leaving sections blank, such as the patient strengths and goals and care preferences, the DON confirmed they had not completed the comprehensive assessment and did not know why those areas were incomplete and left blank. When asked if the comprehensive assessment should all be completed, the DON indicated it should all be completed. 4. A review of the clinical record for Patient #7, SOC date of 03/19/2024, contained a comprehensive reassessment dated 03/04/2026 signed by RN 1. The comprehensive reassessment failed to address Patient #7’s health failed to address Patient #7’s health history of seizures, seizure diagnosis, seizure precautions needed, and wound care needed. The nursing section had been left blank, the aide section had been left blank, the section discussed discharge plans with the patient had been left blank, and the section on rehab potential had been left blank. A review of the medication list for Patient #7 dated 03/04/2026, indicated but was not limited to “Topiramate (an anticonvulsant medication used to treat epilepsy) 100 milligrams (mg) one oral two times a day for migraines. During an interview on 04/14/2026 at 11:30 AM, when asked about Patient #7’s seizures and seizure plan, past medical history, the blank sections not completed for SN services, HHA services, discharge planning, and rehab potential, and addressing orders for Patient #7’s wound, RN 1, indicated they had notified the physician regarding Patient #7’s wound and referred wound care to another agency, Entity 9, a home health agency, because Visiting Angels Home Healthcare does not perform wound care only medication management. When asked about the blanks left in the comprehensive assessment, RN 1 further stated, “I forgot to fill it all out.” During an interview on 04/16/2026 at 1:16 PM, when asked about the medication Patient #7 had been taking for seizures and migraines, and if they were diagnosed with seizures, Patient #7 stated, “Yes, Topiramate doubles as my migraine and seizure medication. My seizures could happen anytime, the doctor said. I haven’t had one in a while, though, thanks to the medication.” When asked about their needed wound care, Patient #7 indicated the wound had now healed and that the ongoing issue was the foam on the arm of the chair being worn. Patient #7 further stated that they did not understand why Visiting Angels could not have completed the wound care, as they were under their care, and that the other agency had not accepted them due to their insurance.

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 patients received the frequency of services listed in the POC (G0572), POCs were individualized and included all pertinent information (G0574), treatments were administered only as ordered by a physician (G0580), provided a current POC (G0612), and provided a current schedule (G0614). The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment, as required by the Condition of Participation at 42 CFR § 484.60, Care Planning, Coordination of Care, and Quality of Care. Findings Include: 410 IAC 17-13-1(a) *

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 all patients received all services as ordered on the POC for 4 of 8 active clinical records reviewed. (Patients: #1, 5, 7, and 8) Findings Include: 5. A review of Patient #8’s active clinical record evidenced a POC with a SOC of 03/15/2021 and a certification period from 02/18/2026 to 04/18/2026. The patient received HHA services for assistance with ADLs 7 days a day, 3 days a week for week 1 and 7 hours a day, 5 days a week for weeks 2-9 according to physician orders. Patient #8’s active clinical record documents notifying the patients’ physician of missed visits on 03/09, 03/10, 03/11, 03/12, 03/13, 03/16, 03/17, 03/18, 03/19, 03/20, 03/23, 03/25, 04/06, and 04/08/2026. The documents revealed the missed visits were due to not having staff available. 410 IAC 17-13-1(a) Review of the clinical record for Patient #5 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 01/15/2025 for the certification period of 01/10/2026 through 03/10/2026. The POC indicated Patient #5 has but is not limited to, Chronic Obstructive Pulmonary Disease (COPD, progressive treatable lung disease that restricts airflow and makes breathing difficult), Fibromyalgia (chronic disorder described as widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), Rheumatoid Arthritis, and Neuropathy (nerve pain). The POC evidenced Patient #5 received HHA services two hours per day, for five days a week, for weeks two through nine. Review of the HHA visit notes evidenced the following: During the week of 02/15/2026 though 02/21/2026, evidenced HHA visits were conducted on 02/16, 02/17, and 02/18/2026. The clinical record failed to evidence HHA visit notes on 02/19 or 02/20/2026. During the week of 02/22/2026 through 02/28/2026, evidenced HHA visits were conducted on 02/24/2026. The clinical record failed to evidence HHA visit notes on 02/23, 02/25, 02/26 or 02/27/2026. During the week of 03/01/2026 through 03/07/2026, evidenced HHA visit were conducted on 3/4, 3/5, and 3/6/2026. The clinical record failed to evidence HHA visit notes on 03/02 or 03/03/2026. During the week of 03/29/2026 through 04/03/206, evidenced HHA visits were conducted on 03/30, 03/31, 04/01, and 04/02/2026. The clinical record failed to evidence HHA visit notes on 04/03/2026. During the week of 04/05/2026 through 04/11/2026, evidenced HHA visits were conducted on 04/07, 04/09, and 04/11/2026. The clinical record failed to evidence HHA visit notes on 04/06, 04/08, or 04/10/2026. During an interview on 04/16/2026 at 1:41 PM, the DON indicated other office staff were responsible for completing missed visit forms. The DON indicated they realized the physician was not being notified of missed visits, so they assumed responsibility for notifying the physician. The DON indicated if there is no visit note, then the visit was missed. 1. A review of an undated agency policy titled “Plan of Care” indicated, but was not limited to, “Policy: Home care services are furnished under the supervision and direction of the client’s physician … addresses the care, treatment, and services to be provided … ” 2. A review of the clinical record for Patient #1 SOC date of 02/06/2025, contained a POC for the recertification period from 02/01/2026 to 04/01/2026. The POC indicated Patient #1 had orders for a HHA two hours a day two days a week-week one, two hours a day for 3 days a week- weeks 2-9, and two hours a day for 1 day a week-week 10, for assistance with ADLs, bathing, transfers, hygiene, safety, mobility, companionship, and light housekeeping related to personal care needs. A review of the home health aide visit notes evidenced the following: the week of 02/15/2026 through 02/21/2026, Patient #1 had 3 visits on 02/15, 02/17, and 02/20/2026; the week of 02/22/2026 through 02/28/2026, Patient #1 had 3 visits on 02/22, 02/24, and 02/27/2026; the week 03/01/2026 through 03/07/2026, Patient #1 had 3 visits on 03/01, 03/03, and 03/06/2026; the week of 03/08/2026 through 03/14/2026, Patient #1 had no HHA visits conducted; the week of 03/15/2026 through 03/21/2026, Patient #1 had two visits on 03/17 and 03/20/2026. A review of documents titled “Missed Visits” dated 03/08, 03/10, and 03/13/2026, indicated missed visits no staff available. The missed visit on 03/15/2026 was due to Patient #1 canceling the HHA visit. A review of the clinical record failed to evidence any communication notes, failing to evidence how Patient #1’s needs were met, or that Patient #1 had been notified. During an interview on 04/15/2026 at 12:20 PM, when asked about the documentation regarding the missed visits and coordination with the patients on how their needs were met, the DON and Admin 4, the scheduler, indicated they had sent the missed visit document to the physician and would notify the patients after they had coverage. When asked about the location of coordination with patients regarding meeting their needs for HHA assistance, they reported they could not provide documentation in the patient’s clinical record. The DON further communicated that if it wasn’t documented, it wasn’t done. 3. A review of the clinical record for Patient #7 SOC date of 03/19/2024, contained a POC for the recertification period from 03/09/2026 to 05/07/2026. The POC indicated Patient #7 had orders for a HHA 8 hours a day 5 days a week-week 1-8, and 8 hours a day for 4 days a week- week 9, for assistance with ADLs, hoyer assistance, transfers, bathing, dressing, hygiene, bathroom clean up, incontinent care, meal prep, med reminders, companionship, and light housekeeping. A review of the home health aide visit notes evidenced the following; the week of 03/08/2026 through 03/14/2026, Patient #7 had 5 visits on 03/09, 03/10, 03/11, 03/12, and 03/13/2026; the week of 03/15/2026 through 03/20/2026, Patient #7 had 5 visits on 03/16, 03/17, 03/18, 03/19, and 03/20/2026; and the week 03/22/2026 through 03/28/2026, Patient #7 had one visit on 03/27/2026. A review of documents titled “Missed Visits” dated 03/23/2026 to 03/26/2026, indicated missed visits, no staff available. A review of the clinical record failed to evidence any communication notes, failing to evidence how Patient #7’s needs were met, or that Patient #7 had been notified. During an interview on 04/16/2026 at 12:36 PM, when questioned about their missing visits and the agency's failure to notify them of a replacement, Patient #7 stated that the agency does not communicate when staff cannot come, and it takes them a long time to get new staff when staff are quiet. Patient #7 further communicated that the agency lacked communication regarding staffing issues.

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 observation, record review, and interview, the agency failed to ensure the individualized plan of care included all pertinent diagnoses, specific frequency and duration of visits, all supplies and equipment, as needed medication indications, safety measures, discharge planning, psychosocial status, measurable outcomes, and goals identified by the home health agency and patient for 5 of 8 active clinical records reviewed. (Patients: #2, 4, 5, 6, and 7) Findings include: A review of Patient #6’s active clinical record evidenced a POC with a SOC of 04/24/2024 and a recertification period of 04/12/2026 to 06/10/2026. The POC revealed the goal for the patient having no skin breakdown for 60 days and have adequate pain management. The medication list included the medication of 17 grams (g) of MiraLAX (used for constipation) as needed in water two times a day. The POC failed to ensure all goals were measurable, including the patients’ psychosocial status, and the as needed medication listed the route and indication for the patient to take the medication. A review of Patient #8’s active clinical record evidenced a POC with a SOC of 03/15/2021 and a certification period from 02/18/2026 to 04/18/2026. The medication listed included the medication of 17 grams (g) of MiraLAX (used for constipation) as needed orally daily and 2 capsules of IBgard orally daily as needed. The POC evidenced there was no plan to discharge the patient with the patient’s need for ADL assistance. A review of Patient #8’s active clinical record evidenced a recertification comprehensive assessment dated 02/17/2026 by the DON. The comprehensive assessment evidenced under “Discharge Plans” the section indicated but was not limited to, “ … Able to remain in residence with assistance of primary caregiver/support form community agencies …”. The POC failed to evidence the as needed medications included the indications and the discharge plan matched the comprehensive assessment for Patient #8. 410 IAC 17-13-1(a)(1)(D)(v, ix, x, xi, xiii) Review of the clinical record for Patient #5 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 01/15/2025 for the certification period of 03/11/2026 through 05/09/2026. The POC indicated Patient #5 has but is not limited to, Chronic Obstructive Pulmonary Disease (COPD, progressive treatable lung disease that restricts airflow and makes breathing difficult), Fibromyalgia (chronic disorder described as widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), Rheumatoid Arthritis, and Neuropathy (nerve pain). The POC evidenced Patient #5 received HHA services two hours per day, for five days a week, for weeks two through nine. The POC failed to include psychosocial status. 1. A review of an undated policy titled “Plan of Care “indicated, but was not limited to, “Policy: Home care services are furnished under the supervision and direction of the client's physician. The Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members ... Purpose: To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs ... Special Instructions: ... The Plan of Care shall be completed in full to include: a. All pertinent diagnosis (es)... b. Mental status … I. Functional limitations and precautions … l. Medications, treatments, and procedures m. Medical supplies and equipment require n. Any safety measures to protect against injury … Instructions for timely discharge or referral r. Discharge plans ... t. Other appropriate items u. All of the above items must always be addressed on the Plan of Care … ” 2. A review of an undated agency policy titled “Visiting Angels Home Health Agency Seizure Protocol Policy” indicated, but was not limited to , “ … 5. All Agency staff assigned to a patient who had a diagnosis or active seizure activity or a history of seizures will be trained on the physician's orders interventions to address patient safety during an active seizure …The patient-specific seizure plan will be written on the Medical Plan of Care … 3. During a home visit at Patient #2’s residence on 04/14/2026 at 1:25 PM, observed the DON set up Patient #2’s medication. The DON further asked Patient #2 how CNA 3 had done today, noting that Patient #2’s first CNA visit was provided. When asked about Patient #3’s SOC date of 03/30/2026 and the services provided, the DON indicated they were awaiting authorization before providing services. The DON further confirmed today had been Patient #2’s first medication setup. A review of the clinical record for Patient #2 with a SOC date of 03/30/2026, contained a POC for the initial certification period of 03/30/2026 to 05/26/2026, dated 03/30/2026 and signed by the DON. The POC evidence Patient #2 had orders for SN 1 hour biweekly for med box set up and skilled assessment, but failed to give duration of SN frequency; and HHA 5 hours a day for 2 days a week-week 1, 5 hours a day for 5 days a week-weeks 2-9 and 5 hours a day for 0 days a week -week 10, for assist with bathing, dressing, hygiene, mobility, fall risk, safety, meal prep, and light housekeeping related to personal care. The POC failed to evidence the correct SOC date and certification period. A review of the OASIS SOC assessment dated 03/30/2026 and signed by the DON, failed to evidence a medication set up or skill had been provided to Patient #2 on 03/30/2026. 4. A review of the clinical record for Patient #7 with a SOC date of 03/19/2026, contained a POC dated 03/04/3036 and signed by RN 1, for the recertification period 03/09/2026 to 05/07/2026. The POC indicated the principal diagnosis of Cerebral Palsy (a condition that affects movement and posture, muscle weakness, and muscle spasticity and trouble with coordination caused by damage that occurs to the developing brain), and other pertinent diagnoses of Ventricular Malacia (a type of brain injury characterized by softening and damage of the white matter surrounding the brain’s ventricles), Depression, and Scoliosis (a condition characterized by an abnormal side-to-side curvature of the spine). The POC failed to list Seizures as a pertinent diagnosis. The section titled “Medications” indicated but was not limited to, “… Albuterol neb 1.25 milligrams (mg)/3 milliliters (ml) solution via neb every 6 hours as needed (PRN)for shortness of breath (SOB) … Topiramate 100 mg one oral two times a day for migraines … Silver Sulfadiazine 1% cream topical PRN skin; but failed to indicate how often, amount, and indication … Triamcinolone topical 0.01% apply PRN; but failed to indicate how often, amount, and indication …. ” The section titled “DME and Supplies” listed motorized wheelchairs, shower seats, gloves, briefs, and Hoyer, but failed to list a nebulizer. The section titled “Safety Measures” listed fall risk, but failed to list seizure precautions. The section titled “Mental Status” listed oriented, but failed to list depression. The POC failed to have treatment orders and interventions to address patient safety during an active seizure. A review of the clinical record for Patient #7, SOC date of 03/19/2024, contained a comprehensive reassessment dated 03/04/2026, signed by RN 1. The comprehensive reassessment failed to address Patient #7’s health failed to address Patient #7’s health history of seizures, seizure diagnosis, seizure precautions needed, and wound care needed. The nursing section, the aide section, the section discussing discharge plans with the patient, and the section on rehab potential had been left blank. During an interview on 04/14/2026 at 11:30 AM with the DON and RN 1, when asked about Patient #7’s seizure plan and past medical history, the blank sections for SN services, HHA services, discharge planning, and rehab potential were not completed. RN 1 indicated they forgot to fill it out, and do not know why seizures and the seizure plan were left off the POC. When shown the previous POC with diagnoses of Seizures and seizure precautions and plan, the DON indicated it should have been on Patient #7’s POC, that the agency had been cited for this in the past, and that they did not know why it had been missed on subsequent recertifications. During an interview on 04/16/2026 at 1:16 PM, when asked about the medication Patient #7 had been taking for seizures and migraines, and if they were diagnosed with seizures, Patient #7 stated, “Yes, Topiramate doubles as my migraine and seizure medication. My seizures could happen anytime, the doctor said. I haven’t had one in a while, though, thanks to the medication.” Patient #7 further confirmed they use a nebulizer PRN for episodes of asthma flare-ups.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure 1 of 3 patients (Patient #1) who received HHA services had a current plan of care. Findings Include: 1. During a home visit at Patient #1’s residence on 04/14/2025 at 8:15 AM, reviewed the agency folder that contained a POC for the previous certification 02/01/2026 to 04/01/2026. When asked for the medication list and POC provided by the agency RN for review, HHA 2 indicated the DON had been to the home the previous week and should have left the current POC. During an interview on 04/14/2026 at 10:10 AM, when asked about Patient #1’s current POC, the DON indicated it had been provided to the surveyor but not the patient.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide the patients with visit schedules of when services were to be provided for 4 of 4 admission packets reviewed during home visits. (Patient: #1, 2, 3, and 4) Findings Include: 1. During a home visit at Patient #1’s residence on 04/14/2026 at 8:15 AM, their admission packet failed to evidence a current or past schedule of visits for the agency. When asked how they know when the HHA or the DON visits, Patient #1 indicated they just call ahead. CNA 1 further confirmed no schedule had been in the agency packet, and they called or let Patient #1 know when they will be arriving for the next visit, and the DON comes to visit about every 2 months. 2. During a home visit at Patient #2’s residence on 04/14/2026 at 1:25 PM, the DON placed the POC and medication list on Patient #2’s end table by the recliner where Patient #2 had been sitting. Patient #2 indicated they could not locate their folder during the visit and would place the medication list and POC in it later. The DON communicated to Patient #2 that they would call to schedule the next visit in two weeks for medication setup. During an interview on 04/14/2026 at 2:15 PM, when asked about patient schedules for home visits, the patient indicated they called prior to visits. 3. During a home visit at Patient #3’s residence on 04/15/2026 at 8:20 AM, their admission packet failed to evidence a current or past schedule of visits for the agency. When asked about the visit schedules, CNA 4 indicated the office schedules the visits, the RN comes to the house every 2 months, and confirmed no schedule had been placed in the agency packet or at the home for Patient #3. 4. During a home visit at Patient #4's residence on 04/15/2026 at 9:30 AM, their admission packet failed to evidence a current or past schedule of visits for the agency. When asked about the visit schedules, Patient #3 indicated that the agency lacks communication. They do not report even when the HHA is not coming until later in the day, even though they know earlier in the morning that the HHA is calling in. HHA 2 reported they let the patient know by calling and following up regarding visit schedules; there were no schedules provided to the patient.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the Governing Body failed to develop, implement, evaluate, and maintain an ongoing, agency-wide QAPI program that measured, analyzed, and tracked measurable and data-driven quality indicators, including adverse events, for health, safety, agency operations, and quality of care (G642); failed to use quality indicator data to monitor the effectiveness and safety of care and services and identified opportunities for improvement (G644); failed to focus on high risk, high volume, or problem-prone areas, such as hospitalizations, infections, adverse events, and home health aide services (G646); initiated performance improvement plans which tracked and analyzed adverse events and implemented corrective or preventative actions (G654); measured and tracked the success of performance improvement in the identified areas to ensure that improvements were sustained (G656); conducted performance improvement projects (PIP) that reflected the scope and complexity of the needs of the agency’s patient needs and previously identified regulatory performance needs, and documented the PIPs undertaken and the measurable progress achieved (G658); failed to ensure the QAPI program established clear expectations for patient safety and assessed for and addressed any findings of fraud or waste (G660) for 1 of 1 Governing Body of a Home Health Agency. The cumulative effects of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.65, Quality Assessment and Performance Improvement. 1. Review of an agency policy titled, “Quality Assessment and Performance Improvement (QAPI)” indicated but is not limited to, “ … Agency will develop, implement, evaluate, and maintain an effective, ongoing agency wide, data driven QAPI program … The agency will identify, measure, analyze, and track quality indicators that include client adverse events, and other relevant data to assess processes of care, services, and operations … The agency’s performance improvement activities will focus on high risk, high volume, or problem prone area tat are specific to this agency … The programs activities will lead to an immediate correction of identified problems … The program will establish timelines for review to measure success and establish ongoing activities to sustain success … The governing body is responsible for ensuring … An ongoing program for quality improvement and patient safety is defined … efforts address priorities for improved quality of care and client safety … All improvement actions will be evaluated for effectiveness …” 2. Review of the QAPI program evidenced a document titled “R&R Daily Standings Report.” The report included but was not limited to information regarding number of unfilled scheduled visits, staff call-ins, staff over/under billable hours, Certifications/Renewals employees such as CPR, insurance, TB, Supply Needs, Recruiting/Retention efforts, and complaints. Review of the QAPI program evidenced a document titled “Program Weekly Standings Report.” The report included, but was not limited to, information regarding admitted clients, discharged clients, caregivers hired/lost, Clinical Concerns, and Supply Needs. The documents failed to evidence the agency identified hospitalizations, missed visits, call-ins, infections, and adverse events were discussed and the action taken to prevent them in the future. The QAPI program failed to evidence the agency identified and analyzed issues affecting the quality of care, patient safety, and the efforts to improve health outcomes. During an interview on 04/16/2026 at 11:32 AM, the Alternate Administrator and DON reviewed QAPI. The Alternate Administrator indicated the agency utilized the daily and weekly logs as their QAPI program. The Alternate Administrator indicated a full report was not completed, only in the logs. When queried about the QAPI program, the DON indicated they did not participate in what they understood QAPI to be. When queried about where the quality measure data was, the Alternate Administrator indicated they thought the weekly logs were enough. When queried about the performance improvement plan, the Alternate Administrator indicated meetings occur, discussions happen, but nothing was written down.

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 agency failed to ensure staff had access to gloves, hand sanitizers, soap and paper towels, and failed to ensure staff used standard precautions to prevent the transmission of infections and communicable diseases with proper use of hand hygiene, and gloving for 3 of 4 home visits conducted. (Employees: DON, and CNA 4, and HHA 2) Findings Include: 1. A review of an undated agency policy titled “Handwashing/Hand Hygiene” indicated, but was not limited to, “ … To improve hand hygiene practices of agency staff and to reduce transmission of pathogenic microorganisms to clients and personnel … 2. Appropriate antiseptic cleanser may be used when appropriate … Indications for handwashing and hand antisepsis: a. Before caring for clients … c. When there is prolonged or intense contact with the client (bathing the client). d. Between tasks on the same client … f. After removing the gloves. g. After touching objects that are potentially contaminated … q. Decontaminate hands after contact with inanimate objects, including equipment in the immediate vicinity of the client. r. Decontaminate hands after removing gloves … ” 2. During a home visit at Patient #2’s residence on 04/14/2026 at 1:30 PM, observed the DON completing medication setup for Patient #2. The DON performed hand hygiene, donned gloves, and retrieved Patient #2’s medication bottles from a plastic bin. The DON then opened the pill organizer and retrieved their clipboard to review the medication list. Next, the DON opened each pill bottle, poured the pills into their gloved hand, and placed each pill into the designated daily compartment. The DON failed to discard their gloves after touching the pill bottles, the top of the pill organizer, and the clipboard before placing the pills in their gloved hand. During an interview on 04/14/2026 at 2:15 PM, when asked about touching the lids of the pill’s bottles, medication planner, and clipboard, and then pouring the pills into their gloved hands, the DON stated, “Yes, the lids are dirty, and the medication planner lids are considered dirty. When I opened the pills, I should have used the lid to obtain the pills.” 3. During a home visit at Patient #3’s residence on 04/15/2026 at 8:20 AM, observed CNA 4 give Patient #3 a bed bath. CNA 4 went to the bathroom, washed their hands with soap and water for 40 seconds, and turned the faucet off with their bare hands. CNA 4 obtained a paper towel, dried their hands, and used it to turn the faucet back on. CNA 4 filled the bath basin and turned the water off with their bare hands. CNA 4 carried the bath basin to the bedside table, placed two washcloths in the water, and donned gloves without performing hand hygiene. CNA 4 removed Patient #3’s nightshirt, retrieved a laundry hamper from the top shelf of the closet, and placed the nightshirt in the hamper. Without removing gloves or performing hand hygiene, CNA 4 obtained a towel from the shelf, placed it against the bedrail, picked up a washcloth, and washed Patient #3’s face. CNA 4 removed Patient #3’s brief, picked up the washcloth from the bath basin, applied soap, and washed Patient #3’s right arm, hand, underarm, abdomen, and right lower extremity. CNA 4 then picked up the rinse washcloth and rinsed the right side of Patient #3, completing that side of the patient’s body. CNA 4 turned Patient #3 onto their left side and removed the chuck. CNA 4 applied soap to the washcloth and washed Patient #3’s peri area, then picked up the rinse washcloth and rinsed the peri area. CNA 4 rolled the patient onto their right side and washed the rectal and buttock areas, then picked up the rinse washcloth from the basin and rinsed these areas. CNA 4 picked up the towel without discarding gloves, performing hand hygiene, or donning new gloves, and dried Patient #3. CNA 4 then retrieved clean clothes from Patient #3’s shelving unit, without discarding gloves, performing hand hygiene, or donning new gloves, and dressed Patient #3 in a purple t-shirt and a new brief. CNA 4 discarded the soiled washcloths and towels, removed the towel protecting Patient #3 from the bed’s siderail, and placed it on the shelf. CNA 4 poured the basin of water into the bathroom sink, discarded gloves, washed their hands, and turned off the faucet with their bare hands. During an interview on 04/15/2026 at 9:03 AM, when asked about infection control with gloving and hand hygiene, and why they wore the same gloves during the complete bath provided to Patient #3, CNA 4 stated, “I should have not turned off the faucet with clean hands, and when I removed the brief and chuck, I should have changed my gloves. I should have changed my gloves during the clean and dirty areas while giving the bath. I transferred germs by obtaining clean clothes. I brought gloves from the office, but they run low there, so we are told to stretch them out. I didn’t change my gloves to stretch them out.” 4. During a home visit at Patient #4’s residence on 04/15/2026 at 9:30 AM, observed HHA 2, obtaining vital signs for Patient #4. When asked about having gloves, and supplies needed for care, HHA 2 and Patient #4 communicated the agency didn’t have gloves and had to use the gloves bought by Patient #4 and their husband. HHA 2 further indicated they forgot to order gloves, and they do not provide alcohol gel, soap, or paper towels. 410 IAC 17-12-1(m)

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all home health aides provided hands-on personal care as ordered per the plan of care for 2 of 8 active clinical records reviewed. (Patients: #4 and 5) Findings include: Review of the clinical record for Patient #5 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 01/15/2025 for the certification period of 01/10/2026 through 03/10/2026. The POC indicated Patient #5 has but is not limited to, Chronic Obstructive Pulmonary Disease (COPD, progressive treatable lung disease that restricts airflow and makes breathing difficult), Fibromyalgia (chronic disorder described as widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), Rheumatoid Arthritis, and Neuropathy (nerve pain). The POC evidenced Patient #5 received HHA services two hours per day, for five days a week, for weeks two through nine. The POC indicated the HHA assists with ADL’s, bathing, transfers, mobility, meal prep, dressing, hygiene, safety, fall risk, and light housekeeping related to personal care needs. Review of the HHA visit notes evidenced the following: The HHA visit note dated 02/16/2026 and signed by HHA 6 evidenced, but was not limited to, “ … Went to pick up medicine …” The HHA visit note dated 02/17/2026 and signed by HHA 6 evidenced, but was not limited to, “ … ran Aaron’s [errands] …” The HHA visit note dated 02/18/2026 and signed by HHA 6 evidenced, but was not limited to, “ … Picked up medications went to gas station …” During an interview on 04/16/2026 at 2:10 PM, the DON indicated an HHA may assist with bathing, transfers, or mobility. When queried if an HHA may run errands or transport a patient, the DON indicated no. 1. A review of an undated agency policy titled “Home Health Aide Services” indicated but was not limited to “Policy: ... The duties of a home health aide include the provision of hands-on personal care and performance of simple procedures ... Special Instructions: ... 3. The Aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising Nurse .... ” 2. A review of the clinical record for Patient #4, SOC 06/05/2024, contained a POC for the recertification period 03/27/2026 to 05/25/2026. The POC indicated Patient #4 had orders for a HHA for 8 hours a day 5 days a week, for assistance with ADLs, transfers, bathing, hygiene, incontinent care, positioning, fall risk, companionship, and light housekeeping as related to personal care. A review of the HHA visit note dated 04/13/2026 indicated HHA 2’s scheduled hours were 10:00 AM to 7:00 PM, and HHA 2 clocked in at 9:55 AM and clocked out at 6:59 PM. The HHA visit notes dated 03/29/2026 to 04/10/2026 indicated HHA 2’s scheduled hours were 8:00 AM to 4:00 PM. During a home visit at Patient #4’s residence on 04/15/2026 at 9:30 AM, Patient #3 indicated they were tired from sitting up all day yesterday during physician appointments. HHA 2 communicated they had to adjust their hours yesterday to accommodate assisting Patient #4 to their appointments, so they came late and stayed later that day. During an interview on 04/16/2026 at 2:20 PM, when asked about HHA 2 assisting Patient #4 to appointments, or HHAs running errands, and grocery shopping for patients, the DON and RN indicated the HHAs are not to be transporting patients, or running errands. During a review of the concerns with the Administrator and Alternate Administrator on 04/16/2026 at 3:20 PM, the Alternate Administrator stated, "We have been clear they can't do that."

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the governing body failed to ensure they developed and maintained an agency-wide QAPI program where they tracked and analyzed data (G0942), appointed the Administrator (G0946), ensure the Administrator was responsible for all day-to-day operations including involvement in an Emergency Preparedness Plan and approved and reviewed bylaws and policies and procedures (G0948), appointed the Alternate Administrator (G0954), and prepare and plan an agency budget (G0988). Findings Include: 1. A review of the agency’s QAPI program failed to evidence the agency identified and analyzed concerns and issues impacting the quality of care, patient safety, and the efforts to improve health outcomes, develop a performance improvement plan (PIP) to reflect the patient and agency needs and documentation of the measurable improvement, and tracking of high risk, high volume, and problem-prone areas. 2. A review of the agency documents failed to evidence the governing body appointed the Administrator, Alternate Administrator, review and update policies and procedures, and prepare an agency budget. 3. A review of the Emergency Preparedness binder failed to evidence the agency developed an emergency preparedness plan, ensured the emergency policy, risk assessment, and communication plan was reviewed and updated every 2 years, and complete a facility and community-based risk assessment, include a plan to continue services and the delegation of authority, the contact information and attempt to contact federal, local, state, regional, and tribal emergency officials to discuss collaboration, a procedure to contact emergency officials for patients needing to vacate their residence, a way to follow-up with staff and patients and contact emergency officials for those staff and patients the agency was unable to reach, a system to preserve patient information, maintain record confidentiality and availability, and releasing patient information in the event of an evacuation to continue care, how the agency utilized volunteers, name and contact information for staff, entities providing services under arrangement, patient physicians, other facilities, and volunteers, how the agency will share necessary information to continue care, review and update their emergency preparedness training every 2 years, and complete a full-scale exercise every 2 years and a mock drill or tabletop exercise on the opposite year of the full-scale exercise. 4. During an interview with the Administrator and the Alternate Administrator on 04/15/2026 at 11:47 AM, they indicated they had not done anything with emergency preparedness and were not aware of the requirements. 5. During an interview with the Alternate Administrator on 04/15/2026 at 3:50 PM, they indicated they were unaware the governing body was to appoint the Administrator and Alternate Administrator. 6. During an interview with the Administrator on 04/16/2026 at 1:50 PM, they indicated they were unaware of the rules and regulations of the Conditions of Participation and Article 17. They explained they thought everyone was doing what they were supposed to do. They indicated they had a budget, but had not done anything with it, including the policies. The bylaws were not approved and reviewed. The Administrator was unaware of the need to appoint the Administrator and Alternate Administrator into their roles. The QAPI program was never discussed. 410 IAC 17-12-1(b)(1)(2)(3) (c)(1) (d)(8)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed transfer summary had been sent within 2 business days of becoming aware of an unplanned transfer to an acute care facility, where the patient had been receiving care, for 1 of 1 clinical records of patients being transferred. (Patient: #9) Findings Include: 1. A review of an undated agency policy tiled “Discharge Process” indicated but was not limited to, “ … g. A completed transfer summary is sent within two business days of becoming aware of an unplanned transfer … ” 2. A review of the clinical record for Patient #9, start of care date of 07/21/2025, transfer date of 10/27/2025, and a discharge date of 11/13/2025. The record contained a transfer/referral summary dated 10/27/2025 and signed by the DON. The transfer summary indicated Patient #9 had been sent to rehab, and last date of service 10/10/2025. The transfer summary failed to evidence the transfer summary and care the agency provided had been sent to the healthcare provider currently providing Patient #9 continued care. A review of a discharge summary dated 11/13/2025, signed by the DON, indicated Patient #9 had been admitted to a facility. The discharge summary failed to evidence the agency had sent to the healthcare provider providing continued care for Patient #9. During an interview on 04/14/2026 at 10:45 AM, when asked about Patient #9’s transfer and discharge from Visiting Angels Home Healthcare, Person 8, a family member of Patient #9, indicated Patient #9 had been admitted to an acute care facility, then transferred to a rehab facility, Entity 7, where they had passed away. Person 8 had spoken to the agency and made them aware of the situation and the location of Patient #9. During an interview on 04/14/2026 at 11:20 AM, when asked about the transfer and discharge summary being sent to the healthcare provider providing care to Patient #9, the DON stated, “I do not send the summaries or coordinate care with the hospitals or rehab facilities. I only send the summaries to the patients’ physicians.” 410 IAC 17-15-1(a)(7)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical records were protected against loss for 1 of 1 home health agencies. Findings include: 1. A review of an undated agency policy titled “Clinical Records/Medical Record Retention” indicated, but was not limited to, “ … All client information shall be regarded as confidential and available only to authorized users … Protected Health information will be available only to those who must use it. Procedures will be followed to assure that this information is protected … ” 2. A review of the personnel record for the Alternate Administrator contained a document titled “Patient Grievance/Concern Report Form.” The document indicated Person 6, a patient from Entity 1, had filed a complaint with the agency, noting the investigation and follow-up documentation had been completed. During an interview on 04/16/2026 at 9:00 AM, when asked about the patient grievance being in their personnel record, the Alternate Administrator communicated they had no idea how the patient’s grievance form with investigation documentation had been placed in their personnel file. The Alternate Administrator further indicated they had informed the Administrator about the patient’s report of concern being located in their personnel record, not in the grievance/complaint binder. 410 IAC 17-12-3(b)(3)

Home Health Aide CFR(s): 484.115(d) Standard: Home health aide. A person who meets the qualifications for home health aides specified in section 1891(a)(3) of the Act and implemented at §484.80. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the personnel qualifications for 1 of 1 HHA personnel records reviewed. (Employee: HHA 2) Findings Include: 1. A review of an undated agency policy titled “Personnel Records” indicated but was not limited to “Policy: Personnel files will be established and maintained for all personnel … a. The personnel record for an employee will include, but not be limited to: … criminal history and background checks as required by law … License and certifications … Orientation checklist-completed and signed … ” 2. A review of an undated agency policy titled “License, Registration, or Certification Requirements” indicated but was not limited to “ … IF a position requires licensure, registration, or certification, documentation that the person possesses these documents and is in good standing with the licensure or registration body will be confirmed prior to employment … ” 3. A review of the personnel record for HHA 2, date of hire 04/04/2024, and first patient contact 04/04/2024, contained an expired HHA certification with the expiration date of 03/18/2024. The personnel record failed to evidence HHA 2's current certification. During an interview on 04/16/2026 at 10:25 AM, when asked about the verification of HHA 2’s certification, the Alternate Administrator and Admin 4 provided a HHA certification with an expiration date of 03/18/2024. When shown the expiration date, the Alternate Administrator and Admin 4 indicated they could not provide HHA 2’s current certification.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health provider. Survey Dates: 08/22/23, 08/23/23, 08/24/23, 08/25/23, 08/28/23, 08/29/23 12 month Unduplicated Census: 0 A fully extended survey was announced on 08/24/23 at 3:45 PM. An immediate jeopardy concerning CoP 484.50 Patient Rights was identified on 05/31/23 when it was determined that the agency had failed to investigate a complaint of a suspected patient injury caused by an untrained home health aide and failed to ensure all patients were protected during the investigation. The Administrator was notified of the Immediate Jeopardy at CoP 484.50 Patient Rights on 08/25/23 at 12:47 PM. An immediate jeopardy concerning CoP 484.80 Home Health Aide Services was identified and announced on 08/29/23 at 12:47 PM, when it was identified that the agency failed to ensure they employed qualified Home Health Aides. The agency failed to submit an acceptable IJ lift plan for 484.50 Patient Rights and 484.80 Home Health Aide Services prior to survey exit on 08/29/23. Based on the Condition-level deficiencies during the Visiting Angels survey, your home health agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 08/29/23. 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 programs for a period of two years beginning August 29, 2023 and continuing through August 28, 2024. QR by Area 3 on 9-01-2023.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to protect a patient's right to a thorough complaint investigation, the right to be free from physical harm and injury while receiving care, the right to receive care based on specific care preferences, and the right to be protected from retaliation and/or harm during investigation of a complaint for 1 of 1 clinical record reviewed for a complaint of physical injury (Patient #2). The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.50 Patient Rights. Findings include: 1. A review of an undated agency policy titled C-381 "Client/family Complaint/Grievance Policy," indicated " ... Grievances will be addressed by the department director ... and response made to the complainant within seven (7) calendar days of receipt. If the grievance is one that will take longer than seven (7) calendar days to investigate and resolve, the director will contact the complainant within that time frame to let him/her know the grievance ... is being investigated ... All persons with a grievance will receive a written notice of the investigators [sic] review which will include the ... steps taken to investigate the grievance, the result of the process and the date of completion ... " The policy failed to evidence a thorough investigation was required for all complaints, failed to evidence investigation processes or steps used to ensure a thorough investigation process, and failed to evidence the need to protect all patients from retaliation, potential harm, or injury during ongoing investigations. 2. A review of the agency's complaint log evidenced a complaint by the spouse and representative of Patient #2, dated 06/01/23 at 8:40 AM and signed by the Administrator. The complaint indicated during the home health aide (HHA) visit on 05/31/23 the spouse was in the other room while HHA 1 was transferring Patient #2. The spouse reported hearing the patient cry out in pain around noon, which was not abnormal for the patient during transfers. Later that day, Patient #2 complained of left arm pain. The report also indicated HHA 1 reported trying to lift the patient "the same as every other time and did not notice anything out of the ordinary." HHA 1 said that Patient #2 tends to cry out frequently during transfers "and today was no different." On 6/05/23 at 3:45 PM, the spouse notified the Administrator that the patient's left arm was broken. The complaint failed to evidence the aide disregarded the spouse's instructions not to transfer the patient, the aide pulled on the patient's arm to assist in standing, the aide was aware of the injury at the time it occurred, or the patient had specific care requests posted throughout the house. 3. A review of the agency's incident log evidenced an "Incident Report," dated 06/01/23, which indicated an incident date of 05/31/23 at 12:30 PM. The report indicated the incident was recorded on camera and an injury was sustained to Patient #2's left arm. 4. A review of the clinical record for Patient #2 evidenced a comprehensive assessment with clinical summary, dated 07/19/23, which indicated "Recent fracture to LUE [Left Upper Extremity], no current treatment, allowing to heal as is. LUE contracted." The clinical record failed to evidence additional documentation related to the patient's frozen arm, specific transfer preferences and needs, or the investigation, findings, or resolution of the care which resulted in the patient's fractured left humorous and shoulder ball and joint. 5. On 08/23/23 at 9:58 AM, Person G, a representative for the patient's physician, was interviewed via phone. Person G confirmed Patient #2 had x-rays and other imaging of the left arm and the results on 06/05/23 indicated a fractured proximal (located toward the center of the body) left humorous (the arm bone that runs from the shoulder to the elbow). Patient #2 was referred to a bone and joint specialist for further evaluation. 6. On 08/24/23 at 3:06 PM, Person H, a Nurse Practitioner (NP) with Entity F, physician's group specializing in bone and joint treatment, stated HHA 1 attended the patient's appointment and said she admitted pulling on the patient's frozen arm during transfer and heard an audible pop. Person H confirmed a fractured left humorous and multiple fractures to the left shoulder ball and socket. 7. During a home visit on 08/24/23 at 11 AM, the spouse indicated Patient #2 had a frozen left arm and had specific care and transfer needs the spouse needed to teach the aide, however HHA 1 wasn't trained, didn't listen to instructions, and insisted on doing things her way. On 05/31/23 the spouse told HHA 1 not to transfer the patient until the spouse returned from the garage because HHA 1 wasn't trained on transferring the patient. The aide ran out to the garage a few minutes later and stated, "I think I just broke your wife's arm." The spouse stated a camera in the patient's room captured HHA 1 pulling on the patient's arm at 3 times while attempting to stand and transfer the patient. The patient was heard crying out each time and during the second attempt the patient yelled, "You bitch! You're hurting me!" On the third attempt an audible pop was heard on the video. When asked what training the spouse provided to the aide, the spouse indicated training the aides in all aspects of the patient's care, including but not limited to transfer, personal care, and feeding because the aides weren't trained and didn't know how to transfer, dress, and bathe the patient without affecting the frozen arm. 8. On 08/23/22 at 2 PM, the Administrator was interviewed concerning the injury to Patient #2's arm. The Administrator indicated HHA 1 completed retraining by reading a packet for proper transferring and a packet for incident reporting, then demonstrating proper transfer with the Administrator as a pseudo-patient. The Administrator denied removing the aide from direct patient care during the investigation and denied contacting other patients also seen by HHA 1 to determine if there were unreported care concerns or unreported complaints. The Administrator failed to verify the competency of HHA 1 by observing direct patient care and transfer, or by verifying previous education, experience, training, or credentialing. The agency failed to ensure the patient's person and body were treated with respect by failing to ensure the home health aide provided the patient-specific care needed to safely accommodate the patient during transfer and personal care, which subsequently caused a fractured left humorous and multiple fractures to the left shoulder ball and socket.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to respect the patient's specific requests and care preferences resulting in a patient injury, for 1 of 1 complaint of injury reviewed. (Patient #2) Findings include: 1. A review of the agency's complaint log evidenced a complaint by the spouse of Patient #2, dated 06/01/23 at 8:40 AM and signed by the Administrator. The complaint indicated during the home health aide (HHA) visit on 05/31/23 the spouse was in the other room while HHA 1 was transferring Patient #2. The spouse reported hearing the patient cry out in pain around noon, which was not abnormal for the patient during transfers. Later that day, Patient #2 complained of left arm pain and continued to complain of pain on 06/01/23 so the spouse made an appointment with the patient's physician. The report also indicated HHA 1 came into the office on 06/08/23 to complete an incident report and reported trying to lift the patient on 05/31/23 "the same as every other time and did not notice anything out of the ordinary." HHA 1 said that Patient #2 tends to cry out frequently during transfers "and today was no different." The complaint indicated on 6/05/23 at 3:45 PM, the spouse notified the Administrator and confirmed that the patient's left arm was broken. The complaint failed to evidence the aide disregarded the spouse's instructions not to transfer the patient, the aide pulled on the patient's frozen left arm 3 times to assist in standing, the aide was aware of the injury at the time it occurred, or the patient had specific care requests posted throughout the house. 2. A review of the agency's incident log evidenced an "Incident Report," dated 06/01/23, which indicated the patient suffered an injury to the left arm on 05/31/23 at 12:30 PM. The incident was recorded on camera. 3. A review of the clinical record for Patient #2 evidenced a comprehensive assessment clinical summary, dated 07/19/23, which indicated "Recent fracture to LUE [Left Upper Extremity], no current treatment, allowing to heal as is. LUE contracted." 4. During a home visit on 08/24/23 at 11 AM, the spouse indicated Patient #2 had a frozen left arm and had specific care and transfer needs the spouse needed to teach the aide, however HHA 1 wasn't trained, didn't listen to instructions, and insisted on doing things her way. On 05/31/23 the spouse told HHA 1 not to transfer the patient until the spouse returned from the garage because HHA 1 wasn't trained on transferring the patient. The aide ran out to the garage a few minutes later and stated, "I think I just broke your wife's arm." The spouse stated a camera in the patient's room captured HHA 1 pulling on the patient's arm 3 times while attempting to stand and transfer the patient. The patient was heard crying out each time and during the second attempt the patient yelled, "You bitch! You're hurting me!" On the third attempt an audible pop was heard on the video. When asked what training the spouse provided for the aide, the spouse stated training the aide in all aspects of the patient's care, including but not limited to transferring, personal care, toileting, and dressing because the aides aren't trained and don't know how to care for the patient without affecting the frozen arm. 5. On 08/23/23 at 9:58 AM, Person G, representative for Person D (the patient's physician), was interviewed via phone. Person G confirmed Patient #2 had x-rays and other imaging of the left arm and the results on 06/05/23 indicated a fractured proximal (located toward the center of the body) left humorous (the arm bone that runs from the shoulder to the elbow). Patient #2 was referred to Entity F, a medical practice that specialized in bone and joint medicine, for further evaluation. 6.On 08/24/23 at 3:06 PM, Person H, a Nurse Practitioner (NP) with Entity F, stated HHA 1 attended the patient's appointment and said she admitted pulling on the patient's arms during transfer and heard an audible pop. Person H confirmed a fractured left humorous and multiple fractures to the left shoulder ball and socket. The agency failed to ensure the patient's person and body were treated with respect by failing to ensure the home health aide provided the patient-specific care needed to safely accommodate the patient during transfer and personal care, which subsequently caused a fractured left humorous and multiple fractures to the left shoulder ball and socket. 410 IAC 17-12-3(b)(4)(8)

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 agency failed to ensure patients received the physician ordered frequency and duration of services and the home health aide services ordered on the plan of care for 1 of 7 active clinical records reviewed. (Patient #2) Findings include: 1. A review of an undated agency policy titled "C-751 Home Health Aide Care Plan,” indicated, but was not limited to, “A complete and appropriate Care Plan … shall be developed … All home health aide staff will follow the identified plan.” 2. A review of the plan of care for Patient #2, for certification period 07/21/23 – 09/18/23, evidenced a physician ordered frequency and duration for home health aide services of 4 hours/day x 1 day/week x 1 week, 4 hours/day x 5 days/week (weeks 2-9), 4 hours/day x 1 day /week x 1 week (week 10) for home health aide to assist with Activities of Daily Living (ADL), weekly bed/chair bath, transfers, meal prep/feeding, toileting, bathroom cleanup, change bed linens, conversation, dressing, encourage fluids, fall risk, hair care, hygiene assistance, incontinence care, nail care, oral care, positioning. A review of the completed visit schedule for 07/21/23 – 08/22/23 indicated Patient #2 received a frequency and duration of 3 hours/day x 1 day/week x 1 week, 3 hours/day x 5 days/week (weeks 2-present). A review of the home health aide visit note dated 07/21/23 indicated the patient received no hygiene assistance, incontinence care positioning or transferring. The visit note failed to indicate meal prep/feeding, toileting, change of linens, dressing, fluids, hair care, nail care, or oral care. The visit note indicated “bed bath refused with all 4 visits” and failed to evidence a chair bath was given in lieu of a bed bath. A review of the home health aide visit note dated 07/24/23 indicated the patient received no incontinence care, positioning, or transferring and had fall risk marked as “no.” The visit note failed to indicate meal prep/feeding, toileting, change of linens, dressing, fluids, hair care, nail care, oral care, or weekly bed/chair bath. A review of the home health aide visit note dated 07/25/23 indicated the patient received no incontinence care, positioning, or transferring and had fall risk marked as “no.” The visit note failed to indicate meal prep/feeding, toileting, change of linens, dressing, fluids, hair care, nail care, oral care, or weekly bed/chair bath. The note indicated “Second day of bed bath and change refusal.” A review of the home health aide visit note dated 07/26/23 indicated the patient received no incontinence care, positioning, or transferring and had fall risk marked as “no.” The visit note failed to indicate meal prep/feeding, toileting, change of linens, dressing, fluids, hair care, nail care, oral care, or weekly bed/chair bath. The note indicated “[Name of spouse]] once again has refused a bed bath for [Name of Patient #2] because [he/she] is sick. I have yet to do one in the two weeks I’ve been here. I just want to document.” A review of the home health aide visit note dated 08/02/23 indicated the patient received no incontinence care, positioning, or transferring and had fall risk marked as “no.” The visit note failed to indicate meal prep/feeding, toileting, change of linens, conversation, fluids, hair care, nail care, oral care, or weekly bed/chair bath. A review of the home health aide visit note dated 08/16/23 indicated the patient received no incontinence care, positioning, or transferring and had fall risk marked as “no.” The visit note failed to indicate meal prep/feeding, toileting, fluids, hair care, nail care, oral care, or weekly bed/chair bath. A review of the home health aide visit note dated 08/23/23 indicated the patient received no incontinence care, positioning, or transferring and had fall risk marked as “no.” The visit note failed to indicate meal prep/feeding, dressing, fluids, hair care, nail care, oral care and indicated upper body bathing was done. A review of home health aide visit notes for 07/27/23, 07/28/23, 07/31/23, 08/01/23, 08/03/23, 08/04/23, 08/07/23, 08/08/23, 08/09/23, 08/10/23, 08/11/23, 08/14/23, 08/15/23, 08/17/23, 08/18/23, 08/21/23, and 08/22/23 indicated the patient received no hygiene assistance, incontinence care positioning or transferring. The visit note failed to indicate meal prep/feeding, toileting, change of linens, dressing, fluids, hair care, nail care, or oral care. 3. On 08/25/23 at 9:06 AM, HHA 2 indicated the visits for Patient #2 consisted of the same tasks she performed when providing unskilled services, such as cleaning tasks and occasional feeding assistance because the patient’s spouse refused to allow any personal care. 4. On 08/24/23 at 3:54 PM, the Administrator indicated there had been problems for a long time with the spouse of Patient #2 because the spouse wanted an aide to come but consistently refused all personal care when the aide arrived. When asked about the agency’s process and policy concerning patients and/or caregivers who refused services the Administrator stated, “There’s never been a hardline rule for how long we can send out a person to work when the patient refuses care. We send them to do non-skilled care while we try to work out services they will accept.” The administrator indicated he was aware the patient had not received personal care for weeks and denied contacting the patient’s physician for changes in the plan of care. The Administrator indicated he’d spoken many times with the spouse about frequency, duration, and services ordered but did not document the conversations. The Administrator confirmed the current home health aide had another patient until 10:30 AM and couldn’t arrive at this patient’s house until 11 AM and could only stay until 2 PM. When asked if the services, frequency, and duration followed physician’s orders the Administrator indicated they did not.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to investigate complaints made by the patient or representative for 1 of 1 complaint reviewed for suspected injury. (Patient #2) Findings include: 1. A review of undated agency policy C-381 "Client/family Complaint/Grievance Policy," indicated " ... Grievances will be addressed by the department director ... and response made to the complainant within seven (7) calendar days of receipt. If the grievance is one that will take longer than seven (7) calendar days to investigate and resolve, the director will contact the complainant within that time frame to let him/her know the grievance ... is being investigated ... All persons with a grievance will receive a written notice of the investigators [sic] review which will include the ... steps taken to investigate the grievance, the result of the process and the date of completion ... " The policy failed to evidence the requirement to investigate all complaints. 2. A review of the agency's complaint log evidenced a "Report of Concern/Complaint/Grievance," signed by the Administrator. The report indicated the spouse for Patient #2 called and spoke with the Administrator on 06/01/23 at 8:40 AM and stated during a home health aide (HHA) visit on 05/31/23 the spouse was in the other room while HHA 1 was transferring Patient #2. Around noon, the spouse heard the patient cry out in pain, which was not abnormal during transfers. Patient #2 continued to complain of left arm pain and x-rays were obtained. An undated/untimed section titled "Immediate Action/Steps Taken" indicated "Call placed to caregiver [Name of HHA 1] to ask about the incident." The complaint form failed to evidence the Administrator initiated a complaint investigation including, but not limited to, assessing the patient, notifying the clinical manager and physician, completing a timely incident report, timely interview of the home health aide, verification of HHA 1's written and skills competency, and on-site observation of HHA 1 during patient transfer and personal care. 3. A review of the clinical record for Patient #2 evidenced a comprehensive assessment with clinical summary, dated 07/19/23, which indicated "Recent fracture to LUE [Left Upper Extremity], no current treatment, allowing to heal as is. LUE contracted." The clinical record failed to evidence additional documentation related to the patient's fractures or the investigation of the complaint of injury. During a home visit on 08/24/23 at 11 AM, the spouse indicated Patient #2 had a frozen left arm and had specific care and transfer techniques the spouse needed to teach the aide, however HHA 1 wasn't trained, didn't listen to instructions, and insisted on doing everything her way. On 05/31/23 the spouse told HHA 1 not to transfer the patient until the spouse returned from the garage because HHA 1 wasn't trained on transferring the patient correctly due to the frozen shoulder. The spouse indicated the aide ran out to the garage a few minutes later and stated, "I think I just broke your wife's arm." The spouse stated a camera in the patient's room captured HHA 1 pulled on the patient's arm 3 times while attempting to stand and transfer the patient. The patient was heard crying out each time and during the second attempt the patient yelled, "You bitch! You're hurting me!" On the third attempt an audible pop was heard on the video. When asked what training the spouse provided for the aide, the spouse stated they trained the aides in all aspects of the patient's care, including transfer, personal care, and feeding because the aides weren't trained and didn't know how to transfer, dress, and bathe the patient without affecting the frozen arm. 4. On 08/23/23 at 9:58 AM, Person G, representative for the patient's physician, Person D, was interviewed via phone. Person G confirmed Patient #2 had x-rays and other imaging of the left arm and the results on 06/05/23 indicated a fractured proximal (located toward the center of the body) left humorous (the arm bone that runs from the shoulder to the elbow). 5. On 08/24/23 at 3:06 PM, Person H, a Nurse Practitioner (NP) with Entity F, physician's group specializing in bone and joint treatment, stated HHA 1 attended the patient's virtual appointment on 06/01/23 and said HHA 1 admitted pulling on the patient's arms during transfer and heard an audible pop. Person H confirmed the patient experienced a fractured left humorous and multiple fractures to the left shoulder ball and socket. 410 IAC 17-12-3(c)(1)(A)

Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all complaints of potential mistreatment were investigated, for 1 of 1 complaint of injury reviewed. (Patient #2) Findings include: 1. A review of an undated policy titled “C-381 Client/Family Complaint/Grievance Policy” failed to evidence the patient’s right to, or an agency policy or process for investigation of complaints related to possible mistreatment. 2. A review of the agency complaint log evidenced a “Report of Concern/Complaint/Grievance” dated 06/01/23 at 8:40 AM, which indicated a “possible accidental left arm injury” to Patient #2. The patient’s spouse called and reported that on 05/31/23 the spouse was in the other room and Home Health Aide (HHA) 1 was transferring Patient #2. The spouse heard the patient cry out in pain around noon, which was not abnormal during transfers. Later in the day, Patient #2 began complaining of pain in the left arm. The complaint report indicated a call was placed to HHA 1 to ask about the incident but failed to evidence a date or time the aide was actually contacted and interviewed concerning the complaint. An undated entry on the complaint report follow-up investigation section indicated HHA 1 reported she lifted the patient “the same as every other time and did not notice anything out of the ordinary. She said that [Name of Patient #2] tends to cry out frequently during transfer and today was no different.” A review of an incident report, dated 06/01/23, indicated the incident was captured on camera. The complaint report and incident report failed to evidence an investigation occurred immediately following the report of suspected injury to the left arm which included determining if mistreatment occurred, whether deliberate or unintended due to lack of training, such as review of the available video recording, observation of the aide’s transfer and care techniques, the aide's competency verification for transferring Patient #2, interview with HHA 1’s other patients to assess for unreported care concerns, and comprehensive assessment of Patient #2 at the time the suspected injury was reported. 3. On 08/24/23 at 10:56 PM, the spouse for Patient #2 indicated on 05/31/23 they instructed HHA 1 not to transfer Patient #2 until the spouse returned from the garage because the aide was not trained on transferring Patient #2, who had a frozen left arm. Soon after, HHA 1 ran into the garage and indicated, “I think I just broke your wife’s arm.” The spouse indicated the video showed HHA 1 pulling on the patient’s frozen left arm at least 3 separate times while trying to transfer the patient. Patient #2 cried out each time and the third time an audible pop was heard. The spouse indicated offering the video to the Administrator for review, but the Administrator stated it wasn’t necessary. 4. On 08/24/23 at 3:06 PM, Person H, a Nurse Practitioner with Entity F, bone and joint specialists, indicated HHA 1 attended the visit for evaluation of the patient's left arm and stated she pulled on the patient's frozen arm while trying to transfer the patient, and heard an audible pop. Person H stated this resulted in Patient #2 experiencing a fractured proximal humorous and multiple fractures in the left shoulder ball and socket. 5. On 08/22/23 at 2:07 PM, the Administrator indicated the patient was not assessed after the report of possible injury because they weren’t sure at the time of report if there was actually an injury, as the patient had not seen a physician yet, and they weren’t sure if the patient could communicate pain effectively. The Administrator also indicated he tried several times to “get [HHA 1] in here in that time between 06/01/23 and 06/08/23 but [he/she] always had a reason [he/she] couldn’t come in or it wouldn’t work.” When asked why the video was not reviewed, the Administrator indicated he didn’t think it was necessary.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all complaints and concerns were documented and evidenced a resolution for 1 of 3 active records (Patient #4) reviewed with a home visit and 1 of 2 inactive records reviewed (Patient #8). Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled “Client/Family Complaint/Grievance Policy, Policy #C-381”. The policy indicated but was not limited to, “ … A complaint is defined as ‘any expression of dissatisfaction by a client/family regarding care or services that can be addressed at the time of complaint by staff present’ … 2. Client complaints will be documented on a client complaint form and filed with the complaint log in an administrative file. …” 2. On 08-28-2023 at 9:05 AM, the complaint log was reviewed. The complaint log failed to evidence Patient #4 and Patient #8’s complaints. 3. During an interview with Patient #4 on 08-24-2023 at 9:25 AM at their residence, when queried regarding whether they had made a complaint with the agency, Patient #4 indicated they made a complaint about a certified nursing assistant (CNA) about 5 months ago. Patient #4 indicated the CNA never had a job and would not listen. Patient #4 indicated the agency resolved the issue and removed the CNA from their home. Patient #4 indicated they could not remember the CNA’s name. The complaint log failed to evidence the complaint. During an interview with the Administrator on 08-25-2023 at 11:58 AM, when queried regarding Patient #4’s complaint, they indicated the patient had never made a complaint with the agency. The Administrator indicated they did not see a “caregiver swap” as a direct complaint. The Administrator indicated the patient’s concern with the agency’s employee was a concern the patient was voicing against the agency. 4. During an interview with Person U, Patient #8’s spouse, on 08-25-2023 at 8:42 AM, they indicated the agency provided “terrible service, terrible communication”. Person U indicated they would never know what aide was coming out and would not let them know if they were unable to get a caregiver to come out and help Patient #8. Person U indicated the management would not listen and they indicated they (the spouse) were not able to care for Patient #8 on their own. Person U indicated they had made a complaint to the Administrator, management, and the owner regarding Patient #8 not receiving HHA services 3 times a week, but nothing was ever done to correct the concern. During an interview with Person U, Patient #8’s spouse, on 08-25-2023 at 8:53 AM, they indicated they “made a complaint with everyone the CEO (sic Chief Executive Officer), Administration, management, and nothing happened.” The complaint log failed to evidence the complaint made by Person U, Patient #8’s spouse. 410 IAC 17-12-3 (c) (2)

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients were protected from potential harm and/or retaliation during investigation of a complaint of suspected injury, for 1 of 1 complaints of suspected injury reviewed. (Patient #2) Findings include: Findings include: 1. A review of undated agency policy C-381 "Client/Family Complaint/Grievance Policy" failed to evidence the policy addressed investigation processes or steps, such as interviewing, observation, confirmation of competency, protection of patients, confidentiality, and the patient's rights during an investigation. 2. A review of the clinical record for Patient #2 evidenced a comprehensive assessment with clinical summary dated 07/19/23, which indicated Patient #2 had a recent fracture of the left upper extremity. 3. On 08/24/23 at 3:06 PM, Person H, a Nurse Practitioner with Entity F, bone and joint specialists, indicated HHA 1 attended the visit for evaluation of the patient's left arm and stated she pulled on the patient's frozen arm while trying to transfer the patient, and heard an audible pop. Person H stated this resulted in Patient #2 experiencing a fractured proximal humorous and multiple fractures in the left shoulder ball and socket. 4. On 08/23/22 at 2 PM, the Administrator was interviewed concerning the injury to Patient #2's arm. The Administrator indicated HHA 1 completed retraining by reading a packet for proper transferring and a packet for incident reporting, then demonstrating proper transfer with the Administrator as a pseudo-patient. The Administrator denied removing the aide from direct patient care during the investigation and denied contacting other patients also seen by HHA 1 to determine if there were unreported care concerns or unreported complaints. The Administrator failed to verify the competency of HHA 1 by observing direct patient care and transfer, or by verifying previous education, experience, training, or credentialing.

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 all patients received a patient-specific comprehensive assessment that reflected the patient’s current status (G526); included the patient’s health, psychosocial, functional, and cognitive status (G528); included the patient’s strengths, goals, and care preferences (G530); the patient’s continuing need for home care (G532); the patient’s medical, nursing, rehabilitation, social, and discharge planning needs (G534); was updated for change in condition (G544); and was updated at least every 60 days (G546) for 7 of 7 active clinical records reviewed. (Patients #1, 2, 3, 4, 5, 6, and 7) The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CoP 484.55 Comprehensive Assessment. *

Content of the comprehensive assessment CFR(s): 484.55(c) 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: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received a comprehensive assessment that reflected the patient’s current status at the time of assessment, for 2 of 7 active clinical records reviewed. (Patients #2, 6) Findings include: 1. A review of an undated agency policy titled “C-145 Comprehensive Client Assessment” indicated … a. The comprehensive Assessment must accurately reflect the client’s status … 2. A review of the comprehensive assessment for Patient #2, dated 07/19/23, indicated a primary diagnosis of Anoxic Brain Damage (brain injury resulting from a complete lack of oxygen to the brain), cephalic seizures (interruption in electrical activity in the brain), Transient Ischemic Attack (TIA – a mini-stroke with no residual effects), Contractures (shortening and hardening of muscles and tendons, often causing deformity), and Cerebral Vascular Accident (CVA – sudden bleeding in or blockage of blood flow to the brain; stroke). The assessment failed to evidence the patient’s current functional, psychosocial, and cognitive status in relation to a anoxic brain injury and a history of CVA and TIA, such as residual effects, mobility, ability to communicate and understand, emotional appropriateness, and level of independence and failed to reflect the patient’s current status related to a history current frequency and risk of TIAs, affected limbs with contractures and their limitations, the frequency and quality of seizures and the last known seizure, the presence of a frozen left arm, current transfer needs, and the current status of the recent fracture, including treatment, therapy, immobilization, and pain. The patient’s cardiopulmonary, neuromuscular, gastrointestinal, and integumentary statuses were marked as “same” and failed to evidence the patient’s current state of health. 3. A review of the comprehensive assessment for Patient #6, dated 08/02/23, evidenced a primary diagnosis of Paraplegia (paralysis of the lower extremities) and a secondary diagnosis of Type 2 Diabetes Mellitus (a condition where the pancreas is unable to regulate insulin production for the metabolism of sugars. The assessment failed to evidence a functional assessment related to the patient’s paraplegia. A skin assessment indicated “No Problem. C/D/I BLE (Clean/Dry/Intact Bilateral Lower Extremity) wrapped.” The assessment failed to evidence a diagnosis related to wounds, the type of wound or the reason for BLE wraps, and the current status of the wound(s). The assessment failed to evidence a functional, psychosocial, or cognitive assessment was completed and failed to evidence the patient’s current status related to a diagnosis of paraplegia, such as the ability to transfer independently, risk for pressure sores, mobility, risk for depression, and level of independence. 4. On 08/24/23 at 3:54 PM, the contents of the comprehensive assessments were reviewed with the Administrator. The Administrator indicated they lacked detail for Patients #2 and 6, such as a comprehensive assessment of body systems, a detailed seizure plan for Patient #2, the functional assessments, and follow-up related to Patient #6's severe pain of 8-9/10. 410 IAC 17-15-1(a)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(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 all patients received a comprehensive assessment that accurately reflected their current health status, such as assessment of body systems; psychosocial status, such as support systems, living arrangements, and ability to communicate; functional status, such as level of independence, safety precautions, mobility challenges, and need for modifications; and cognitive status, such as ability to understand, need for education concerning disease process, and risk for depression, for 7 of 7 active patient records reviewed. (Patients: #1, 2, 3, 4, 5, 6, and 7) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021, Visiting Angels Home Health Agency policy titled “Comprehensive Patient Assessment”. The policy indicated but was not limited to, “ … 5. The Comprehensive Assessment includes an assessment and documentation … List of Current diagnoses and symptom control … height and weight are recorded … assessment of the patient’s pain level, location, what makes it better, worse, frequency of pain, activities affected … endocrine system … cardiopulmonary assessment … Assessment of the integumentary system … identification of any wounds, including the assessment and staffing of the identified wounds … diabetic foot exam … assessment of the patient’s overall nutritional status … assessment of urinary elimination … assessment of bowel sounds, frequency, and consistency of bowel movements … urinary status, ability to urinate, frequency … neuro status … psychosocial status …” 2. On 08-22-2023 at 11:05 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification/Follow-up Assessment” with a date of 07-03-2023 and timed for 2:00 PM. The document evidenced under a section titled “Frequency of Pain Interfering”, the Alternate Director of Nursing (ADON) indicated the patient had pain interfering with activity and movement. The remaining questions regarding pain where left blank. The document failed to indicate how the patient’s pain affected different activities and how pain was relieved. The section titled “Systems Review” evidenced the patient was “not weighed”. The ADON failed to follow the policy and include the patient’s weight. The section titled “Neuro” indicated the patient had a neurological disorder called Multiple Sclerosis (a disorder where the immune system attacks the brain and spinal cord causing communication problems from the brain to the rest of the body). The “Neuro” section indicated but was not limited to, “ … How does the patient’s condition affect functional ability and/or safety? …” The ADON indicated, “monoplegia LLE (sic paralysis of the left lower extremity). The document failed to indicate how the neurological disorder affected the patient’s safety and their functional ability. The section titled “Risk Factors/Hospital Admission/Emergency Room” was left blank, when they noted on page 4, the patient was at risk for hospitalization due to multiple emergency room visits in the past 6 months and the patient had 5 or more medications they were taking. The comprehensive assessment failed to provide a current, accurate view of Patient #1’s current health status. 3. On 08-23-2023 at 1:13 PM, Patient #3’s clinical record was reviewed. The clinical record evidenced a plan of care (POC) with a start of care date of 01-29-2021 and a certification period of 07-18-2023 to 09-15-2023. The plan of care indicated the patient had the diagnoses Chronic Obstructive Pulmonary Disease (COPD, a disease causing difficulty breathing and narrowing of the airway) and Diabetes Mellitus Type 2 (a disease were the body is unable to regulate the sugar levels in the body). The POC evidenced the patient also had oxygen for their COPD. The POC evidenced the patient had allergies to Amoxicillin, Celebrex, Levaquin, and Morphine. Patient #3’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 07-14-2023 at 8:00 AM. The section titled “Gastrointestinal” indicated the patient required a regular diet, which was not appropriate for a patient with a diagnosis of Diabetes. The section titled “Medication” indicated there were changes noted, and the question “instructed on” was left blank. The section titled “Skin/Wound/Ostomy” indicated there were no problems, the comments section indicated “reddened buttocks”. The section titled “Allergies” had the box “None known” marked. The section failed to indicate all the allergies Patient #3 had. The comprehensive assessment failed to evidence a Diabetic foot exam was conducted. The comprehensive assessment failed to provide a current, accurate view of Patient #3’s current health status. The clinical record evidenced a document titled “Recertification/Follow-up Assessment” with a date of 08-02-2023 and timed for 7:00 AM. The document contained a section titled “Advance Directives”, the ADON marked “Education needed”, no teaching or instructions were provided to the patient regarding Advance Directives. The section titled “Skin Condition/Wounds” indicated but was not limited to, “ … Skin … Left great toe surgical …” The document failed to provide additional information about Patient #3’s surgical wound on their left great toe. The section titled “Cardiopulmonary” failed to indicate how much oxygen the patient was on, and/or when they need oxygen. The section titled “Nutritional Status” indicated the patient was on a regular diet, which was not appropriate for a patient with a Diabetes diagnosis. The section titled “Elimination” failed to indicate the patient’s bowel frequency as necessary according to the agency’s policy. The section titled “DME (sic Durable Medical Equipment) Supplies” failed to include the patient’s brief pads for urinary incontinence. The comprehensive assessment failed to indicate a diabetic foot exam was conducted for the patient. The comprehensive assessment failed to provide a current, accurate view of Patient #3’s current health status. During an interview with the ADON on 08-23-2023 at 2:43 PM, when queried regarding if diabetic foot assessments were conducted during the comprehensive assessments, they indicated they did not do diabetic foot assessments and document on the comprehensive assessments. 4. On 08-24-2023 at 12:36 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a document “Recertification Comprehensive Assessment” dated 06-19-2023 at 10:00 AM. The section titled “Assessment and Observation signs/symptoms” failed to indicate which quadrants the bowel sounds were active. The section titled “Skin/Wound/Ostomy” indicated the patient had a right heel wound with wound care performed weekly. The document failed to evidence what type of wound the patient had, if a dressing covered the wound or if it was open to air, what the wound looked like, and who managed the wound for the patient. Patient #4’s clinical record evidenced a document “Recertification Comprehensive Assessment” dated 08-18-2023 at 9:00 AM. The section titled “Medication” indicated there was a medication change, but no evidence the patient was instructed on expiration dates and drug to drug interactions for the medication change. The section titled “Skin/Wound/Ostomy” indicated the patient had a right heel ulcer, and received weekly wound care from Entity T, a wound center. The section failed to indicate if the patient had a dressing on or if the wound was open to air. The comprehensive assessment failed to provide a current, accurate view of Patient #4’s current health status. 5. On 08-25-2023 at 9:30 AM, Patient #5’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-08-2023 at 12:00 PM. The section titled “Assessment and Observation signs/symptoms” indicated Patient #5 had no pain, but indicated in the comments, the document evidenced the patient had pain in their neck at times. The comprehensive assessment failed to indicate what caused the pain, how the pain was relieved, and the intensity of the pain when it occurred. The section titled “Genitourinary” indicated the patient had incontinence and the foley catheter was replaced by the physician. The comprehensive assessment failed to indicate the type of catheter, when it was placed, who replaced the catheter, and the color and consistency of the urine. Patient #5’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 08-07-2023 at 12:00 PM. The section titled “Genitourinary” indicated the patient had a catheter, but failed to indicate the type of catheter, who managed it, when it was last changed, and the color and consistency of the urine. The comprehensive assessment failed to provide a current, accurate view of Patient #5’s current health status. 6. On 08-25-2023 at 2:55 PM, Patient #7’s clinical record was reviewed. The clinical record evidenced a document titled “Comprehensive Adult Assessment” dated 07-05-2023 at 2:00 PM. The document contained a section titled “Prognosis”, and the document failed to indicate the patient’s prognosis. The section titled “Cardiopulmonary” failed to indicate the patient’s height and weight, identify if the patient’s respirations were regular or irregular, indicate what the patient used for oxygen, if needed at night, and failed to indicate if the patient’s capillary refill was less than or greater than 3 seconds. The section titled “Elimination” evidenced the patient had an ileostomy/colostomy site (a surgical opening made for the small intestine to protrude out of the abdomen and remove waste from the body) but failed to evidence a description of the site. The section titled “Mental Status” indicated the patient was “comatose”, but the section titled “Activities permitted” indicated the patient was “up as tolerated” and able to transfer from the bed and chair. The section titled “Enteral Feedings – Access Device” failed to indicate where the gastrostomy tube (a surgical opening in the abdomen, where a tube was placed to provide nutrients to the individual) was located and the skin around the site. The section titled “Professional Services” failed to evidence the Director of Nursing (DON) taught the disease process, signs and symptoms of infection, home safety, medication education, and oxygen education. Patient #7’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 07-12-2023 at 9:00 AM. The document evidenced a section titled “Assessment and observation signs/symptoms” failed to evidence the patient’s weight. The section titled “Cardiopulmonary” failed to indicate the patient used oxygen as needed at night as evidenced by the comprehensive assessment dated 07-05-2023 and as evidenced in the section titled “Summary Checklist”, DME (sic durable medical equipment) indicated the patient had and oxygen concentrator. The section titled “Enteral Feedings – Access Device” failed to indicate the amount of feeding the patient was to receive through the gastrostomy tube, the rate, the flush amount, and rate, and who managed the gastrostomy tube. The clinical record evidenced a document titled “Comprehensive Adult Assessment” dated 08-15-2023 at 8:00 AM. The document evidenced a section titled “Pertinent Background Information”, which failed to indicate why the patient went to the hospital for a routine baclofen pump replacement (a device bringing medication for spasticity directly to the spinal cord) and was hospitalized from 08-04-2023 to 08-14-2023. The section titled “Skin Condition/Wounds” indicated the patient had an incision on their left lower abdomen to replace the baclofen pump, if failed to indicate if the incision was open to air, had a dressing, and a description of the incision. The section titled “Cardiopulmonary” failed to evidence a height and weight for the patient, failed to indicate the device used to deliver the oxygen to the patient, and failed to indicate whether the patient’s capillary refill was less than or greater than 3 seconds. The section titled “Mental Status” indicated the patient was comatose, but the section titled “Activities Permitted” indicated the patient could be up as tolerated and could transfer from the bed and chair. The section titled “Enteral Feedings – Access Device” failed to indicate when the caregivers were to initiate a water flush and the rate to flush the water. The section titled “Professional Services” failed to evidence the Director of Nursing (DON) taught the disease process, signs and symptoms of infection, home safety, medication education, and oxygen education. The comprehensive assessment failed to provide a current, accurate view of Patient #7’s current health status. 7. During an interview with the Alternate Director of Nursing (ADON) on 08-23-2023 at 11:35 AM, they indicated the comprehensive assessment was to be patient-specific, complete, and accurate to the patient. 8. During an interview with the DON on 08-25-2023 at 11:58 AM, they indicated the comprehensive assessment should include who managed the wound, foley catheter, and gastrostomy tube and indicate if there was a dressing, date of when it was last changed or verified, and/or open to air. A1. review of an undated agency policy titled “C-145 Comprehensive Client Assessment” indicated … a. The comprehensive Assessment must accurately reflect the client’s status, and must include at a minimum … the client’s current health, psychosocial, functional, and cognitive status. This includes an evaluation of mental health and functional capacity … Cognitive assessment refers to the degree of client’s ability to understand, remember and participate … b. Assess the functional status and their ability to function independently in the home … 4. … Functional status is assessed … using the OASIS (Outcome and Assessment Information Set) data elements with agency specific assessment criteria. When the client is not required to have OASIS data collected the functional status … will be assessed using this tool or a related tool … “ 2. A review of the comprehensive assessment for Patient #2, dated 07/19/23, indicated a primary diagnosis of anoxic brain damage (brain injury resulting from a complete lack of oxygen to the brain), cephalic seizures (interruption in electrical activity in the brain), transient ischemic attack (TIA – a mini-stroke with no residual effects), contractures (shortening and hardening of muscles and tendons, often causing deformity), cerebral vascular accident (CVA – sudden bleeding in or blockage of blood flow to the brain; stroke). The functional limitations included incontinence and endurance and failed to include contracture, speech, or the frozen left arm. A summary of care indicated the patient required the assistance of a Home Health Aide (HHA) for Activities of Daily Living (ADL), transfers, bathing, hygiene, toileting, meals, and safety. The assessment failed to evidence an OASIS functional assessment or alternate tool, per agency policy, including but not limited to evaluation of the musculoskeletal system, mobility and performance, safety, and transfer methods and failed to evidence the patient’s psychosocial and cognitive statuses were assessed. The patient’s cardiopulmonary, neuromuscular, gastrointestinal, and integumentary systems were marked “same” of “NA” (not applicable) and failed to evidence the patient’s current health status such as quality of breathing, perfusion, skin integrity, and wound status. 3. A review of the comprehensive assessment for Patient #6, dated 08/02/23, indicated a primary diagnosis of paraplegia and a secondary diagnosis of type 2 diabetes mellitus. Functional limitations included paralysis, endurance, and ambulation. The assessment failed to evidence an OASIS functional assessment or alternate tool, per agency policy, including but not limited to evaluation of the musculoskeletal system, mobility and performance, safety, and transfer methods and failed to evidence the patient’s psychosocial and cognitive statuses were assessed. The patient’s cardiopulmonary, neuromuscular, gastrointestinal, and integumentary systems were marked “same” or “NA” and failed to evidence the patient’s current health status such as quality of breathing, perfusion, skin integrity, and seizure activity.

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 observation, record review and interview, the agency failed to ensure all patient’s received a comprehensive assessment that reflected their current strengths, patient-specific and measurable goals, and care preferences, for 6 of 7 active clinical records reviewed. (Patients #2, 3, 4, 5, 6, 7) Findings include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021, Visiting Angels Home Health Agency policy titled “Comprehensive Patient Assessment”. The policy indicated but was not limited to, “ … 5. The Comprehensive Assessment includes an assessment and documentation … Assessment of the patient’s care preferences and their personal goals … the patient’s ‘strengths/limitations’ …” 2. On 08-23-2023 at 1:13 PM, Patient #3’s clinical record was reviewed. Patient #3’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 07-14-2023 at 8:00 AM. The comprehensive assessment failed to identify the patient’s strengths, goals, and care preferences and their progress toward their goals. 3. On 08-24-2023 at 12:36 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a document “Recertification Comprehensive Assessment” dated 06-19-2023 at 10:00 AM and another comprehensive assessment dated 08-18-2023 at 9:00 AM. The comprehensive assessments failed to identify the patient’s strengths, goals, care preferences, and their progress toward their goals. 4. On 08-25-2023 at 9:30 AM, Patient #5’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-08-2023 at 12:00 PM and another dated 08-07-2023 at 12:00 PM. The comprehensive assessments failed to identify the patient’s strengths, goals, care preferences, and their progress toward their goals. 5. On 08-25-2023 at 2:55 PM, Patient #7’s clinical record was reviewed. The clinical record evidenced documents titled “Comprehensive Adult Assessment” dated 07-05-2023 at 2:00 PM and 08-15-2023 at 8:00 AM. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 07-12-2023 at 9:00 AM. The comprehensive assessments failed to identify the patient’s strengths, goals, care preferences, and their progress toward their goals. 6. During an interview with the Director of Nursing (DON) and Alternate Director of Nursing (ADON) on 08-23-2023 at 11:35 AM, the DON indicated the assessment was to include patient-specific and patient-identified goals. The ADON indicated the comprehensive assessment was to be patient-specific, complete, and accurate to the patient. A review of an undated agency policy titled “C-145 Comprehensive Client Assessment” indicated … a. The comprehensive Assessment must accurately reflect the client’s status, and must include at a minimum … c. The client’s strengths, goals, and care preferences … During a home visit on 08/24/23 at 10:56 AM, hand-written care lists were observed in clear view posted on the kitchen cabinets, which indicated numbered points for care preferences, including but not limited to assist with drinks and finger foods, never cut the patient’s hair, check under breasts for redness and apply triple antibiotic ointment, apply right boot when standing, braces on both legs daily, never leave on the toile for >15 minutes, and seat patient at the table with DVD player in the kitchen. The patient’s spouse stated there were care lists throughout the house, including the bedroom and bathroom and stated no one had ever asked about specific care preferences, including the specific way the patient must be transferred due to a frozen left arm. A review of the comprehensive assessment for Patient #2, dated 07/19/23, evidenced a section titled “Rehabilitation Potential/Goals.” A selected goal under the aide category indicated “Assumes responsibility for personal care needs by: (date).” The date was blank. The comprehensive assessment failed to evidence patient-specific, measurable, and pertinent goals or patient strengths and failed to evidence any care preferences, including the ones posted in the patient’s home. 2. A review of the comprehensive assessment for Patient #3, dated 08/02/23, evidenced a section titled "Rehabilitation Potential/Goals." A selected goal under the aide category indicated “Assumes responsibility for personal care needs by: 60 days. (date).” The comprehensive assessment failed to evidence patient-specific, measurable, and pertinent goals or patient strengths. Based on observation, record review and interview, the agency failed to ensure all patient’s received a comprehensive assessment that reflected their current strengths, patient-specific and measurable goals, and care preferences, for 2 of 7 active clinical records reviewed. (Patients #2, 6) Findings include: A review of an undated agency policy titled “C-145 Comprehensive Client Assessment” indicated … a. The comprehensive Assessment must accurately reflect the client’s status, and must include at a minimum … c. The client’s strengths, goals, and care preferences … During a home visit on 08/24/23 at 10:56 AM, hand-written care lists were observed in clear view posted on the kitchen cabinets, which indicated numbered points for care preferences, including but not limited to assist with drinks and finger foods, never cut the patient’s hair, check under breasts for redness and apply triple antibiotic ointment, apply right boot when standing, braces on both legs daily, never leave on the toile for >15 minutes, and seat patient at the table with DVD player in the kitchen. The patient’s spouse stated there were care lists throughout the house, including the bedroom and bathroom and stated no one had ever asked about specific care preferences, including the specific way the patient must be transferred due to a frozen left arm. A review of the comprehensive assessment for Patient #2, dated 07/19/23, evidenced a section titled “Rehabilitation Potential/Goals.” A selected goal under the aide category indicated “Assumes responsibility for personal care needs by: (date).” The date was blank. The comprehensive assessment failed to evidence patient-specific, measurable, and pertinent goals or patient strengths and failed to evidence any care preferences, including the ones posted in the patient’s home.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to indicate the patient’s medical, nursing, rehabilitative, and discharge planning needs for 6 of 7 active records reviewed. (Patient# 2, 3, 4, 5, 6, and 7) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021, Visiting Angels Home Health Agency policy titled “Comprehensive Patient Assessment”. The policy indicated but was not limited to, “ … 5. The Comprehensive Assessment includes an assessment and documentation … Document the patient’s rehabilitation potential, Discharge planning is initiated, goals are identified, and/or continuing care needs are recognized …” 2. On 08-23-2023 at 1:13 PM, Patient #3’s clinical record was reviewed. Patient #3’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 07-14-2023 at 8:00 AM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by 60 days”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. Patient #3’s clinical record evidenced a document titled “Recertification/Follow-up Assessment” with a date of 08-02-2023 and timed for 7:00 AM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by 60 days”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. 3. On 08-24-2023 at 12:36 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-19-2023 at 10:00 AM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by (sic blank)”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. Patient #4’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 08-18-2023 at 9:00 AM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by 60 days”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. 4. On 08-25-2023 at 9:30 AM, Patient #5’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-08-2023 at 12:00 PM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by (sic blank)”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. Patient #5’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 08-07-2023 at 12:00 PM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by 60 days”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. 5. On 08-25-2023 at 2:55 PM, Patient #7’s clinical record was reviewed. The clinical record evidenced a document titled “Comprehensive Adult Assessment” dated 07-05-2023 at 2:00 PM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by 07-16-2023”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. The clinical record evidenced documents titled “Recertification Comprehensive Assessment” 07-12-2023 at 9:00 AM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by 09-14-2023”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. The clinical record evidenced documents titled “Comprehensive Adult Assessment” 08-15-2023 at 8:00 AM. The section titled “Rehabilitation Potential / Goals” had the Aide box marked indicating, “Assumes responsibility for personal care needs by 09-14-2023”. The comprehensive failed to identify the patient’s potential to reach the identified goal. The comprehensive assessment failed to indicate the patient’s social planning needs. 6. During an interview with the Director of Nursing (DON) and Alternate Director of Nursing (ADON) on 08-23-2023 at 11:35 AM, the DON indicated the assessment was to indicate the needs of the patient. The ADON indicated the comprehensive assessment was to be patient-specific, complete, and accurate to the patient according to the agency policy. 1. A review of the clinical record for Patient #2 evidenced a comprehensive assessment dated 07/19/23 and indicated a primary diagnosis of anoxic brain injury (brain injury caused by a complete lack of oxygen to the brain) and secondary diagnoses of cephalic seizures (a burst of uncontrolled electrical activity that causes temporary abnormalities in motor skills, sensation, awareness, and emotion), transient ischemic accident (TIA - a temporary period of symptoms similar to a stroke but which are brief and have no lasting effects), contractures (shortening or hardening of the muscles and/or tendons causing deformity), and cerebrovascular accident (CVA - stroke; sudden bleeding in or blockage of blood flow to the brain) The comprehensive assessment clinical summary indicated "Recent fracture to LUE [Left Upper Extremity], no current treatment, allowing to heal as is. LUE contracted." The assessment indicated rehab potential was fair but failed to evidence the patient's rehabilitative needs, treatments, or goals including, but not limited to, use of leg braces and a left boot, functional status, need for physical therapy related to contractures and the previous CVA and anoxic brain injury, difficult transfers, frozen left extremity, and any treatment or immobilization requirements of the recently fractured LUE. The comprehensive assessment failed to indicate the frequency, severity, or type of seizures experienced by the patient and whether there were nursing needs related to the management and mitigation of seizures. During a home visit on 08/24/23 at 10:56 AM, the patient's spouse indicated signs posted in the kitchen which listed patient-specific care requests, including use of a left boot and leg braces when the patient was up and weightbearing to pivot. 2. A review of the comprehensive assessment for Patient #6, dated 08/02/23, evidenced a primary diagnosis of paraplegia and secondary diagnosis of type 2 diabetes mellitus. The pain assessment indicated chronic pain in the bilateral lower extremities and back at 8-9/10 and failed to evidence the patient's medical needs were assessed in relation to managing and mitigating severe pain. The assessment indicated the patient's rehab potential was fair but failed to evidence the patient's rehabilitative needs, treatments, or goals related to functional status, mobility, or need for physical or occupational therapy related to paraplegia, A skin assessment evidenced "No Problem" and a comment section indicated "C/D/I BLE [Clean/Dry/Intact Bilateral Lower Extremity] wrapped." The assessment failed to evidence if both extremities were wrapped, the reason for and the type of wrap, and the patient's nursing needs related to the leg wraps or unknown wound.

Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient's primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the patient’s primary caregiver or a potential temporary caregiver and their availability for 5 of 7 active clinical records reviewed. (Patients: #1, 3, 4, 5, and 7) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021, Visiting Angels Home Health Agency policy titled “Comprehensive Patient Assessment”. The policy indicated but was not limited to, “ … 5. The Comprehensive Assessment includes an assessment and documentation … access to a temporary caregiver and availability of caregiver is assessed and documented … any available “primary caregiver” is identified and a list of the hours and days the caregiver is available …” 2. On 08-22-2023 at 11:05 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification/Follow-up Assessment” with a date of 07-03-2023 and timed for 2:00 PM. The comprehensive assessment evidenced the following diagnoses Multiple Sclerosis (damage to the spinal cord causing numbness, speech and muscle impairment, fatigue, and blurred vision), Monoplegia of the lower limb (paralysis of the lower limb), and Hypertension (high blood pressure). The document failed to include the outside providers, Person B, a case worker for a social services agency, Entity A, and Person L and Person M, case workers with Entity K, who help provide the patient with community resources. During an interview with Person B, a case worker for Entity A, a social services agency, on 08-24-2023 at 12:45 PM, they indicated they coordinate with service providers and had monthly visits to check-in with Patient #1 and provided guidance to the caregiver. During an interview with Person L, a case manager at Entity K, indicated they have never been contacted by the home health agency and indicated they provided nursing advice, and provide Patient #1 and their caregivers resources they would need. 3. On 08-23-2023 at 1:13 PM, Patient #3’s clinical record was reviewed. Patient #3’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 07-14-2023 at 8:00 AM. The comprehensive assessment evidenced the diagnoses Chronic Obstructive Pulmonary Disease (COPD, disease causing airflow to be blocked and difficulty breathing), Fibromyalgia (generalized pain, stiffness, and fatigue in the body), and Diabetes Mellitus Type 2 (a disease were the body was unable to regulate the sugar levels in the body). The comprehensive assessment failed to indicate a primary or temporary caregiver and their availability to provide care for the patient. The comprehensive assessment failed to include the other providers providing care in the home Entity O, for wound care, and Person P, a podiatrist. The clinical record evidenced a document titled “Recertification/Follow-up Assessment” with a date of 08-02-2023 and timed for 7:00 AM. The section titled “Living Arrangements/Caregiver Information” indicated the patient lived in an apartment alone and “NA (sic not applicable)”. The section titled “Emergency Preparedness Plan” indicated Patient #3’s child, Person FF, would provide evacuation assistance. The comprehensive assessment failed to indicate whether Person FF was a potential temporary caregiver. The comprehensive assessment failed to include the other providers providing care in the home Entity O, for wound care, and Person P, a podiatrist. Attempted to call Person P, Patient #3’s podiatrist, a voicemail was left requesting a return call. The call was never returned for the remainder of the survey. During an interview with Person R, a nurse from Entity O, on 08-24-2023 at 12:10 PM, they indicated they care for Patient #3’s wound on their toe. They indicated started care with Patient #3 on 08-01-2023, after the patient was hospitalized for osteomyelitis, an infection in the bone, with a left great toe amputation. 4. On 08-24-2023 at 12:36 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-19-2023 at 10:00 AM and another one dated 08-18-2023 at 9:00 AM. The comprehensive assessment evidenced diagnoses, COPD, Right Foot Drop (difficulty in lifting the front part of the foot), Arthritis (stiffness of the joints), Fibromyalgia (generalized pain, stiffness, and fatigue in the body), and Bradycardia (a low heart rate). The comprehensive assessment failed to include whether the patient had a primary caregiver or a temporary caregiver and their schedule and availability. The comprehensive assessments failed to include the other providers Entity A, a social work service, and Entity T, a wound center, providing care for Patient #4. Attempted to contact Person S, a case worker at Entity A for Patient #4, on 08-25-2023 at 8:35 AM. A voicemail was left, but the call was never returned. Attempted to contact Entity T, the wound center for Patient #4, on 08-25-2023 at 8:39 AM. A voicemail was left, but the call was never returned. 5. On 08-25-2023 at 9:30 AM, Patient #5’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-08-2023 at 12:00 PM and another dated 08-07-2023 at 12:00 PM. The comprehensive assessment evidenced a primary diagnosis of Quadriplegia (paralysis in all 4 limbs). The comprehensive assessment failed to include whether the patient had a primary caregiver or a temporary caregiver and their schedule and availability. The comprehensive assessment failed to include the other provider, Entity X, a urology physician office, Patient #5 received care. 6. On 08-25-2023 at 2:55 PM, Patient #7’s clinical record was reviewed. The clinical record evidenced documents titled “Comprehensive Adult Assessment” dated 07-05-2023 at 2:00 PM and 08-15-2023 at 8:00 AM. The comprehensive assessment the patient had diagnoses TBI (Traumatic Brain injury, trauma caused damage to the brain), seizures (uncontrolled electrical activity causes abnormal movement in the body), and Oglivies Syndrome (a distended abdomen when the individual does not have a mechanical obstruction in the abdomen). The comprehensive assessment failed to include the caregivers, Person Z and Person DD, Patient #7’s parents, availability to care for the patient. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 07-12-2023 at 9:00 AM. The comprehensive assessment failed to indicate who Patient #7’s primary caregivers were and their availability and willingness to assist in care. 7. During an interview with the Alternate Director of Nursing (ADON) on 08-23-2023 at 11:35 AM, the ADON indicated the comprehensive assessment was to be patient-specific, complete, and accurate to the patient according to the agency policy.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received an updated comprehensive assessment when a change in condition was identified, for 1 of 7 active patient records reviewed. (Patient #2) Findings include: 1. A review of an undated agency policy titled “C-145 Comprehensive Client Assessment” indicated, but was not limited to, “The assessment identifies facilitating factors and possible barriers to client reaching his or her goals including presenting problems. The depth and frequency of ongoing assessments will depend on client needs, goals and the care treatment and services provided, but will be done at least once in every sixty (60) day period … 12. Reassessments are conducted based on client needs, physician orders, professional judgement and/or OASIS or other regulatory requirement … “The policy failed to indicate the requirement to reassess patients for a change in condition. 2. A review of the agency's complaint log evidenced a complaint report dated 06/01/23 which indicated the spouse for Patient #2 called in and informed the Administrator that they called the patient's physician because the patient suffered a left arm injury on 05/31/23 and was still complaining of pain. The agency failed to complete a comprehensive assessment on Patient #2 after notification of a change in condition due to a possible injury. 3. On 08/22/23 at 2:07 PM, the Administrator indicated a nurse didn't assess Patient #2 "because at the time we didn't know if there was actually an injury." The Administrator indicated they should have seen the patient immediately for an assessment but didn't know if the patient could accurately communicate pain. The agency failed to complete a comprehensive assessment for a patient with a significant change in condition. 4. On 08/22/23 at 9:36 AM, during the entrance conference, the Clinical Manager was asked how the agency determined if a patient had a major decline or improvement in health status. The Clinical Manager indicated determination was made based on assessments, which occurred every 60 days. If they go to the hospital, they receive an assessment visit upon return home unless there was no notice of changes from the hospital, in which case the assessment was made with the next supervisory visit. 410 IAC 17-14-1(a)(1)(B)

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 all patients received a comprehensive assessment at least every 60 days, for 1 of 7 active patient records reviewed. (Patient #6) Findings include: 1. A review of an undated agency policy titled “C-145 Comprehensive Client Assessment” indicated, but was not limited to, “The assessment identifies facilitating factors and possible barriers to client reaching his or her goals including presenting problems. The depth and frequency of ongoing assessments will depend on client needs, goals and the care treatment and services provided, but will be done at least once in every sixty (60) day period … " 2. A review of the clinical record for Patient #6 evidenced a "Recertification Comprehensive Assessment," dated 04/03/23 for the recertification period of 04/05/23 - 06/03/23; a "Comprehensive Adult Assessment," dated 05/24/23 which indicated it was completed because the patient was hospitalized on 05/22/23 - 05/23/23; and a comprehensive assessment dated 08/02/23 for certification period 08/03/23 - 10/01/23. The record failed to evidence a recertification comprehensive assessment was completed between day 56 - 60 for the certification period of 06/04/23 - 08/02/23. On 08/24/23 at 2:25 PM, the Alternate Clinical Manager and the Administrator indicated a comprehensive assessment for Patient #6 was due between 05/30/23 and 06/03/23 but was not done. 3. On 08/22/23 at 9:36 AM, during the entrance conference, the Clinical Manager was asked how the agency determined if a patient had a major decline or improvement in health status. The Clinical Manager indicated determination was made based on assessments, which occurred every 60 days. 410 IAC 17-14-1(a)(1)(B)

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a current medication profile and goals were sent to the physician for 2 of 2 inactive clinical records reviewed. (Patients: #8 and 9) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, “Discharge Summary, Policy No. C-820”. The policy indicated but was not limited to, “ … Special Instructions … 3. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan … Discharge Criteria … 5. Agency staff will document the following … b. Client status (clinical, mental, psychosocial, cognitive, and functional) at the start of care … e. A description of the client’s clinical, mental, psychosocial, cognitive, and functional status at the end of care. f. The client’s most recent drug profile …” 2. On 08-24-2023 at 3:25 PM, Patient #8’s inactive clinical record was reviewed. The clinical record evidenced a document titled “Summary (Non-OASIS)”. The document indicated it was a discharge summary because the patient/family requested for Patient #8 to be discharged from the agency. The subsection titled “Condition at Discharge” indicated “same”. The document failed to provide a description of the patient at discharge or their condition at their most current assessment. The document failed to include the medications the patient was taking at the time of discharge. The document evidenced instructions were not provided to the patient and caregiver, but the document indicated the patient and caregiver understood the instructions provided. The clinical record failed to evidence instructions were provided to the patient and caregiver. The document failed to identify the patient’s treatment preferences and goals of care after discharge. The document indicated the patient’s spouse, Person U, was transferring services to another agency. The document failed to indicate under the reason for discharge, the patient was transferred to another agency. The clinical record failed to evidence the home health agency contacted and sent a discharge summary, medication profile, and order to the patient’s new home health provider. 3. On 08-24-2023 at 3:40 PM, Patient #9’s inactive clinical record was reviewed. The clinical record evidenced a document titled “Summary (Non-OASIS)”. The document indicated it was a discharge summary because the patient and/or family requested. The subsection titled “Condition at Discharge” indicated “no change”. The document failed to indicate the patient’s condition at discharge or their condition at their most current assessment. The document failed to include the medications the patient was taking at the time of discharge. The document failed to identify the patient’s treatment preferences and goals of care after discharge. 4. During an interview with the Alternate Director of Nursing (ADON) on 08-28-2023 at 3:10 PM, the ADON indicated they would send to the physician the discharge summary according to the policy and order only, if the patient was discharged to home. They indicated if the patient were to transfer to another home health agency, they would send the discharge summary, order, and medication profile to the other home health agency.

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 they met the needs of 7 of 7 active (Patients: #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed by failing to provide all services written in the plan of care (G572), failing to provide patient-specific interventions, education, and measurable outcomes and goals, safety measures, supplies and equipment needed, discharge planning and nutritional requirements, and other providers involved in the patient’s care (G574), failed to include all orders in the plan of care (G576), failed to provide care as ordered by a physician’s orders (G578), failed to provide services and treatments only as ordered by a physician (G580), failed to receive verbal orders to provide services (G584), failed to ensure a plan of care was reviewed and revised by the ordering physician every 60 days, or as the patient’s condition warrants (G588), failed to ensure the plan of care contained all necessary information from the updated comprehensive assessment and their progress toward their identified goals (G592), failed to ensure the physician and patient were involved in the discharge planning process (G598), failed to ensure they coordinated care with patients, family members/caregivers, patient representatives, and other providers (G608), failed to ensure the patient and their caregiver received ongoing education and training regarding the care and services provided by the agency (G610), and failed to provide all pertinent information and instructions related to the patient’s care and treatment (G620). The cumulative effects of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Conditions of Participation of 42 CFR 484.60, Care Planning, Coordination of Care, and Quality of Care. Findings Include: * 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received all services as outlined in a plan of care that included patient-specific, measurable, and pertinent goals for 5 of 7 active clinical records (Active Patients: #2, 4, 5, 6, and 7) and 1 of 2 closed clinical records (Patient: #8) reviewed. Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, “Home Health Aide Services, Policy No. C-220”. The policy indicated but was not limited to, “ … 3. The Aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising Nurse … “ 2. On 08-24-2023 at 12:36 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 10-24-2022 and a certification period of 06-21-2023 to 08-19-2023. The plan of care evidenced Patient #4 was to receive Home Health Aide (HHA) services 2.5 hours a day, 3 days a week for the first week and 2.5 hours a day, 4 days a week for the remainder of the certification period. The clinical record evidenced document titled “Physician Notification” dated 6-30-2023 and 07-14-2023. The notification dated 6-30-2023 evidenced Patient #4 had missed home visits on 06-26-2023 and 06-30-2023 because the caregiver called in. The notification dated 07-14-2023 evidenced Patient #4 had missed home visits on 07-13-2023 and 07-14-2023 because the caregiver called in. The agency failed to ensure the patient received all the services, days, and hours as ordered in the plan of care. During an interview with Patient #4 on 08-24-2023 at 9:25 AM, the patient indicated the agency did not contact them if HHA 12 was unavailable and were “not good about getting me a new one if (sic HHA 12) misses”. 3. On 08-24-2023 at 3:25 PM, Patient #8’s discharge record was reviewed. The clinical record evidenced a plan of care with a start of care date of 05-02-2022 and a certification period of 12-28-2022 to 02-25-2023. The plan of care evidenced Patient #8 was to receive Home Health Aide (HHA) services 1 hour a day, 2 times a week for the first week and 1 hour a day, 3 times a week for the remainder of the certification period. The discharge clinical record of Patient #8 evidenced documents titled “Physician Notification”. The “Physician Notification” note dated 12-9-2022 indicated on 12-07-2022 and 12-09-2022 the patient had missed HHA visits because the caregiver called in. The “Physician Notification” note dated 12-23-2022 indicated on 12-19-2022 and 12-23-2022 the patient had missed HHA visits because the caregiver called in. The “Physician Notification” note dated 01-27-2023 indicated on 01-25-2023 the patient had missed a missed visit because the caregiver called in. The “Physician Notification” note dated 02-03-2023 indicated on 01-30-2023 and 02-03-2023 the patient had missed HHA visits because the caregiver called in. During an interview with Person U, Patient #8’s spouse, on 08-25-2023 at 8:42 AM, they indicated the agency provided “terrible service, terrible communication”. Person U indicated they never knew what aide was coming out and would not let them know if they were unable to get a caregiver to come out and help Patient #8. Person U indicated the management would not listen and they indicated they (the spouse) were not able to care for Patient #8 on their own. Person U indicated they had made a complaint to the Administrator, management, and the owner regarding Patient #8 not receiving HHA services 3 times a week, but nothing was ever done to correct the concern. 4. On 08-25-2023 at 9:30 AM, Patient #5’s active clinical record was reviewed. The clinical record evidenced plans of care with a start of care date of 10-12-2022 and a certification period from 06-09-2023 to 08-07-2023. The plan of care indicated the patient was to receive HHA services 8 hours a day, 1 day a week for the first week, 8.5 hours a day, 4 days a week and 8 hours a day 1 day a week for weeks 2-9 of the certification period, and 8.5 hours a day, 1 day a week for the last week of the certification period. The aide was to assist the patient with activities of daily living (ADLs), bathing, hygiene, dressing, transfers, toileting, positioning, fall risk/safety, companionship, and light housekeeping. The clinical record evidenced aide visit notes from HHA 13. On the visit note dated 06-13-2023, the note evidenced HHA 13 worked from 7:19 AM to 11:12 AM and 9:34 PM to 12:00 AM. The document failed to evidence Patient #5 received all hours according to the plan of care. On the visit note dated 06-14-2023, the note evidenced HHA 13 worked from 8:08 AM to 3:49 PM and 10:05 PM to 11:53 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 06-15-2023, the note evidenced HHA 13 worked from 8:13 AM to 4:45 PM to 11:11 PM to 1:38 AM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 06-16-2023, the note evidence HHA 13 worked from 8:30 AM to 10:30 AM and 9:00 PM to 11:30 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 06-17-2023, the note evidenced HHA 13 worked from 7:00 AM to 10:30 AM. The document failed to evidence the plan of care was followed by the patient receiving an additional day of services. On the visit note dated 06-19-2023, the note evidenced HHA 13 worked from 7:58 AM to 3:30 PM and 10:00 PM to 11:30 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 06-20-2023, the note evidenced HHA 13 worked from 8:03 AM to 1:30 PM and 10:03 PM to 11:30 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 06-21-2023, the note evidenced HHA 13 worked from 8:23 AM to 3:00 PM and 10:00 PM to 11:30 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 06-22-2023, the note evidenced HHA 13 worked from 8:30 AM to 4:30 PM and 9:30 PM to 12:30 AM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 06-27-2023, the note evidenced HHA 13 worked from 8:15 AM to 3:30 PM and 10:00 PM to 12:00 AM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 06-28-2023, the note evidenced HHA 13 worked from 8:50 AM to 2:22 PM and 10:06 PM to 11:39 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 06-29-2023, the note evidenced HHA 13 worked from 8:17 AM to 12:00 PM and 7:30 PM to 12:30 AM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-06-2023, the note evidenced HHA 13 worked from 8:10 AM to 3:22 PM and 9:00 PM to 11:30 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-06-2023, the note evidenced HHA 13 worked from 6:00 PM to 11:00 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 07-10-2023, the note evidenced HHA 13 worked from 7:36 AM to 3:30 PM and 10:15 PM to 11:30 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-11-2023, the note evidenced HHA 13 worked from 8:35 AM to 4:26 PM and 10:10 PM to 11:40 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-17-2023, the note evidenced HHA 13 worked from 7:31 AM to 1:29 PM and 10:15 PM to 11:59 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 07-20-2023, the note evidenced HHA 13 worked from 7:57 AM to 11:45 AM and 8:02 PM to 11:45 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 07-21-2023, the note evidenced HHA 13 worked from 8:48 AM to 4:21 PM and 9:23 PM to 10:53 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-24-2023, the note evidenced HHA 13 worked from 8:30 AM to 4:00 PM and 10:04 PM to 11:30 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-25-2023, the note evidenced HHA 13 worked from 8:18 AM to 3:24 PM and 10:00 PM to 11:29 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-26-2023, the note evidenced HHA 13 worked from 8:15 AM to 1:20 PM and 10:08 PM to 11:45 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 07-28-2023, the note evidenced HHA 13 worked from 8:04 AM to 5:30 PM and 10:03 PM to 11:30 PM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 07-31-2023, the note evidenced HHA 13 worked from 8:06 AM to 4:30 PM and 9:53 PM to 12:00 AM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 08-01-2023, the noted evidenced HHA 13 worked from 8:03 AM to 2:00 PM and 10:07 PM to 11:30 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 08-02-2023, the note evidenced HHA 13 worked from 7:47 AM to 11:45 AM and 10:12 PM to 11:45 PM. The document failed to evidence the patient received all hours according to the plan of care. On the visit note dated 08-04-2023, the note evidenced HHA 13 worked from 8:56 AM to 12:32 PM and 9:00 PM to 3:00 AM. The document evidenced the patient received more hours than ordered on the plan of care. On the visit note dated 08-07-2023, the note evidenced HHA 13 worked form 7:17 AM to 2:41 PM and 9:15 PM to 11:00 PM. The document evidenced the patient received more hours than ordered on the plan of care. Attempted to call Patient #5 on 08-25-2023 at 2:08 PM, a voicemail was left requesting a return call. The call was never returned. 5. On 08-25-2023 at 2:55 PM, Patient #7’s active clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 03-24-2022 and a certification period from 07-17-2023 to 09-14-2023. The plan of care evidenced Patient #7 was to receive HHA services 8 hours a day, 5 days a week for the first 8 weeks of the certification period and 8 hours a day, 4 days a week for the last week of the certification period. A review of the clinical record evidenced the agency sent a discharge notice to Patient #7 and their family. During a review of the HHA visit notes, they evidenced the patient had not received HHA services since 08-18-2023. A visit note dated 08-22-2023 evidenced HHA 11 clocked in and clocked out, but no services were provided to the patient. On 08-28-2023 at 9:30 AM, attempted to call Patient #7’s family member, Person Z, a voicemail was left requesting a return call. Person Z never returned the call. During an interview with the Director of Nursing (DON) on 08-28-2023 at 10:43 AM, they indicated HHA 11 had put their notice in, and Patient #7 had not been staffed since the aide had put in their notice. The DON indicated Patient #7’s family refused another HHA than the normal aide. The record failed to evidence Patient #7, and their family, refused services from another HHA. 6. During an interview with the Administrator on 08-28-2023 at 11:58 AM, they indicated if an on-call HHA was not available, they cancel the visit if they are unable to staff it and notify the physician of the missed visit. 7. During an interview with the Administrator on 08-28-2023 at 12:18 PM, they indicated the plan of care was to be followed. 8. On 08-28-2023 at 1:08 PM, an attempt to call HHA 11 was made. A voicemail was left requesting a return call. The call was not returned by HHA 11. 1. A review of the comprehensive assessment for Patient #2 indicated a primary diagnosis of anoxic brain damage (brain injury resulting from a complete lack of oxygen to the brain), cephalic seizures (interruption in electrical activity in the brain), transient ischemic attack (TIA – a mini-stroke with no residual effects), contractures (shortening and hardening of muscles and tendons, often causing deformity), cerebral vascular accident (CVA – sudden bleeding in or blockage of blood flow to the brain; stroke). The assessment further indicated the patient was a fall risk, was incontinent, had a recent fracture, and utilized a wheelchair. Review of the patient's home health aide visit notes for 07/19/23 - 08/22/23 indicated the patient and/or spouse continued to refuse bathing, personal care, assist with feeding, dressing, oral care, and assist with toileting. A review of the plan of care for Patient #2, for certification period 07/21/23 - 09/18/23, indicated the patient received home health aide services 4 hours/ day x 5 days/week for personal care including, but not limited to weekly bed/chair bath, transfers, meal prep/feeding, and dressing and evidenced a goal of "Patient to maintain good hygiene with no impaired skin AEB [As Evidenced By] complying with bathing schedule and incontinence care as needed. The plan of care failed to evidence patient-specific, individualized, and measurable goals pertinent to the patient's diagnoses, mobility and personal care needs as determined by comprehensive assessment, and reason for home health services. A review of the comprehensive assessment for Patient #6 indicated a primary diagnosis of paraplegia and a secondary diagnosis of type 2 diabetes mellitus. The patient used a slide board, experienced chronic pain at 8-9/10, utilized leg wraps, was a fall risk, and denied monitoring blood sugars. A review of the plan of care, for certification period 08/03/23 - 10/01 23 evidenced a goal of "Patient to elevate BLEs (Bilateral Lower Extremities) 2x/day to decrease edema x 60 days." The plan of care failed to evidence patient-specific, individualized, and measurable goals pertinent to the patient's mobility, fall risk status, severe chronic pain, application of leg wraps, and diabetic non-compliance.

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 observation, record review and interview, the agency failed to implement its policy requiring the plan of care to be individualized to include all pertinent diagnoses, all supplies and equipment necessary to meet the patient’s needs, mental status, nutritional requirements, type, frequency, and duration of all services the patient was receiving, all safety measures, services being provided by outside agencies and facilities, all necessary interventions, specific education and training, measurable outcomes and goals, discharge planning needs for 5 of 7 active clinical records reviewed. (Patients: #1, 3, 4, 5, and 7) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021, Briggs Healthcare policy titled, “Plan of Care, Policy No. C580”. The policy indicated but was not limited to, “ … 2. The Plan of Care shall be completed in full to include:. a. all pertinent diagnoses … c. type, frequency, and duration of all visits/services … h. Rehabilitation potential … k. specific dietary or nutritional requirements or restrictions … l. medications … m. Medical supplies and equipment required, n. Any safety measures to protect against injury, o. Instructions to client/caregiver … p. Treatment goals … r. Discharge plans … t. other appropriate items …” 2. On 08-22-2023 11:05 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 09-13-2021 and a certification period of 07-05-2023 to 09-02-2023. The plan of care (POC) evidenced the following diagnoses Multiple Sclerosis (damage to the spinal cord causing numbness, speech and muscle impairment, fatigue, and blurred vision), Monoplegia of the lower limb (paralysis of the lower limb), and Hypertension (high blood pressure). The POC indicated the patient was to receive Skilled Nursing (SN) services 2 hours every 60 days for recertification assessments and as needed for injury, complaint, or supervisory visit. The POC failed to indicate the patient was to have their medication setup every 2 weeks by the Registered Nurse. The POC failed to indicate the patient’s rehabilitation potential. The POC evidenced a section titled “Goals/Rehabilitation Potential/Discharge Plans”, the section indicated, “Patient to maintain good skin integrity r/t (sic related to) decreased mobility and incontinence AEB (sic as evidenced by) no alterations in skin during certification period. …” The plan of care failed to include treatment goals and discharge plans. The POC failed to include the other agencies and facilities involved in Patient #1’s care. The clinical record for Patient #1 evidenced a document titled “Recertification of care – Physician Verbal Orders”. The document indicated the patient was to receive SN 1 hour every two week for medication setup, assessment, and supervisory visit. The order failed to be listed on Patient #1’s plan of care. During an interview with Person B, a case worker for Entity A, a social services agency, on 08-24-2023 at 12:45 PM, they indicated they coordinate with service providers and had monthly visits to check-in with Patient #1 and provided guidance to the caregiver. During an interview with Person L, a case manager at Entity K, indicated they had never been contacted by the home health agency and indicated they provided nursing advice, and provided Patient #1 and their caregivers community resources to improve the patient’s quality of care. 3. On 08-23-2023 at 1:13 PM, Patient #3’s clinical record was reviewed. The POC evidenced a start of care date of 01-29-2021 and a certification period from 07-18-2023 to 09-15-2023. The POC indicated the patient had the following diagnoses Chronic Obstructive Pulmonary Disease (COPD, a disease causing difficulty breathing and narrowing of the airway) and Diabetes Mellitus Type 2 (a disease were the body is unable to regulate the sugar levels in the body). The POC failed to identify the patient’s rehabilitation potential. The POC evidenced a section titled “DME (sic Durable medical equipment) and Supplies”, the section listed, “O2 (sic oxygen), nebulizer, commode, wheelchair, gloves, walker, insulin pump. The POC failed to include the equipment used to bring the oxygen to the patient for a diagnosis of COPD, failed to include a glucometer and chemstrips for a diagnosis of Diabetes Mellitus Type 2. The POC indicated the patient had bowel/bladder incontinence limitations, the DME failed to evidence incontinence supplies for the patient. The POC evidenced a section titled “Goals/Rehabilitation Potential/Discharge Plans”, the section indicated, “PT (sic Patient) will maintain adequate nutrition for this recertification period AED (sic as evidenced by) eating 3 meals a day. Patient education provided on importance of adequate nutrition. …” The POC failed to include patient-specific education, instruction, and treatment goals. The POC failed to provide blood sugar parameters for their diagnosis of Diabetes Mellitus Type 2. 4. On 08-24-2023 at 9:25 AM, a home observation was conducted at Patient #4’s residence. Upon entry into the patient’s residence the patient indicated they had an ulcer on their right heel for a year, the patient had a sock on the right foot. It was observed the patient had an electric wheelchair in the home. On 08-24-2023 at 11:25 AM, Patient #4’s record was reviewed. The clinical record evidenced plans of care with a start of care date of 10-24-2022 and a certification period from 06-21-2023 to 08-19-2023 and a certification period from 08-20-2023 to 10-18-2023. The POC evidenced the following diagnoses, COPD, Right foot drop (difficulty in lifting the front part of the foot), Arthritis (stiffness of the joints), Fibromyalgia (generalized pain, stiffness, and fatigue in the body), and Bradycardia (low heart rate). The POC failed to evidence the patient’s right heel ulcer on the list of the patient’s diagnoses. The POC failed to identify the patient’s rehabilitation potential. The plans of care evidenced a section titled “DME and Supplies”, the section listed the patient had bilateral lower extremity braces, a walker, and a shower seat. The POC failed to include the electric wheelchair found in the patient’s home during the home observation. The POC failed to indicate when the as needed medication Albuterol would be used. The POC evidenced a section titled “Goals/Rehabilitation Potential/Discharge Plans”, the section indicated, “Patient to maintain adequate hygiene aeb showering 3x weekly. Educated patient on when to call SN (Skilled Nurse), MD (Medical Doctor) or 911. Educated to utilize adaptive equipment for safe mobility and transfers.” The POC failed to include patient-specific education, instruction, treatment goals, and discharge plans. The POC failed to include all other providers involved in Patient #4’s care. The other providers included Entity A, a social work service, and Entity T, a wound center, providing care for Patient #4. Patient #4’s clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-19-2023 at 10:00 AM. The section titled “Skin/Wound/Ostomy” indicated the patient had a right heel wound with wound care performed weekly. A document titled “Recertification Comprehensive Assessment” dated 08-18-2023 at 9:00 AM, included a section titled “Skin/Wound/Ostomy” and indicated the patient had a right heel ulcer, and received weekly wound care from Entity T, a wound center. Attempted to contact Person S, a case worker at Entity A for Patient #4, on 08-25-2023 at 8:35 AM. A voicemail was left, but the call was never returned. Attempted to contact Entity T, the wound center for Patient #4, on 08-25-2023 at 8:39 AM. A voicemail was left, but the call was never returned. 5. On 08-25-2023 at 9:30 AM, Patient #5’s clinical record was reviewed. The clinical record evidenced a POC with a start of care date of 10-12-2022 and a certification period from 06-09-2023 to 08-07-2023 and a POC with a certification period from 08-08-2023 to 10-06-2023. The POC evidenced a primary diagnosis of Quadriplegia (paralysis in all 4 limbs). The POC failed to identify the patient’s rehabilitation potential. The POC evidenced a section titled “DME and Supplies”, the section listed the patient had a wrist brace, abdominal binder, stand-up lift, power chair, ramp, shower chair, gloves, and a hospital bed. The POC indicated the patient had bowel/bladder incontinence limitations and failed to include the necessary supplies, briefs, in the DME. The POC evidenced a section titled “Goals/Rehabilitation Potential/Discharge Plans”, the section indicated, “Patient to have no new skin breakdown due to pressure injuries x 60 days. …” The POC failed to include patient-specific education and treatment goals. The POC failed to include all other providers involved in Patient #5’s care. The other provider included Entity X, a urology physician office, where Patient #5 received care. 6. On 08-25-2023 at 2:55 PM, Patient #7’s clinical record was reviewed. The clinical record evidenced a POC with a start of care date of 03-24-2023 and a certification period from 05-18-2023 to 07-16-2023 and a POC with a certification period from 07-17-2023 to 09-14-2023. The comprehensive assessment the patient had diagnoses TBI (Traumatic Brain injury, trauma caused damage to the brain), seizures (uncontrolled electrical activity causes abnormal movement in the body), and Oglivies Syndrome (a distended abdomen when the individual does not have a mechanical obstruction in the abdomen). The POC contained a section titled “Nutritional Req. (sic Requirements), the section indicated, “Two cal 2.0 via (sic through) g-tube (gastrostomy tube, a surgical opening in the abdomen, where a tube was placed to provide nutrients to the individual). The POC failed to evidence the amount, rate, duration, and frequency of the feedings. The POC failed to evidence a water flush amount, rate, duration, and frequency for before and after the feedings. The POC indicated the patient had oxygen on their DME and supplies list but failed to indicate oxygen as a safety measure. The section titled “DME and Supplies” failed to list seizure pads for the patient’s hospital bed to protect the patient during a seizure episode. The POC evidenced a section titled “Goals/Rehabilitation Potential/Discharge Plans”, the section indicated, “PT (sic Patient) to maintain skin integrity aeb no skin breakdown r/t incontinence of bowel and bladder within this certification period. …” The POC failed to include patient-specific education, interventions, and treatment goals. 7. During an interview with the Director of Nursing (DON) on 08-23-2023 at 11:35 AM, when queried regarding the elements to be included on the POC, they indicated they would include the patient’s diagnoses, medications, services provided, 60-day recertification dates, allergies, DME, facility information, patient information, goals, discharge planning, prognosis. The DON indicated the goals and discharge planning were to be patient-specific and patient-identified goals. 8. During an interview with the DON on 08-28-2023 at 10:50 AM, they indicated the POC should be patient specific and include all pertinent information pertaining to the patient’s care. The DON indicated the nutritional needs and safety measures were to be patient-specific, and all pertinent information should be included. 410 IAC 17-13-1(a)(1)(D)(ii, iii, v, viii, x, xi, and xiii)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all physician orders, including verbal orders, were listed on the plan of care for 1 of 3 active clinical records reviewed with a home visit. (Patients: #1) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021, Briggs Healthcare policy titled, “Plan of Care, Policy No. C580”. The policy indicated but was not limited to, “ … 2. The Plan of Care shall be completed in full to include:. … c. type, frequency, and duration of all visits/services … t. other appropriate items …” 2. On 08-22-2023 11:05 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 09-13-2021 and a certification period of 07-05-2023 to 09-02-2023. The plan of care indicated the patient was to receive Skilled Nursing (SN) services 2 hours every 60 days for recertification assessments and as needed for injury, complaint, or supervisory visit. The plan of care failed to indicate the patient was to have their medication setup every 2 weeks by the Registered Nurse. The clinical record for Patient #1 evidenced a document titled “Recertification of care – Physician Verbal Orders”. The document indicated the patient was to receive SN 1 hour every two week for medication setup, assessment, and supervisory visit. The order failed to be listed on Patient #1’s plan of care.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure orders were obtained in advance of providing care and failed to ensure verbal/phone orders were obtained by a Registered Nurse, then documented, read back, and verified at the time of receipt and in advance of providing care for 3 of 7 active clinical records reviewed. (Patients: #1, 2, and 6) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021, Briggs Healthcare policy titled, “Physician Orders, Policy No. C635”. The policy indicated but was not limited to, “ … 1. When the nurse … receives a verbal order from the physician, he/she shall write the order as given and then read the order back to the physician verifying that the person receiving the order heard it correctly and interpreted the order correctly … The order must include the date, specific order, be signed with the full name and titled of the person receiving the order and be sent to the physician for signature …” 2. On 08-22-2023 at 11:05 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification of Care – Physician Verbal Orders” dated 07-03-2023 at 2:00 PM by the Alternate Director of Nursing (ADON) and signed by Person J, Patient #1’s physician, on 07-05-2023. During an interview with Person N, a registered nurse from Entity I, Patient #1’s physician’s office on 08-23-2023 at 3:33 PM, they indicated the home health agency only notified Patient #1’s physician, Person J, through fax for verbal orders. 3. On 08-25-2023 at 2:55 PM, Patient #7’s active clinical record was reviewed. The clinical record evidenced a document titled “Resumption of Care, Physician Orders” dated by the Director of Nursing (DON) on 08-14-2023 at 2:00 PM. During an interview with Person 29, a nurse from Entity 27, Patient #7’s physician’s office, on 08-28-2023 at 11:13 AM. Person 29 indicated the home health agency communicated with Person 28, Patient #7’s physician, through fax. The last communication they received from the home health agency was the resumption of care starting 08-14-2023. 1. A review of the comprehensive assessment for Patient #2, dated 07/19/23, evidenced care coordination with the physician was marked but failed to evidence the 07/19/23 comprehensive assessment findings were reviewed with the physician and verbal orders for continued services were received, documented, read back and verified, and sent for signature. A review of a "Recertification of Care/Physician Verbal Orders" document indicated the patient's physician was notified of the assessment findings on 07/19/23 at 10 AM. The record failed to evidence additional documentation that the orders were discussed with the physician or representative, rather than created and faxed to the physician for review, then documented, read back, and verified including but not limited to the patient's nutrition, durable medical equipment, care of a fractured extremity, patient-specific and measurable goals, functional limitations, and seizure precautions. 2. A review of the comprehensive assessment for Patient #6, dated 08/02/23, evidenced care coordination with the physician was marked but failed to evidence the date and time that the orders were discussed with the physician or representative, rather than created and faxed to the physician for review, then documented, read back, and verified including but not limited to the patient's nutrition, durable medical equipment, patient-specific and measurable goals, functional limitations, and chronic pain. 3. On 08/24/23 at 2:15 PM, the Clinical Manager indicated after a comprehensive assessment was completed, and the orders needed to continue services were placed by nursing onto a plan of care then faxed to the physician for review and signature. The Clinical Manager indicated the physician's receipt of the plan of care of the "Recertification of Care/Physician Verbal Orders" form was considered review of orders. When asked if the comprehensive assessment findings were reviewed verbally or only via a faxed plan of care, the Clinical Manager indicated yes. When asked if a nurse was allowed to give or write orders not received verbally from a physician the Clinical Manager indicated no. When asked if the nurse wrote orders, rather than obtaining them verbally from the physician, then provided care based on those orders in advance of physician review and signature, the Clinical Manager indicated yes.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of a patient's change in condition, for 1 of 7 active patient records reviewed. (Patient #2) Findings include: A review of the agency's complaint log evidenced a complaint dated 05/31/23, which indicated Patient #2's spouse called and stated the patient was complaining of pain after the aide injured the patient's left frozen arm by pulling on it during a transfer on 05/31/23. The log failed to evidence the patient's physician was contacted to notify the physician of a potential injury and change in condition. Further review of the clinical record failed to evidence documentation that the agency communicated with the patient's primary care physician or the bone and joint specialist. On 08/22/23 at 2:07 PM, the Administrator indicated the physician was not contacted because they weren't sure there was actually an injury, and the patient hadn't seen the physician yet. 410 IAC 17-13-1(a)(2)

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received a revised plan of care that reflected current information from an updated comprehensive assessment, including but not limited to the patient's progress toward previous goals, changes since the previous care plan, updated medications, and all orders, for 1 of 7 active patient records reviewed. (Patient #6) Findings include: A review of the clinical record for Patient #6 evidenced a comprehensive assessment titled "Recertification Comprehensive Assessment," dated 04/03/23, for the recertification period of 04/05/23 - 06/03/23 and a plan of care for the certification period of 04/05/23 - 06/03/23. The record review evidenced a second comprehensive assessment titled "Comprehensive Adult Assessment," dated 05/24/23, indicated the patient was hospitalized from 05/22/23 - 05/23/23 and was resuming services. The record review evidenced a third comprehensive assessment titled "Recertification Comprehensive Assessment," dated 08/02/23 for the recertification period of 08/03/23 - 10/01/23 and a plan of care for the certification period of 08/03/23 - 10/01/23. The record failed to evidence an updated or revised plan of care for the certification period of 06/04/23 - 08/02/23. On 08/29/23 at 1:52 PM, the Administrator indicated there was no comprehensive assessment completed at the time the patient's recertification was due for the certification period starting 06/04/23, which resulted in a missed plan of care for the same certification period and Patient #6 received services from 06/04/23 - 08/02/23 without orders or a physician ordered plan of care.

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 ensure the physician was notified of a change in the patient's condition requiring a discharge and transfer to another agency for 1 of 7 active clinical records reviewed. (Patient #7) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled “Client Discharge Process, Policy # C-500”. The policy indicated but was not limited to, “ … 3. The physician will be involved in the discharge plan … 6. The Registered Nurse shall ensure … appropriate referrals are made to agencies/institutions to meet continuing client needs … 8. … a. Evidence that the decision was not made unilaterally. The client, family, and physician participated in the decision to discharge client from the agency. … d. Documentation of all communication with the client …” 2. On 08-25-2023 at 2:55 PM, Patient #7’s active clinical record was reviewed. The clinical record evidenced a discharge notification letter sent to the patient and their family on 08-18-2023. The clinical record failed to evidence coordination notes to the physician regarding the need to discharge the patient. The clinical record failed to evidence coordination notes to the patient assisting them in finding a new home health agency to transfer to after discharge. The clinical record failed to evidence coordination notes to other potential agencies the patient would go to after discharge. The clinical record evidenced a document titled “Coordination of care with other providers” for Patient #7. The document indicated but was not limited to, “ … Provider: (sic Person BB), Date of Contact: 08-15-2023 … Contact Person: (sic Person CC, a medical assistant at Person BB’s physician’s office) … Concerns/Goals/ Barriers to achievement of goals: resumption findings, acuity level, possible other providers …” During an interview with the Director of Nursing (DON) on 08-28-2023 at 10:26 AM, they indicated they contacted Patient #7’s physician’s, Person BB, office, Entity AA, regarding the need to discharge the patient for nursing services. The DON indicated they contacted the other agencies they recommended the Patient #7’s family to determine if they offered Skilled Nursing (SN) services. The DON indicated there were no other communication notes documented. During an interview with Person CC, a medical assistant at Patient #7’s physician’s, Person BB, office, Entity AA, on 08-28-2023 at 11:13 AM, Person CC indicated the home health agency would typically communicate only through fax. They indicated the agency faxed them a resumption of care on 08-15-2023. Person CC indicated there were no notes or communication from the agency regarding them discharging or planning to discharge Patient #7. Person CC indicated Person DD, Patient #7’s family member, called Entity AA on 08-15-2023 at 10:01 AM, and indicated they required a referral for a home health agency because they were losing their aide on Friday, 08-18-2023 and the patient required more assistance. Person CC indicated the only recent communication from the home health agency was regarding the resumption of care order. Person EE, an office assistant from Entity AA, sent a document titled “All Conversations: Patient Outreach” and confirmed the conversation from Patient #7’s family member, Person DD and the Medical Assistant, Person CC.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care with all individuals and other agencies and facilities involved in the patient’s care for 6 of 7 clinical records reviewed. (Patients: #1, 2, 3, 4, 5, and 6) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, “Coordination of Client Services, Policy No. C360”. The policy indicated but was not limited to, “ … 4. Agency will communicate with ALL physicians who are writing orders regarding the plan of care … 5. Coordination of care will include dealing with multiple programs for the complex clients … 6. Clients, their representatives, and other caregivers will be included in the coordination activities and will receive direct communication related to planning and change in the plan … 11. Coordination will include providers of care who are not part of the agency …” 2. On 08-22-2023 at 11:05 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced documents titled “Coordination of Care with Other Providers”. The document failed to indicate the home health coordinated care with Entity A, a social services agency, and Entity K, an agency who provided the patient with community resources. During an interview with Person B, a case worker for Entity A, a social services agency, on 08-23-2023 at 12:45 PM, they indicated they coordinate with service providers and had monthly visits to check-in with Patient #1 and provided guidance to the caregiver. They indicated Patient #1 received services from Entity K, an agency who provided patients with community resources. During an interview with Person L, a case manager at Entity K, on 08-23-2023 at 2:07 PM, indicated they have never been contacted by the home health agency and indicated they provided nursing advice, and provide Patient #1 and their caregivers resources they would need. During an interview with Person N, a registered nurse from Entity I, Patient #1’s physician’s office on 08-23-2023 at 3:33 PM, they indicated the home health agency only notified Patient #1’s physician, Person J, through fax for verbal orders. 3. On 08-23-2023 at 1:13 PM, Patient #3’s clinical record was reviewed. Patient #3’s clinical record evidenced documents titled “Coordination of Care with Other Providers”. The documents failed to evidence Person P, a Patient #3’s podiatrist, was contacted to coordinate with for the patient. During an interview with HHA 15 on 08-24-2023 at 8:59 AM, they indicated Patient #3 went to Person P, a podiatrist, once a week for the patient’s left great toe amputation. Attempted to call Person P, Patient #3’s podiatrist, on 08-24-2023 at 9:15 AM, a voicemail was left requesting a return call. The call was never returned for the remainder of the survey. 4. On 08-24-2023 at 12:36 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced documents titled “Case Conference/Coordination of Care”. The documents failed to evidence care was coordinated with Person S, Patient #4’s case worker from social work service agency, Entity A. Attempted to contact Person S, a case worker at Entity A for Patient #4, on 08-25-2023 at 8:35 AM. A voicemail was left, but the call was never returned. 5. On 08-25-2023 at 9:30 AM, Patient #5’s clinical record was reviewed. The clinical record evidenced a document titled “Recertification Comprehensive Assessment” dated 06-08-2023 at 12:00 PM and another dated 08-07-2023 at 12:00 PM. The comprehensive assessment failed to include whether the patient had a primary caregiver or a temporary caregiver and their schedule and availability. The clinical record of Patient #5 failed to evidence Coordination of care notes with the patient, caregiver, and Entity X, a urology physician office, Patient #5 received care. 7. On 08-25-2023 at 2:55 PM, Patient #7’s active clinical record was reviewed. The clinical record evidenced a discharge notification letter sent to the patient and their family on 08-18-2023. The clinical record failed to evidence coordination notes to the physician regarding the need to discharge the patient. The clinical record failed to evidence coordination notes to the patient assisting them in finding a new home health agency to transfer to after discharge. The clinical record failed to evidence coordination notes to other potential agencies the patient would go to after discharge. The clinical record evidenced a document titled “Coordination of care with other providers” for Patient #7. The document indicated but was not limited to, “ … Provider: (sic Person 28), Date of Contact: 08-15-2023 … Contact Person: (sic Person 29, a medical assistant at Person 28’s physician’s office) … Concerns/Goals/ Barriers to achievement of goals: resumption findings, acuity level, possible other providers …” During an interview with the Director of Nursing (DON) on 08-28-2023 at 10:26 AM, they indicated they contacted Patient #7’s physician’s, Person 28, office, Entity 27, regarding the need to discharge the patient for nursing services. The DON indicated they contacted the other agencies they recommended the Patient #7’s family to determine if they offered Skilled Nursing (SN) services. The DON indicated there were no other communication notes documented. During an interview with Person 29, a medical assistant at Patient #7’s physician’s, Person 28, office, Entity 27, on 08-28-2023 at 11:13 AM, Person 29 indicated the home health agency would typically communicate only through fax. They indicated the agency faxed them a resumption of care on 08-15-2023. Person 29 indicated there were no notes or communication from the agency regarding them discharging or planning to discharge Patient #7. Person 29 indicated Person 30, Patient #7’s family member, called Entity 27 on 08-15-2023 at 10:01 AM, and indicated they required a referral for a home health agency because they were losing their aide on Friday, 08-18-2023 and the patient required more assistance. Person 29 indicated the only recent communication from the home health agency was regarding the resumption of care order. Person 31, an office assistant from Entity 27, sent a document titled “All Conversations: Patient Outreach” and confirmed the conversation from Patient #7’s family member, Person 30 and the Medical Assistant, Person 29. 8. During an interview the Administrator and Director of Nursing (DON) on 08-29-2023 at 8:55 AM, the Administrator indicated they had discussed improving on documentation of coordination of care with all providers and individuals involved in the plan of care for the patients. The DON indicated the communication to physician offices and all outside providers was not all included in the clinical records. 1. A review of the agency's complaint log evidenced a complaint, dated 06/01/23, which indicated the spouse of Patient #2 notified the Administrator of a suspected injury to the patient's left arm which occurred on 05/31/23 because of the HHA pulling on the patient's frozen arm. the complaint indicated on 06/05/23 that the patient's spouse notified the Administrator that the patient's left arm was fractured. The complaint failed to evidence the agency contacted the patient's physician to coordinate care concerning the suspected injury. 2. A review of the comprehensive assessment for Patient #2, dated 07/19/23, evidenced a box checked for care coordination with the physician. The assessment failed to evidence which physician was contacted and what care was discussed, including but not limited to the current assessment findings, the recent left arm fracture, functional limitations, progress toward previous goals, and the patient's and representative's non-compliance with personal care. On 08/23/23 at 2 PM, the patient's spouse indicated the patient was seen virtually by Person E, a nurse practitioner, and received x-rays on 06/01/23. The patient was then referred to Person H, a nurse practitioner with Entity F, a bone and joint specialist, who determined the patient had a left humorous fracture and multiple fractures in the left shoulder ball and joint. The record failed to evidence care coordination concerning the fractured extremity with the physician, specialist, Clinical Manager, Alternate Clinical Manager, or Administrator. 3. A review of the comprehensive assessment for Patient #6, dated 08/02/23, evidenced a box was checked for coordination of care with the physician. The comprehensive assessment failed to evidence what care was coordinated, who was involved, the date and time of the care coordination and whether the assessment findings were reviewed. A review of a document titled "Coordination of Care with Other Providers," dated 08/03/23, evidenced a provider name of Person GG, the patient's physician, and the physician representative, Person HH. Concerns/goals/Barriers to achievement was answered as "Recert/POC (Recertification/Plan of Care)" The remainder of the form was blank. The record failed to evidence care coordination occurred with the patient's care team, including the physician, the Administrator, the Clinical Manager, the Alternate Clinical Manager, and the home health aides assigned to the patient's case.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the Governing Body failed to develop, implement, evaluate, and maintain an ongoing, agency-wide QAPI program that measured, analyzed, and tracked measurable and data-driven quality indicators, including adverse events, for health, safety, agency operations, and quality of care (G642); failed to use quality indicator data to monitor the effectiveness and safety of care and services and identified opportunities for improvement (G644); failed to focus on high risk, high volume, or problem-prone areas, such as hospitalizations, infections, adverse events, and home health aide services (G648); Considered the frequency and severity of problems in those areas (G650); failed to immediately correct any identified problem(s) that threatened the health and safety of patients (G652); initiated performance improvement plans which tracked and analyzed adverse events and implemented corrective or preventative actions G654); measured and tracked the success of performance improvement in the identified areas to ensure that improvements were sustained (G656); conducted performance improvement projects (PIP) that reflected the scope and complexity of the needs of the agency’s patient needs and previously identified regulatory performance needs, and documented the PIPs undertaken and the measurable progress achieved (G658); failed to ensure the QAPI program established clear expectations for patient safety and assessed for and addressed any findings of fraud or waste (G660) for 1 of 1 Governing Body of a Home Health Agency. The cumulative effects of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.65, Quality Assessment and Performance Improvement. 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, Quality Assessment and Performance Improvement (QAPI), Policy No. C260”. The policy indicated but was not limited to, “ … To use performance improvement activities to track adverse client events, analyze their causes and implement preventive actions … 1. The program will be capable of showing measurable improvement in indicators that will improve health outcomes, client safety, and quality of care. 2. The agency will … analyze … indicators that include client adverse events, and other relevant data to assess processes of care, services, and operations … Standard Program Activities … 1. The agency’s performance improvement activities will focus on high risk, high volume, or problem prone areas …” 2. On 08-24-2023 at 11:35 AM, QAPI and the binders associated with QAPI were reviewed with the Administrator. The binder titled “QAPI Meeting” evidenced documents titled “Monthly QAPI Meeting”. The documents dated 06-06-2023, 07-03-2023, and 08-01-2023 evidenced the issue with visit notes not being turned in on time and the efforts made to decrease the number of visit notes not being turned in on time. 3. On 08-29-2023 at 8:55 AM, QAPI was reviewed with the Administrator. The Administrator provided a binder titled “Monthly QAPI meetings. The binder contained documents titled “Monthly QAPI Meeting”. The document dated 01-03-2023 evidenced the agency had 4 hospital visits, 1 complaint, and 3 coronavirus 19 infections. The document dated 02-07-2023 evidenced the agency had 1 fall with no injury and 4 hospital visits for seizure, bradycardia, dyspnea, and unstable vital signs. The document dated 03-07-2023 evidenced the agency had 1 resolved complaint, 3 hospital visits, 2 coronavirus infections. The document dated 04-04-2023 evidenced the agency had 1 fall, 1 hospital visit, and 1 infection. The document dated 05-02-2023 evidenced the agency had 2 hospital visits for bowel obstruction and facial burn and 1 coronavirus infection. The document dated 06-06-2023 evidenced the agency had 1 fall and 3 hospitalizations. The document dated 07-03-2023 evidenced the agency had 1 complaint and 3 hospital visits. The document dated 08-01-2023 evidenced the agency had 2 hospital visits. The documents failed to evidence the identified hospitalizations, cancellations, call-ins, and infections were discussed and action taken to prevent them in the future. The QAPI program failed to evidence the agency analyzed all adverse events and identified issues affecting the quality of care, patient safety, and efforts to improve health outcomes. 4. On 08-29-2023 at 12:30 PM, a review of the binder titled “Home Visit/Attendance QAPI” evidenced documents titled “Weekly Scheduling/Attendance Meeting”. The document dated 01-06-2023 evidenced the agency had a total of 22 missed visits because of 4 cancelations and 18 caregiver call-ins. The document dated 01-13-2023 evidenced the agency had a total of 24 missed visits because of 1 hospitalization, 8 cancellations, and 15 caregiver call-ins. The document dated 01-20-2023 evidenced the agency had a total of 13 missed visits because of 2 cancellations and 11 caregiver call-ins. The document dated 01-27-2023 evidenced the agency had a total of 30 missed visits because of 5 cancellations and 25 caregiver call-ins. The document dated 02-03-2023 evidenced the agency had a total of 23 missed visits because of 4 hospitalizations, 4 cancellations, and 15 caregiver call-ins. The document dated 02-10-2023 evidenced the agency had a total of 17 missed visits because of 1 hospitalization, 2 cancellations, 12 caregiver call-ins, and 2 coronavirus 19 infections. The document dated 02-17-2023 evidenced the agency had a total of 35 missed visits because of 5 hospitalizations, 11 cancellations, and 19 caregiver call-ins. The document dated 02-24-2023 evidenced the agency had a total of 30 missed visits because of 2 hospitalizations, 6 cancellations, and 22 caregiver call-ins. The document dated 03-03-2023 evidenced the agency had a total of 30 missed visits because of 4 hospitalizations, 7 cancellations, and 19 caregiver call-ins. The document dated 03-10-2023 evidenced the agency had a total of 43 missed visits because of 9 hospitalizations, 11 cancellations, 19 caregiver call-ins, and 4 coronavirus 19 infections. The document dated 03-17-2023 evidenced the agency had a total of 15 missed visits because of 6 cancellations and 9 caregiver call-ins. The document dated 03-24-2023 evidenced the agency had a total of 10 missed visits because of 1 cancellation and 9 caregiver call-ins. The document dated 03-31-2023 evidenced the agency had a total of 15 missed visits because of 1 hospitalization, 2 cancellations, and 12 caregiver call-ins. The document dated 04-07-2023 evidenced the agency had a total of 23 missed visits because of 6 cancellations and 17 caregiver call-ins. The document dated 04-14-2023 evidenced the agency had a total of 16 missed visits because of 6 cancellations and 10 caregiver call-ins. The document dated 04-21-2023 evidenced the agency had a total of 20 missed visits because of 3 hospitalizations, 7 cancellations, and 10 caregiver call-ins. The document dated 04-28-2023 evidenced the agency had a total of 23 missed visits because of 6 hospitalizations, 10 cancellations, and 7 caregiver call-ins. The document dated 05-05-2023 evidenced the agency had a total of 20 missed visits because of 2 hospitalizations, 12 cancellations, and 6 caregiver call-ins. The document dated 05-12-2023 evidenced the agency had a total of 20 missed visits because of 5 hospitalizations, 2 cancellations, and 10 caregiver call-ins. The documents failed to evidence the identified hospitalizations, cancellations, call-ins, and infections were discussed and action taken to prevent them in the future. The QAPI program failed to evidence the agency analyzed all adverse events and identified issues affecting the quality of care, patient safety, and efforts to improve health outcomes. The agency failed to ensure adverse events were analyzed and actions taken to prevent further actions. 5. During an interview with the Administrator on 08-24-2023 at 11:35 AM, when queried regarding whether complaints were incorporated into the QAPI program, the Administrator indicated complaints were not directly incorporated into the program. The Administrator indicated the performance improvement program focused on reviewing visit notes and identifying missing notes. They indicated they were assessing to determine what tasks the aide performed, what tasks the patients were accepting, and whether they were needing to modify the aide plan of care. The QAPI documents failed to evidence they discussed the tasks performed by the aides, what tasks the patients were denying, and any modification needed to the care plans. The QAPI program failed to evidence discussions and meetings evidencing how the aide visit notes affected the quality of patient care. 5. During an interview with the Administrator on 08-29-2023 at 8:55 AM, the Administrator indicated the QAPI program was focusing on visit notes being turned in in a timely manner. The Administrator indicated the Owner, Director of Nursing (DON), and Alternate Director of Nursing (ADON), and the Administrator had meetings daily to discuss concerns and issues. The Administrator indicated they focused on the most severe issues. When queried regarding the number of hospitalizations recorded each month, the Administrator indicated they had not noticed any patterns or view it as an issue. They indicated many of the hospitalizations were because of Patient #7. They evidenced they had an issue with Coronavirus 19 infections in their patient and employee population but did not analyze the data and determine an action to take to prevent the spread of Coronavirus 19.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, record review, and interview the agency failed to maintain an infection control program with a goal of prevention, control of infections and communicable diseases. The agency failed to ensure proper hand hygiene and infection control (G 682). The agency failed to prevent, control, and investigate infections for their patients (G 684). The cumulative effects of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for all patients and staff under the Condition of Participation of 42 CFR 484.70, Infection Control. Findings Include: *

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 and interview, the agency failed to ensure infection control practices were followed according to the agency’s policy in 2 of 3 home visits for hand hygiene and gloving. (Patients: #1 and 4) Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, “Competency Evaluation – Supply Bag Technique, Policy No. D-160”. The policy indicated but was not limited to, “ … Hands washed before entering bag … Hands washed prior to re-entry after possible contamination …” 2. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, “Handwashing/Hand Hygiene”, Policy No. D-330”. The policy indicated but was not limited to, “ … 3. Indications for handwashing and hand antisepsis … d. between tasks on the same client … f. after removing gloves … o. Decontaminate hands before having direct contact with clients … p. Decontaminate hands after contact with client’s intact skin …” 3. On 08-22-2023 at 1:02 PM, during a home visit with Patient #1, the Alternate Director of Nursing (ADON) was observed performing a medication set-up and assessment for the patient. The ADON failed to complete hand hygiene before reaching into the bag after handling dusty medication containers without gloves. The ADON failed to perform hand hygiene prior to entering the bag to retrieve a stethoscope. Failed to perform hand hygiene prior to re-entering the bag to retrieve a blood pressure cuff. Failed to perform hand hygiene prior to reaching into the bag to retrieve the pulse oximeter and temporal thermometer probe. The ADON failed to perform hand hygiene prior to entering the bag to grab a wipe to clean equipment. During an interview with the ADON on 08-22-2023 at 1:30 PM, they indicated they were to perform hand hygiene before and after care, before entering the bag, when hands were soiled, before donning gloves, and after doffing gloves. 4. On 08-24-2023 at 9:25 AM, during a home visit with Patient #4, Home Health Aide (HHA) 12 was observed providing personal care for the patient. HHA 12 was observed assisting the patient in washing their back, bottom, and the back of the patient’s legs with gloves. HHA 12 doffed the used gloves and failed to perform hand hygiene. HHA 12 proceeded to provide the patient with their clean towel, wiped the patient’s back with the towel, helped transfer the patient to a chair out of the shower, then removed the bag protecting the patient’s foot dressing from the water, and then washed their hands. During an interview with HHA 12 during the home observation on 08-24-2023 at 9:55 AM, they indicated they were to wash their hands before putting gloves on and taking gloves off, and anytime they touch something new.

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 record review and interview, the agency failed to track, trend and investigate infectious and communicable diseases for 40 of 40 active patients. Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, “Infection Control Surveillance, Policy No. B-402”. The policy indicated but was not limited to, “ … Total surveillance – all infections identified in clients and employees … The Agency will implement a process of identifying all infections in the client and/or employee population and evaluate effectiveness of current control measures or identify an action plan to improve incidence of infections … b. When a pattern or trend in infections is identified, the agency will investigate where clients and/or staff may have acquired the infections and what the source of contamination was … 6 … The agency will identify follow-up actions taken as a result of identified infections …” 2. On 08-29-2023 at 12:30 PM, the binder titled “Infection Control” was reviewed. The binder contained documents titled “Infection Control Tracking and Reporting Tool”. The documents evidenced infection of Coronavirus (COVID) 19 on the documents dated 09-22-2022, 11-28-2022, 12-05-2022, 12-08-2022, 12-20-2022, 02-03-2023, 02-12-2023, 03-06-2023, and 04-24-2023. The document failed to evidence an investigation or action plan took place to prevent the spread of COVID 19. The document evidenced urinary tract infection for the documents dated 09-21-2022, 10-24-2022, 11-27-2022, and 08-18-2023. The documents failed to indicate the potential cause of the urinary tract infections. The documents failed to evidence an investigation or action plan took place to prevent urinary tract infections in all active patients. The document dated 08-01-2023 indicated Patient #3 had a bone infection, but the document failed to evidence an investigation and action plan was enacted to prevent further harm or infection risks. The document dated 09-30-2022 evidenced an upper respiratory infection, but failed to evidence an investigation and action plan was enacted to prevent further infection risks. 3. During an interview with the Administrator on 08-29-2023 at 8:55 AM, when queried regarding the infection tracking, they indicated for the COVID infections, nothing was specifically done to prevent the spread of infections. They indicated they did not have the next steps to prevent the spread of infections.

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 aide services were provided by qualified individuals who successfully completed an approved training and competency program, including the required minimum number of hours for classroom and practical training, and are in good standing on the state aide registry and failed to maintain documentation of the employee's successful completion of certification, testing, competency, and aide registry status for 5 of 5 active home health aide personnel files reviewed (HHA 2, 3, 4, 5, 6) and 1 of 1 former home health aide personnel file reviewed. (HHA 1) The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.80 Home Health Aide Services. Findings include: 1. A review of the personnel file for terminated HHA 1, date of hire 02/28/23, evidenced an application, dated 02/28/23, with an incomplete employment history showing as a Certified Nursing Assistant (CNA) and 3 illegible previous places of employment without dates, contact information, or reason for leaving. An interview form dated 02/28/23 indicated HHA 1 had 15 years of experience as a CNA. An undated CNA license information verification failed to evidence HHA 1's CNA license was verified in advance of providing patient care. The personnel file failed to evidence documentation of successful completion of a home health aide or CNA training program, written test, and skills competency. 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, evidenced an interview form dated 05/23/23 which indicated HHA 2 had worked for an unskilled personal services agency for approximately 5 years and took care of a spouse during the spouse's hospice treatment. A review of the "Home Health Aide Applicant Checklist," dated 05/23/23, indicated HHA 2 had no experience in rehabilitation facilities, with quadriplegics (paralysis of all limbs), or seizure disorders. A review of the job description for HHA 2, dated 05/23/23, evidenced a qualified aide must evidence successful completion of a formal certification training program and/or a written skills test and competency evaluation. The personnel file failed to evidence documentation of successful completion of a home health aide or CNA training program, written test, and skills competency. 3. A review of the personnel file for HHA 3, date of hire 03/06/23, evidenced an application dated 03/06/23. The work history indicated experience at a personal services agency but no dates of employment. An applicant checklist indicated HHA 3 had no experience with hospitals, rehabilitation facilities, hospice care, or post-mortem care, The personnel file failed to evidence verification of license, written or skills competency, or successful completion of an HHA or CNA program. 4. A review of the personnel file for HHA 4, date of hire 06/15/23, evidenced an application dated 06/15/23. The section for work history was blank. HHA 4 indicated their training or experience was "My mom was a CNA. I volunteered where she worked at I took care of my granparents." [sic] The personnel file failed to evidence an aide registry verification or confirmation of written and skills competency and completion of an HHA or CNA program. 5. A review of the personnel file for HHA 5, date of hire 07/20/23, evidenced an incomplete application dated 07/20/24 which indicated a work history of "Burger King, 2016." HHA 5 indicated their training and experience was "I went for a CNA when I was 19 than [sic] I have taken care of relative for 7 years." An agency interview form indicated HHA 5 " ... took care of a relative for 7 years. It persisted of transferring. total care." A home Health Aide Applicant Checklist indicated sections for hospital, rehabilitation facility, and geriatrics were blank and HHA 5 had no experience in hospice care, Alzheimer's/dementia, psychiatric patients, stroke, post-mortem care, Parkinson's, and paraplegia care. The personnel file failed to evidence verification of completion of an HHA or CNA program, written competency, skills competency, and license verification. 6. A review of the personnel file for HHA 6, date of hire 07/31/23, evidenced an application dated 07/31/23 with a with a work history showing a personal services agency from "June to current." The personnel file failed to evidence verification of completion of an HHA or CNA program, written competency, skills competency, and license verification. 7. On 08/28/23 at 2 PM, the Administrator indicated he did not verify employment due to staffing shortages. When asked for the process followed to determine if an individual was qualified to provide aide services, the Administrator indicated the check for a license online. If there is an active license, they hire the individual because the license is proof that they passed their competency. The Administrator indicated they have not verified licenses in many of the personnel files because it takes up to 60 days for the license to show on the registry after the class and testing is passed.

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 all home health aides successfully completed a training and competency program or successfully completed a nurse aide training and competency program and are in good standing on the state aide registry for 1 of 1 terminated home health aide (HHA 1) and 5 of 5 active home health aides. (HHA 2, 3, 4, 5, 6) Findings include: 1. A review of the personnel file for HHA 1, date of hire 02/28/23, evidenced an undated Certified Nursing Assistant (CNA) license verification but failed to evidence the aide was verified in good standing on the nurse aide registry in advance of providing care, and failed to evidence verification of previous home health aide or CNA training, written, and/or skills competency verification. 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, failed to evidence documentation of successful completion of a home health aide or CNA training program, written test, or skills competency and failed to evidence the license was verified in good standing on the state aide registry. 3. A review of the personnel file for HHA 3, date of hire 03/06/23, failed to evidence verification of license in good standing on the state aide registry, successful completion of an HHA or CNA program, and/or verification of written and skills competency. 4. A review of the personnel file for HHA 4, date of hire 06/15/23, evidenced an application dated 06/15/23, which indicated HHA 4's training or experience was "My mom was a CNA. I volunteered where she worked at I took care of my granparents." [sic] The personnel file failed to evidence the aide's license was verified in good standing on the state aide registry and failed to evidence verification of written and skills competency and/or completion of an HHA or CNA program. 5. A review of the personnel file for HHA 5, date of hire 07/20/23, evidenced an application dated 07/20/24, which indicated training and experience was "I went for a CNA when I was 19 than [sic] I have taken care of relative for 7 years." The personnel file failed to evidence verification of completion of an HHA or CNA program, written competency, skills competency, and license verification in good standing on the state aide registry. 6. A review of the personnel file for HHA 6, date of hire 07/31/23, failed to evidence verification of completion of an HHA or CNA program, written competency, skills competency, and license verification in good standing on the state aide registry. 7. On 08/28/23 at 2 PM, the Administrator indicated an aide applicant was qualified if the applicant had an active CNA license on the state aide registry. Due to the lack of available applicants, if the license was active the applicant was hired because an active license was proof the applicant passed their competency. If an applicant was not a CNA, the agency paid for the applicant to attend a nurse aide training program. After the applicant passed written competency testing, they could work as an HHA while finishing the nurse aide training program and practical competency portion. Once they received their certificate of completion they were qualified to work as an HHA or CNA. The Administrator indicated he thought the certificate of completion was sufficient to ensure the aide was qualified since it can take up to 60 days for the aide's name to show on the registry. The Administrator indicated he would need to contact the training facility to obtain the certificates of completion for aides 1-6. When asked how he confirmed successful completion of a qualified CNA or HHA program without the certificate the Administrator indicated he paid the bill for the applicant's training and assumed that meant they successfully finished.

Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all home health aides received training that included classroom and supervised practical training totaling at least 75 hours under the supervision of a registered nurse for 1 of 1 terminated home health aides (HHA 1) and 5 of 5 active home health aides. (HHA 2, 3, 4, 5, 6) Findings include: 1. A review of the personnel file for HHA 1, date of hire 02/28/23, failed to evidence a certificate or comparable document which indicated successful completion of a qualified training program that included classroom and supervised practical training totaling at least 75 hours under the supervision of a registered nurse. 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, failed to evidence a certificate or comparable document which indicated successful completion of a qualified training program that included classroom and supervised practical training totaling at least 75 hours under the supervision of a registered nurse. 3. A review of the personnel file for HHA 3, date of hire 03/06/23, failed to evidence a certificate or comparable document which indicated successful completion of a qualified training program that included classroom and supervised practical training totaling at least 75 hours under the supervision of a registered nurse. 4. A review of the personnel file for HHA 4, date of hire 06/15/23, failed to evidence a certificate or comparable document which indicated successful completion of a qualified training program that included classroom and supervised practical training totaling at least 75 hours under the supervision of a registered nurse. 5. A review of the personnel file for HHA 5, date of hire 07/20/23, failed to evidence a certificate or comparable document which indicated successful completion of a qualified training program that included classroom and supervised practical training totaling at least 75 hours under the supervision of a registered nurse. 6. A review of the personnel file for HHA 6, date of hire 07/31/23, failed to evidence a certificate or comparable document which indicated successful completion of a qualified training program that included classroom and supervised practical training totaling at least 75 hours under the supervision of a registered nurse. 7. On 08/28/23 at 2 PM, the Administrator indicated an aide applicant was qualified if the applicant had an active CNA license on the state aide registry. The Administrator indicated he thought the certificate of completion was sufficient to ensure the aide was qualified since it can take up to 60 days for the aide's name to show on the registry. The Administrator indicated he would need to contact the training facility to obtain the certificates of completion for aides 1-6. When asked how he confirmed successful completion of a qualified CNA or HHA program without the certificate the Administrator indicated he paid the bill for the applicant's training and assumed that meant they successfully finished.

HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all home health aides completed a training and competency program including, but not limited to communication skills, observation/reporting/documentation, basic elements of body functioning, recognizing and reporting changes in skin integrity, and appropriate and safe techniques for bed/sponge/tub/shower bath and shampoo, nail and skin care, oral hygiene, safe transfer, range of motion, and adequate nutrition and fluid intake for 1 of 1 terminated home health aides (HHA 1) and 5 of 5 active home health aides. (HHA 2, 3, 4, 5, 6) Findings include: 1. A review of the personnel file for Home Health Aide (HHA) 1, date of hire 02/28/23, failed to evidence documentation of successful completion of a home health aide or CNA training program that included the content specified in 484.80(b)(3). 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, failed to evidence documentation of successful completion of a home health aide or CNA training program that included the content specified in 484.80(b)(3). 3. A review of the personnel file for HHA 3, date of hire 03/06/23, failed to evidence documentation of successful completion of a home health aide or CNA training program that included the content specified in 484.80(b)(3). 4. A review of the personnel file for HHA 4, date of hire 06/15/23, failed to evidence documentation of successful completion of a home health aide or CNA training program that included the content specified in 484.80(b)(3). 5. A review of the personnel file for HHA 5, date of hire 07/20/23, failed to evidence documentation of successful completion of a home health aide or CNA training program that included the content specified in 484.80(b)(3). 6. A review of the personnel file for HHA 6, date of hire 07/31/23, failed to evidence documentation of successful completion of a home health aide or CNA training program that included the content specified in 484.80(b)(3). 7. On 08/28/23 at 2 PM, the Administrator indicated Visiting Angels paid for an aide applicant to attend CNA training at Entity II, but he was not familiar with the specific content the program provided.

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 maintain documentation of aide training for 5 of 5 active home health aides (HHA 2, 3, 4, 5) and 1 of 1 terminated home health aides. (HHA 1) Findings include: 1. A review of the personnel file for Home Health Aide (HHA) 1, date of hire 02/28/23, failed to evidence documentation of the individual's successful completion of a home health aide or CNA training program. 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, failed to evidence documentation of the individual's successful completion of a home health aide or CNA training program. 3. A review of the personnel file for HHA 3, date of hire 03/06/23, failed to evidence documentation of the individual's successful completion of a home health aide or CNA training program. 4. A review of the personnel file for HHA 4, date of hire 06/15/23, failed to evidence documentation of the individual's successful completion of a home health aide or CNA training program. 5. A review of the personnel file for HHA 5, date of hire 07/20/23, failed to evidence documentation of the individual's successful completion of a home health aide or CNA training program. 6. A review of the personnel file for HHA 6, date of hire 07/31/23, failed to evidence documentation of the individual's successful completion of a home health aide or CNA training program. 7. On 08/28/23 at 2 PM, the Administrator indicated Visiting Angels paid for an applicant to attend CNA training at Entity II and he considered the payment to Entity II as confirmation that the individual successfully completed a CNA training and competency program. When asked if they are only required to pay for the training if the individual passed it, the Administrator stated no.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all home health aides successfully completed a competency evaluation program that included the subjects indicated in 484.80(c)(3), in advance of providing care, for 1 of 1 terminated home health aide (HHA 1) and 5 of 5 active home health aides (HHA 2, 3, 4, 5, 6). Findings include: 1. A review of the personnel file for HHA 1, date of hire 02/28/23, failed to evidence verification of skills competency as listed in 484.80(b)(3). 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, failed to evidence verification of skills competency as listed in 484.80(b)(3). 3. A review of the personnel file for HHA 3, date of hire 03/06/23, failed to evidence verification of skills competency as listed in 484.80(b)(3). 4. A review of the personnel file for HHA 4, date of hire 06/15/23, failed to evidence verification of skills competency as listed in 484.80(b)(3). 5. A review of the personnel file for HHA 5, date of hire 07/20/23, failed to evidence verification of skills competency as listed in 484.80(b)(3). 6. A review of the personnel file for HHA 6, date of hire 07/31/23, failed to evidence verification of skills competency as listed in 484.80(b)(3). 7. On 08/28/23 at 2 PM, the Administrator indicated an aide applicant was qualified if the applicant had an active CNA license on the state aide registry. Due to the lack of available applicants, if the license was active the applicant was hired because an active license was proof the applicant passed their competency. If an applicant was not a CNA, the agency paid for the applicant to attend a nurse aide training program. After the applicant passed written competency testing, they could work as an HHA while finishing the nurse aide training program and practical competency portion. Once they received their certificate of completion they were qualified to work as an HHA or CNA. The Administrator indicated he thought the certificate of completion was sufficient to ensure the aide was qualified since it can take up to 60 days for the aide's name to show on the registry. The Administrator indicated he would need to contact the testing facility to obtain verification of skills competency for HHAs 1 - 6.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which 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 maintain documentation of competency verification for all aides, including a description of the program, qualification of instructors, method used to determine competency, such as direct care or use of a pseudo-patient, for 1 of 1 terminated aide (HHA 1) and 5 of 5 active aides. (HHA 2, 3, 4, 5, 6) Findings include: 1. A review of the personnel file for HHA 1, date of hire 02/28/23, failed to evidence documentation of the aide's competency verification that included a description of the competency program, instructor qualifications, and methods used to verify competency. 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, failed to evidence documentation of the aide's competency verification that included a description of the competency program, instructor qualifications, and methods used to verify competency. 3. A review of the personnel file for HHA 3, date of hire 03/06/23, failed to evidence documentation of the aide's competency verification that included a description of the competency program, instructor qualifications, and methods used to verify competency. 4. A review of the personnel file for HHA 4, date of hire 06/15/23, failed to evidence documentation of the aide's competency verification that included a description of the competency program, instructor qualifications, and methods used to verify competency. 5. A review of the personnel file for HHA 5, date of hire 07/20/23, failed to evidence documentation of the aide's competency verification that included a description of the competency program, instructor qualifications, and methods used to verify competency. 6. A review of the personnel file for HHA 6, date of hire 07/31/23, failed to evidence documentation of the aide's competency verification that included a description of the competency program, instructor qualifications, and methods used to verify competency. 7. On 08/28/23 at 2 PM, the Administrator indicated an aide applicant was qualified if the applicant had an active CNA license on the state aide registry. The Administrator indicated he thought the certificate of completion was sufficient to ensure the aide was qualified since it can take up to 60 days for the aide's name to show on the registry. The Administrator indicated they paid for applicants to attend Entity II for CNA training but he was not familiar with the details of the program offered.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the agency policies were reviewed and revised annually (G 948). The agency failed to ensure the agency employed qualified personnel (G 952). The agency failed to coordinate patient care (G 962). The agency failed to ensure patient needs were continuously assessed (G 966). The agency failed to assure the development, implementation and updates to the plans of care (G 968). These deficiencies had a potential cumulative effect on all 40 patients and 39 active staff. The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Conditions of Participation of 42 CFR 484.105, Organization and Administration of Services. Findings Include: * 410 IAC 17-12-1(a)(1)(2)

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 Administrator failed to ensure the agency’s policies and procedures were reviewed and revised at least annually by 1 of 1 Governing Body. Findings Include: 1. On 08-29-2023 at 8:10 AM, the Administrator provided a February 22, 2021 Briggs Healthcare policy titled, “Policy Development, Policy No. B-210”. The policy indicated but was not limited to, “ … Selected policies and procedures will be reviewed and revised at least annually by the Governing Body and designees …” 2. On 08-29-2023 at 8:10 AM, during the review of the policy binder, it evidenced a document titled “Effective Date, Policy No. A-100”. The document evidenced the policy manual went into effect on 02-22-2021. The section titled “Annual Review” was blank. The Administrator failed to ensure the policies and procedures were reviewed annually by the Governing Body and Administrator. 3. On 08-29-2023 at 9:30 AM, the Governing Body Meeting Minutes were reviewed with the Administrator. The Governing Body Meeting Minutes failed to evidenced the policies and procedures were reviewed annually. 3. During an interview with the Administrator on 08-29-2023 at 8:55 AM, they indicated the last time the policies and procedures were reviewed would be listed in the policy and procedures binder. The policy and procedures binder failed to evidence the policies and procedures were reviewed annually. 410 IAC 17-12-1(c)(1)

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all home health aides were qualified to provide patient care services, including but not limited to verification of previous experience, verification of completion of a qualified home health aide or certified nursing assistant program, verification of references, and verification of successful training and competency testing for 1 of 1 terminated home health aides (HHA 1) and 5 of 5 active home health aides. (HHA 2, 3, 4, 5, 6) Findings include: 1. A review of the personnel file for terminated HHA 1, date of hire 02/28/23, evidenced an application, dated 02/28/23, with an incomplete employment history showing as a Certified Nursing Assistant (CNA) and 3 illegible previous places of employment without dates, contact information, or reason for leaving. An interview form dated 02/28/23 indicated HHA 1 had 15 years of experience as a CNA. An undated CNA license information verification failed to evidence HHA 1's CNA license was verified in advance of providing patient care. The personnel file failed to evidence documentation of successful completion of a home health aide or CNA training program, written test, and skills competency. 2. A review of the personnel file for Home Health Aide (HHA) 2, date of hire 06/07/23, evidenced an interview form dated 05/23/23 which indicated HHA 2 had worked for an unskilled personal services agency for approximately 5 years and took care of a spouse during the spouse's hospice treatment. A review of the "Home Health Aide Applicant Checklist," dated 05/23/23, indicated HHA 2 had no experience in rehabilitation facilities, with quadriplegics (paralysis of all limbs), or seizure disorders. A review of the job description for HHA 2, dated 05/23/23, evidenced a qualified aide must evidence successful completion of a formal certification training program and/or a written skills test and competency evaluation. The personnel file failed to evidence documentation of successful completion of a home health aide or CNA training program, written test, and skills competency and failed to evidence the agency followed its policy for pre-employment reference and employment verification. 3. A review of the personnel file for HHA 3, date of hire 03/06/23, evidenced an application dated 03/06/23. The work history indicated experience at a personal services agency but no dates of employment. An applicant checklist indicated HHA 3 had no experience with hospitals, rehabilitation facilities, hospice care, or post-mortem care, The personnel file failed to evidence verification of license, written or skills competency, or successful completion of an HHA or CNA program. 4. A review of the personnel file for HHA 4, date of hire 06/15/23, evidenced an application dated 06/15/23. The section for work history was blank. HHA 4 indicated their training or experience was "My mom was a CNA. I volunteered where she worked at I took care of my granparents." [sic] The personnel file failed to evidence an aide registry verification or confirmation of written and skills competency and completion of an HHA or CNA program. 5. A review of the personnel file for HHA 5, date of hire 07/20/23, evidenced an incomplete application dated 07/20/24 which indicated a work history of "Burger King, 2016." HHA 5 indicated their training and experience was "I went for a CNA when I was 19 than [sic] I have taken care of relative for 7 years." An agency interview form indicated HHA 5 " ... took care of a relative for 7 years. It persisted of transferring. total care." A home Health Aide Applicant Checklist indicated sections for hospital, rehabilitation facility, and geriatrics were blank and HHA 5 had no experience in hospice care, Alzheimer's/dementia, psychiatric patients, stroke, post-mortem care, Parkinson's, and paraplegia care. The personnel file failed to evidence verification of completion of an HHA or CNA program, written competency, skills competency, and license verification. 6. A review of the personnel file for HHA 6, date of hire 07/31/23, evidenced an application dated 07/31/23 with a with a work history showing a personal services agency from "June to current." The personnel file failed to evidence verification of completion of an HHA or CNA program, written competency, skills competency, and license verification. 7. On 08/28/23 at 2 PM, the Administrator indicated he did not verify employment due to staffing shortages. When asked for the process followed to determine if an individual was qualified to provide aide services, the Administrator indicated the check for a license online. If there is an active license, they hire the individual because the license is proof that they passed their competency. The Administrator indicated they have not verified licenses in many of the personnel files because it takes up to 60 days for the license to show on the registry after the class and testing is passed.