Every finding on record at Tjf Investment Group Inc

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to maintain patient information in accordance with the Health Insurance Portability and Privacy Act (HIPPA) for 1 of 1 active patients' medical and insurance information (Patient: #14), found in an agency binder in another patient’s home. Findings Include: 1. A review of a D-Best Home Care policy revised on 04/11/2016, titled “Privacy and Confidentiality of Information” indicated but was not limited to, “To effectively and efficiently preserve and maintain the privacy and confidentiality of patient … information in accordance with the Health Insurance Portability and Privacy Act (HIPPA) and other applicable federal and state laws … Information regarding patients shall not be in areas that are available to the public and/or unauthorized staff … ” 2. During the entrance conference on 11/24/2025 at 9:00 AM, when questioned how confidentiality of patients’ records had been maintained out of the office and who had access to patients’ records, the Administrator and Clinical Manager communicated the phones and tablets are dual password protected, and only the staff who had seen the patient have patient access to the patient’s record. 3. During a home visit at Patient #2's residence, a residential group home, on 11/24/2025 at 3:00 PM, entering the home of Patient #2, had been asked to sign in a binder to the residential group home by HHA 8. Noted several binders on top of the cabinet upon entering the living area. HHA 8 communicated that the group home had two other gentlemen with other service providers living there, but was unsure of their names or the staff's names. Observed two other people come in and then leave the home again during the home visit observation. When asked for the agency binder for Patient #2, HHA 8 grabbed one binder from the top of the cabinet for review. 4. During a review of the agency’s binder, a stack of 20 documents containing health and personal information regarding Patient #14 was found in the front side pocket behind Patient #2's HHA Care Plan. The documents included the following: Patient 14’s POC; multiple faxed cover sheets containing Patient #14’s name, and insurance information; two documents titled “Prior Authorization” containing Patient #14’s name, address, phone number, diagnoses codes, D-Best name, address, phone number, fax number and preparer’s name listed the CM date of birth, member id, address, phone number; two documents titled “Approved Service Request Covered By Your Plan” containing Patient 14’s name, date of birth, authorization number, insurance member id, services approved, and amount of services approved; a physician signed Face to Face Encounter containing Patient #14’s name, address, phone number, physician name address, diagnosis and D-Best name address, phone number and fax number; a document titled “ Clinical Summary” signed by the CM and dated 01/30/2025, containing Patient #14’s date of birth, diagnoses, and clinical summary regarding Patient #14. When asked HHA 8 if this was their patient and if they lived in this home, HHA 8 stated, “No. [Patient #14] had not been their patient or did not live in this home. The [Administrator] came by earlier to but updated information in the binder around 11:00 AM, he must had been in a hurry.” During an interview on 11/24/2025 at 4:05 PM, the Administrator confirmed they had been to Patient #2’s residence and had placed information in Patient #2’s agency binder. The Administrator and CM communicated and identified the documents obtained from Patient #2’s agency binder, found upon review at Patient #2’s residence, as belonging to Patient #14, an active agency client. The Administrator and CM further indicated there should be no other patients' personal or medical information in any other patients’ homes, and that an incident report would need to be filed, and Patient #14 would need to be notified. 410 IAC 17-12-3(b)(2)(E)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 09/17, 09/18, and 09/19/2025. Active Census: 30 At this Emergency Preparedness survey, D-Best Home Care, was found to be in compliance with Emergency Preparedness Requirements for a Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR by Area 3 on 9/30/2025.

This visit was for a Complaint/Incident Investigation survey of a Home Health Provider. Survey Dates: 09/17, 09/18, and 09/19/2025. Complaint: IN002617228 was investigated, with related and unrelated deficiencies cited. 12-Month Unduplicated Skilled Admissions: 3 Survey was fully extended on 09/18/2025. During this Federal Recertification Survey, D-Best Home Care was found to be out of compliance with the Condition of Participation of 42 CFR 484.60, Care Planning, Coordination of Care. Based on the Condition-level deficiencies during the 09/19/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(C)(2)(D) of the Social Security Act on 09/18/2025. Therefore, the 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 September 19, 2025, and continuing through September 18, 2027. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide RN Registered Nurse DON Director of Nursing POC Plan of Care SOC Start of care SN Skilled Nursing OASIS Outcome and Assessment Information Set QR completed by Area 3 on 9/30/2025.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS (Outcome Assessment Information Set) within 30 days of assessment completion for 2 of 2 patients who received skilled services. (Patient: #1 and 3) Findings Include: 1. A review of a D-Best Home Care policy revised on 05/18/2014, titled “Reporting OASIS Information,” indicated, “Policy: D-Best Home Care HHA shall encode and electronically transmit each completed OASIS assessment to the State agency or the CMS OASIS contractor … within 30 days of completing the assessment … ” 2. A review of an agency document titled “OASIS (The Outcome and Assessment Information Set) (a comprehensive assessment designed to collect information related to a home care recipient’s demographic, clinical, functional, and service needs) Agency Final Validation.” The document was for the reporting period of the year to date 09/16/2024 through 09/16/2025, which indicated Active Patient #1 had a section titled “RFA” (Reason For Assessment) listed as 04, indicating a recertification OASIS assessments were submitted on 06-10-2025 with M0090 date of 04/14/025, and Patient #3 RFA listed 04 recertification OASIS assessment submitted on 06/10/2025 with a M0090 date of 03/24/2025. The error message indicated the 3330 warning; the record submitted had been more than 30 days after the M0090 date. The agency validations failed to report submissions for Patient #3’s recertification OASIS assessment with a M0090 date of 07/19/2025. 3. A review of the agency’s report titled “HHA Error Summary by Agency” dated 09/16/2024 through 09/16/2025, indicated but was not limited to “… Message Type: Warning … Error # 3330, Error Description … Record Submitted Late: The submission date is more than 30 Days after M0090 [date assessment had been completed] on this new record. Number of assessments with error 94. Percentage of Assessments with error 68.12 % … ” 4. A review of the active clinical record for Patient #1, with a SOC date of 02/10/2025 and a recertification assessment dated 04/14/2025, submission date 06/10/2025. The record failed to provide evidence that an OASIS submission occurred within 30 days of completion, and failed to provide evidence the recertification assessment dated 08/06/2025 had been submitted. 5. A review of the clinical record for Patient #3, with a SOC date of 05/29/2024 and a recertification assessment dated 04/14/2025 submission date 06/10/2025. The record failed to provide evidence that an OASIS submission occurred within 30 days of completion and failed to provide evidence the recertification assessment dated 07/19/2025 had been submitted. On 09/18/2025, when queried regarding OASIS submission and review of the validation reports, the DON communicated they submitted OASIS one time a month on all the agency’s patients and confirmed the OASIS final validation reports noted untimely submissions.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a transfer summary containing necessary medical information pertinent to the patient’s care had been provided to the healthcare practitioner and receiving facility ensuring safe transfer of care for 1 of 1 patient transferred from care. (Patient: Patient #7) Findings Include: 1. A review of a D-Best Home Care policy revised on 05/22/2024, titled “Discharge/Transfer Summary,” indicated but was not limited to, “ … To ensure that appropriate information related to the care, treatment, and/or services provided is exchanged with other service members when patients are transferred … The completed discharge/transfer summary shall be sent via fax to the patient’s primary care practitioner or other responsible healthcare professional(s) … Unplanned Transfer: within two (2) business days of becoming aware … ” 2. A review of the inactive record for Patient #7, SOC 03/03/2025 and transfer date of 08/05/2025, contained a transfer discharge OASIS Assessment dated 08/05/2025. The Assessment dated 09/15/2025, by the DON, indicated Patient #7 had been admitted to an acute care facility. The clinical record failed to evidence a transfer summary or that it had been sent to Entity 1, the acute care facility, and the patient’s primary care provider for continuity of care. During an interview on 09/17/2025 at 10:51 AM, when questioned about the location of the transfer summary in Patient #7’s clinical record, the DON communicated they had been made aware by HHA 1 Patient #7 had been transported to Entity 1 on 09/13/2025. The DON further confirmed a transfer summary had not been completed or had not been sent to the patient’s physician or the acute care facility. 410 IAC 17-13-2(a)(b)(9)

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), provide a current POC (G0612), and provide a current medication list (G0616). 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 484.60, 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 follow the physician’s orders for 1 of 2 (Patient #3) active records reviewed, receiving SN and HHA services. Findings Include: 1. A review of a D-Best Home Care policy revised on 04/11/2016, titled “Plan of Care” indicated but was not limited to, “ … All clinical services shall be implemented only in accordance with a plan of care established by a physician’s written orders … ” 2. A review of Patient #1’s clinical record evidenced a signed POC for the certification period of 08/09/2025 through 10/07/2025. The POC evidenced physician orders for HHA services 10 hours a day for 7 days a week x 26 weeks, and the cost estimate indicated orders for SN 1 hour every 2 weeks for 26 weeks. The clinical record failed to evidence any new orders for changes to update Patient #1’s POC. A review of the HHA’s completed visits for the dates of 08/09/2025 through 10/07/2025 evidenced Patient #1 had received HHA services 8 hours 7 days a week. During an interview on 09/18/2025 at 2:05 PM the Administrator/Case Manager for Patient #1 reported the HHA schedule change was due to the hours approved by Patient #1’s insurance. The Administrator could not provide updated orders or physician notification regarding the change in plan of care. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC was individualized and included all the required elements in 4 of 4 active patient records reviewed (Patients: #1, 2, 3, and 4) and 1 of 3 inactive patient records. (Patient: #7) Findings Include: 1. A review of a D-Best Home Care policy revised on 04/11/2016, titled “Plan of Care” indicated but was not limited to, “ … Care planning is a collaborative process that takes into consideration the patient’s wishes with regard to medical intervention, treatment choices, family involvement … is a dynamic process … includes at least the following … measurable, objective goal statements … interventions to address the identified problems/needs … all pertinent diagnoses … types of services … required equipment . . . frequency of visits … functional limitations … medications and treatments … Other items as appropriate … ” 2. A review of Patient #1’s clinical record, SOC date 02/10/2025, contained a POC and a certification period from 08/09/2025 to 10/07/2025. The POC indicated a primary diagnosis of End Stage Renal Disease (complete loss of kidney function, causing the body to be unable to remove waste and excess fluids), and other diagnoses included; Chronic Pain Syndrome, Multiple Myeloma (cancer of the plasma cells, a type of white blood cell found in the bone marrow that produces antibodies), Epistaxis (nose bleeds), and Conversion Disorder with Seizures or Convulsions (a condition where psychological stress or trauma leads to physical symptoms such as seizures). The POC evidenced physician orders for HHA services, 10 hours a day, 7 days a week, for 26 weeks, and the cost estimate indicated orders for SN, 1 hour every 2 weeks, for 26 weeks. The section titled “Caregiver Status” noted home health care assist at home to assist in activities of daily living. The discharge planning for the patient had when goals met, discharge when wound(s) healed. The section titled “Safety Measures indicated Patient #1 had D-Best Home Care for their Attendant care services, and SN services for vital sign checks and medication setup. The POC failed to have a seizure plan, failed to have call parameters for temperature, pulse, oxygen saturations, and blood pressure readings, and all necessary interventions to address the underlying risk factors, failed to include the correct Attendant care agency, failed to list the caregiver status, and the discharge plan failed to be patient-specific. During an interview on 09/17/2025 at 12:55 PM, Patient #1 reported they receive infusion treatments every one to two weeks for bone strengthening. When questioned regarding whether they had a port, Patient #1 stated, “No, I used to. They took it out. They start a new IV every time.” The patient denied any wounds and wound care treatments at this time. Patient #1 indicated they received Attendant care services from 5:00 PM to 10:00 PM daily, from Entity 6, a personal service agency. 3. A review of the clinical record for Patient #2, SOC date 06/06/2024, contained a signed POC for the recertification period 07/15/2025 to 09/12/2025. The POC indicated a primary diagnosis of Profound Intellectual Disabilities and other diagnoses included: Down Syndrome (a condition where an extra chromosome impacts looks, ability to think, learn, and reason), and Major Depressive Disorder. The POC indicated orders for HHA 10 hours daily, 5 days a week, for 26 weeks, but failed to list the SN frequency and duration of supervisory visits for the HHA. The treatment orders were for SN to instruct the client to wear proper footwear when ambulating and to instruct the client to change positions slowly. SN to instruct client to remove clutter from client’s path, such as clothes, books, shoes, and electrical cords that may cause client to trip, but the POC failed to list the SN amount, frequency, and duration. 4. A review of the clinical record for Patient #3, SOC date 05/29/2024, contained a physician signed POC for the recertification period 02/24/2025 to 07/22/2025, electronically dated 05/22/2025, and signed by the Clinical Manager. The POC indicated a primary diagnosis of Multiple Sclerosis (a condition that affects the nervous system and makes it difficult for the brain to send signals to the rest of the body) and other diagnoses included; Weakness, Muscle Weakness, Age Related Osteoporosis (a condition of gradual loss of bone density weakening the bones), and Unspecified Asthma (a condition of narrowing and swelling in the lung airways making it difficult to breath). The section titled “Nutritional Requirements” was left blank. 5. A review of the clinical record for Patient #4, SOC date 05/16/2025, contained a signed POC for the recertification period 07/15/2025 to 09/12/2025. The POC indicated a primary diagnosis of Multiple Sclerosis (a condition that affects the nervous system and makes it difficult for the brain to send signals to the rest of the body) and other diagnoses included: History of Falling, Mixed Incontinence, and Dependent on Wheelchair. The POC indicated orders for HHA 12 hours daily, 7 days a week, for 26 weeks, but failed to list the SN frequency and duration of supervisory visits for the HHA. The treatment orders were for SN to instruct on establishing a bowel regimen and a bladder regimen. The SN is to instruct on pain management, proper body mechanics, and safety measures; however, the POC failed to list the SN's amount, frequency, and duration. 6. A review of the clinical record for Patient #7, SOC date 03/03/2025, contained a physician signed POC for the recertification period 08/30/2025 to 09/12/2025. The POC indicated a primary diagnosis of Unspecified Sequelae of Cerebral Infarct (a condition of long-term effects of a stroke when there is a lack of blood flow to the brain), and other diagnoses included: Other Seizures, History of Falling, and Hypertension (high blood pressure). The POC indicated orders for HHA 8 hours daily, 7 days a week, for 26 weeks, but failed to list the SN frequency and duration of supervisory visits for the HHA. The section titled “Psychosocial Status” indicated no problems identified. The section Advance Directives” noted there is no data for this section. The treatment orders were for SN to assess cardiovascular status, assess knowledge of medication regimen, teach disease process, and teach oxygen use. Patient #7’s clinical record failed to have used or contain orders for oxygen. The POC failed to list the SN amount, frequency, and duration. A review of an agency document dated 06/26/2025, titled “Do Not Resuscitate (DNR) Order/Request,” had been signed by Patient #7 and the patient’s physician. During an interview on 09/19/2025 at 10:03 AM, when questioned regarding the clinical record review concerns regarding no seizure plan, advance directives, psychosocial indicating no problems, and SN orders, the DON/Case Manager for Patient #7 communicated they had been made aware Patient #7 drank daily and confirmed Patient #7’s DNR status had been missing on the POC. The DON further indicated the family member had previously been Patient #7’s provider, but had been replaced because they could not be around Patient #7 due to their drinking and behaviors. 7. During an interview on 09/18/2025 at 4:00 PM, when reviewing the clinical records for Patients #1, 2, 3, 4, and 7’s concerns with the POC elements and asked what should be on the POC, with the Administrator and DON, indicated the POC was supposed to be individualized based on the patient’s needs, develop the POC from the assessment, patient-specific goals, allergies, seizure plans, DME, diagnoses, services along with correct frequency and duration. 410 IAC 17-13-1(a)(1)(D)(ii, iii, vii, xii)

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 the patients were provided with current POCs with instructions regarding care for 2 of 2 patients (Patients: #1, and 3) receiving skilled nursing and HHA services, admission binders reviewed. Findings Include: 1. During a home visit at Patient #1’s residence on 09/17/2025 at 12:55 PM, a review of the patient’s agency admission binder evidenced a POC for the recertification period of 02/10/2025 to 04/10/2025. The agency failed to ensure a current POC with instructions had been provided to the patient. 2. During a home visit at Patient #3’s residence on 09/17/2025 at 2:45 PM, a review of the patient’s agency admission binder evidenced a POC for the recertification period of 05/24/2025 to 07/24/2025, and a HHA care plan with a recertification period from 05/24/2025 to 07/24/2025. The agency failed to ensure a current POC with instructions regarding care had been provided to the patient. During an interview on 09/18/2025 at 12:30 PM, during a review regarding concerns with the home visits for Patient #1 and 3, regarding the patient’s POCs not being updated, the Administrator /DON for Patient #1, and DON/Case Manager for Patient #3, communicated the updated POCs were to be updated, and placed in the patient’s binders in the homes.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients were provided with a current medication lists for 2 of 2 (Patients: #1 and 3) patients receiving skilled nursing services admission binders reviewed in patient residences. Findings Include: 1. During a home visit at Patient #1’s residence on 09/17/2025 at 12:55 PM, a review of the patient’s agency admission binder evidenced a medication profile from the recertification period of 02/10/2025 to 04/10/2025, and a Medication profile dated 02/11/2025. 2. During a home visit at Patient #3’s residence on 09/17/2025 at 2:45 PM, a review of the patient’s agency admission binder evidenced a POC and a HHA care plan with a recertification period from 05/24/2025 to 07/24/2025. During an interview on 09/18/2025 at 12:30 PM, during a review of the concerns with the home visits for Patient #1 and 3, in regards to the patient’s POCs and medication lists not being updated, and the process for medication list being provided to the patients, the Administrator /Case Manager for Patient #1, and DON/Case Manager for Patient #3, communicated the updated POCs and medication lists were to be updated, and placed in the patient’s binders in the homes.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure the HHA care plan was individualized and patient-specific for 1 of 1 active patients (Patient : #1) receiving SN and HHA services with a history of seizures and 1 of 1 patients on hold (Patient: #7). Findings Include: 1. A review of a D-Best Home Care policy revised on 05/20/2024, titled “Care Planning,” indicated but was not limited to, “… To plan and provide individualized care, treatment and /or services appropriate to the goals and needs of patients serviced … To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes … ” 2. A review of the clinical record for Patient #1, SOC date of 02/10/2025, contained a physician signed POC for the recertification period 08/09/2025 to 10/05/2025, electronically dated 08/07/2025, and signed by the Administrator. The POC indicated but was not limited to diagnoses of End Stage Renal Disease (a condition where the kidneys do not function removing waste from the blood), Chronic Pain Syndrome, Multiple Myeloma (cancer of the plasma cells, a type of white blood cell found in the bone marrow that produces antibodies), Epistaxis (nose bleeds), and Conversion Disorder with Seizures or Convulsions (a condition where psychological stress or trauma leads to physical symptoms such as seizures). The POC contained orders for Skilled Nursing to assess the pain level and effectiveness of pain medication. A HHA 10 hours daily, 7 days a week, for 60 days for assistance with shower, chair bath, dressing, ambulation, meal prep, skin care, shampoo, and house chores. A review of the HHA Care Plan dated 08/06/2025 failed to evidence a signature by the Administrator overseeing Patient #1’s care. The POC indicated Patient #1 had a primary diagnosis of End Stage Renal Disease and a secondary diagnosis of Chronic Pain Syndrome and failed to evidence Patient #1’s diagnosis of Conversion Disorder with Seizures or Convulsions. HHA frequency had been left blank. The section titled “Plan Details” listed, “Assist with chair bath patient request, tub bath Not applicable, Shower patient request, shower with chair patient request, shampoo every visit, hair comb/comb hair patient request, oral care not applicable, peri care patient request nail care patient request, shave not applicable, assist with dressing every visit, medication reminder every visit, assist with feeding not applicable, meal set et-up every week, light housekeeping every week, change linen patient request, make bed patient request, equipment care every week, range of motion every week, dangle on side of bed every week, turn and position every week, and assist with transfer every week. HHA Care Plan failed to be individualized to the patient’s specific needs regarding safety needs for seizures, a seizure plan, and failed to give the HHA frequency and duration. During an interview on 9/18/2025 at 4:00 PM, when asked if they could show the seizure plan for HHA 2 while providing care for Patients #1 and 7, the Administrator and DON were unable to provide one. 3. A review of the clinical record for Patient #7, SOC date 03/03/2025, contained a physician signed POC for the recertification period 08/30/2025 to 09/12/2025. The POC indicated a primary diagnosis of Unspecified Sequelae of Cerebral Infarct (a condition of long-term 4effects of a stroke when there is lack of blood flow to the brain), and other diagnoses included: Other Seizures, History of Falling, and Hypertension (high blood pressure). The POC indicated orders for HHA 8 hours daily for 7 days a week for 26 weeks. A review of the HHA Care Plan dated 03/03/2025, signed by the DON, who had been overseeing Patient #7’s care. Patient #7 had a primary diagnosis of Unspecified Sequelae of Cerebral Infarct and secondary Other Seizures. HHA frequency had been left blank. The section titled “Plan Details” listed, “Assist with chair bath not applicable, tub bath patient request, Shower patient request, shower with chair not applicable, shampoo patient request, hair comb/comb hair every visit, oral care every visit, peri care patient request, nail care patient request, shave patient request, assist with dressing every visit, medication reminder every visit, assist with feeding patient request, meal set et-up every week, light housekeeping every visit, change linen every week, make bed patient request, equipment care every week, range of motion every week, dangle on side of bed not applicable, turn and position not applicable, and assist with transfer every visit. HHA Care Plan failed to be individualized to the patient’s specific needs regarding safety needs for seizures, a seizure plan, and failed to provide the HHA frequency and duration. During an interview on 09/19/2025 at 10:03 AM, when questioned regarding the HHA care plan being patient-specific for Patient #7 and a seizure plan, the DON confirmed the HHA care plan did not contain a seizure plan for Patient #7 410 IAC 17-13-2(a)

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHA reported changes in the patients' condition to the Registered Nurse (RN) in the patient's condition as part of the interdisciplinary team for 1 of 2 patients with falls. (Patient: #7) Findings Include: 1. A review of a D-Best Home Care policy revised on 04/11/2016, titled “Standards of Conduct” indicated but was not limited to, “ … If an emergency arises, staff are to notify the manger immediately … ” 2. A review of a D-Best Home Care policy revised on 04/11/2016, titled “Communication Process-Staff, Patients and Community” indicated but was not limited to, “ … Effective communication and interdisciplinary relationships improve patient care and safety in the organization … ” 3. A review of an agency document titled “Incident Report" dated 09/15/2025, noted on 09/12/2025, Patient #7 had fallen while in the shower, becoming unconscious, and had been transported to Entity 1, an acute care facility. HHA 1's report narrative indicated the family of Patient #7 had been informed, and the DON had been informed later. During an interview on 09/18/2025 at 3:59 PM, when asked regarding the process for the HHAs of reporting emergencies or changes in the patient’s condition to the RN, the DON stated, "They are to call me right away. " The DON further confirmed HHA 1 had not called to report Patient #7’s fall and being transported to Entity 1 until the following morning on 09/13/2025.

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 be responsible for the day-to-day operations of 1 of 1 home health agency. Findings include: In regards to individualized care planning, coordination of services, and quality of care. 1. The Administrator failed to ensure they provided HHA services to meet the personal care needs of a patient according to the POC (See G572); failed to ensure the individualized POC contained disciplines, frequency and duration of all visits, all safety measures, psychosocial, advance directives, patient specific education and training provided (See G574); failed to ensure patients were provided with an updated medication list (See G612); and failed to ensure updated instructions were provided to the patients (See G616). In regards to Home Health Aide Services (HHA). The Administrator failed to ensure the HHA failed to ensure the aide care plan was individualized and patient-specific including seizure plans, and HHA frequency (G798); and failed to ensure the HHAs reported changes in the patient’s care (G804). In regards to patient safety. The Administrator failed to ensure employees had tuberculosis (TB) (a serious contagious disease affecting the lungs) test either by x-ray or a 1st step and a 2nd step baseline TB skin test for 2 of 2 active records reviewed (Employees: HHA 2, and 3) requiring TB baseline skin tests, prior to providing direct patient care with the potential to affect all active employees. 410 IAC 17-12-1(c)(1)

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure a Clinical Manager/DON is available to provide HHA and patient oversight for services provided for 1 of 1 agency. Findings Include: 1. A review of a D-Best Home Care policy revised on 04/11/2016, titled “Supervising Physician or Registered Nurse,” indicated but was not limited to, “ … The supervising physician or RN is available at all times … The supervising physician or RN participates in all activities relevant to professional services furnished …. ” 2. A review of a D-Best Home Care policy revised on 04/11/2016, titled “On Call Coverage,” indicated but was not limited to, “ … A nurse will be on call for all hours D-Best Home Care office is closed … ” 3. During the entrance conference on 09/17/205 at 9:30 AM, when queried regarding the process of staff or patients calling with a concern, the DON communicated the calls placed to the agency rolls to the on-call phone, answered by staff who directs the calls where needed. The DON further indicated they were always available for calls. 6. On 09/18/2025 at 6:43 AM, a call was placed to the agency to verify on-call for an emergency, 317-243-5824, no answer, recording stated, “unable to answer the phone right now, leave a voicemail”. At 7:55 AM, I received a return call from Admin 4, an office staff member from the agency, who stated, “Sorry about that. I missed your call. I woke up late.” 7. A review of an agency document titled "Incident Report" dated 09/15/2025, noted on 09/12/2025, Patient #7 had fallen while in the shower, becoming unconscious, and had been transported to Entity 1, an acute care facility. HHA 1's report narrative indicated the family of Patient #7 had been informed, and the DON had been informed later. The DON failed to ensure direct care staff reported incidents in a timely manner. During an interview on 09/18/2025 at 3:59 PM, when reviewing concerns regarding the on-call not being answered after hours, the DON confirmed the on-call was to be answered. When asked regarding the HHA's reporting incidents, the DON stated, "They are to call me right away. " The DON further revealed HHA 1 called the DON the following morning on 09/13/2025. 410 IAC 17-14-1(a)(1)(K)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the DON failed to ensure visit notes were incorporated within the clinical record in a timely manner for 1 of 2 active patient records (Patient: Patient #3) receiving SN and HHA services. Findings Include: 1. A review of a D-Best Home Care policy revised on 04/11/2016, titled “Standards of Conduct,” indicated but was not limited to, “ … To provide an ethical framework and standard of conduct for HHA staff … All paperwork is to be completed accurately and in a timely manner … ” 2. A review of the clinical record for Patient #3, SOC date of 05/29/2024, contained a POC for the recertification period 02/24/2025 to 07/22/2025, electronically dated 05/22/2025, and signed by the DON. The record failed to contain a current POC 07/23/2025 to 09/20/2025, until 09/18/2025 when a request to obtain the POC was made. The POC indicated, but was not limited to, an order for Skilled weekly for 26 weeks. A review of SN notes dated 07/20/2025 through 09/07/2025, evidence 07/29/025 SN visit note had been entered after the requested document on 09/19/2025. A review of the clinical record evidenced the comprehensive reassessment dated 07/19/2025, and the POC for the recertification period 07/23/2025 to 09/20/2025, had not been entered until 09/18/2025. During an interview on 09/19/2025 at 9:06 AM, when asked regarding Patient #3’s RN visit note for the week of 07/27/2025 through 08/02/2025, and the sudden appearance on 09/18/2025, in the electronic record of the recertification assessment and POC documented completion date 07/19/2025, the DON/Case Manager for Patient #3, communicated they had just put the note in late and confirmed the note had not been there for 08/29/2025, and the recertification assessment and POC had been entered as well. When asked regarding the agency’s expectation for the clinical staff to had completed documentation in the electronic record, the DON indicated 48 hours.

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 ensure the physician was notified of missed visits for 1 of 3 active clinical records reviewed. (Patient #2) Findings Include: 1. A review of D-Best Home Care policy revised 05-20-2024 and titled “Plan of Care (Plan of Treatment)” indicated but was not limited to, “ … HHA professional staff promptly alerts the physician to any changes that suggest a need to alter the plan of care …” 2. During a review of Patient #2’s clinical record, it evidenced a Plan of Care (POC) with a Start of Care (SOC) date of 04-18-2024 and a certification period from 06-17-2024 to 08-15-2024. The POC indicated the patient received Home Health Aide (HHA) services 5 hours a day, 5 days a week for 8 weeks, and 4 days a week for 1 week for assistance with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). The clinical record evidenced the patient had not received services from 07-05-2024 to 07-15-2024. The clinical record failed to evidence the physician was notified of the missed visits. During an interview with the Administrator (Admin 1) on 07-22-2024 at 2:27 PM, they indicated HHA 1 for Patient #2 was gone and had not notified Admin 1 they were gone. Admin 1 confirmed they were unaware the patient was not receiving services at the time. The Office Manager (Admin 4) indicated HHA 1 had informed Admin 4 they were away for testing the week of June 1, 2024 through June 5, 2024. Admin 4 confirmed Patient #2 was made aware the HHA was not going to be there. Admin 1 and Admin 4 evidenced HHA 1 was supposed to be back the next week, but the HHA had not made them aware they had to extend their time off. Admin 1 evidenced the physician was not notified of the missed visits. During an interview with Admin 1 and the Director of Nursing (DON, Admin 2) on 07-23-2024 at 12:00 PM, they indicated HHA 1 was away for a week and had made the office staff aware, but had not returned at the end of the week. They indicated they were unaware the HHA had not returned and was not providing services for Patient #2. They evidenced HHA 1 made them aware a week later, after the agreed-upon return date. HHA 1 went to see Patient #2 to provide services, the patient refused to receive services from the HHA. Admin 1 confirmed from 07-01-2024 to 07-15-2024, Patient #2 had not received services and the physician was not notified by the agency regarding the missed visits. Admin 2 evidenced their communication with each other was not effective and the physician should have been notified of the missed visits as soon as they were informed by HHA 1 of the missed visits. 410 IAC 17-13-1(a)(2)

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Home Health Aide (HHA) supervisory visit was completed every 30 days according to their policy for 1 of 3 active clinical records reviewed. (Patient #2) Findings Include: 1. A review of D-Best Home Care policy revised 04-11-216 and titled “Certified Home Health Aide Supervision” indicated but was not limited to, “ … The Registered Nurse … evaluates patients receiving only Home health Aide services at least every 30 days with the Home Health Aide present at least once every 60 days …” 2. A review of Patient #2’s clinical record evidenced a Plan of Care with a Start of Care date of 04-18-2024 and a certification period from 06-17-2024 to 08-15-2024. The record evidenced the last HHA supervisory visit note was completed on 05-28-2024. The clinical record failed to evidence an HHA supervisory visit was completed every 30 days. During an interview with the Administrator (Admin 1) and the Director of Nursing (DON, Admin 2) on 07-23-2024 at 12:00 PM, they indicated they were supposed to perform an HHA supervisory visit every 30 days for nonskilled patients. Admin 1 reviewed Patient #2’s clinical record and confirmed there were no HHA supervisory visit notes since 05-28-2024. During the Exit Conference on 07-23-2024 at 3:43 PM, Admin 1 and Admin 2 evidenced the HHA they were supposed to supervise for Patient #2 was gone the week they were going to perform the supervisory visit. They indicated they should have done the supervisory the week the aide returned, but planned the next supervisory visit for 07-28-2024.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 04/30/2024, 05/01/2024, and 05/02/2024 Active Census: 14 At this Emergency Preparedness survey, D-Best Home Care was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102 QR by Area 3 on 5/8/2024.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive emergency preparedness program met all requirements to meet the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to ensure an Emergency Preparedness Plan was in place and reviewed every 2 years, at minimum (E0004); failed to ensure a facility based and community based risk assessment utilizing an all-hazards approach (E0006), failed to ensure the agency had a plan for the subsistence needs for staff and patients, whether they evacuated or sheltered in place; failed to ensure access to a plan or a system / defined procedure to track the location of on-duty staff and sheltered patients under the agency’s care during an emergency (E0021) , failed to ensure a system of medical documentation that would preserve patient information, protects the confidentiality of patient information , secures and maintains the availability of records (E0023), failed to ensure that an emergency preparedness communication plan included all staffing addresses and phone numbers, entities providing services under arrangements, and patient physicians for all districts/ territories that the agency provided services to (E0030), and failed to ensure all staff providing services in all districts / territories were trained in emergency preparedness and failed to ensure the agency maintained documentation of the training provided (E0037). The cumulative effect of these systemic problems resulted in the agency being found out of compliance with the condition, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies. at 42 CFR 484.102. Findings include: 1. A review of an agency’s policy titled “D-Best Home Care EMERGENCY OPERATIONS PLAN “ dated “Reviewed” 03/01/2016, indicated but was not limited to “ . . . scope is to provide for a program that ensures effective mitigation, preparation, response and recovery to disasters or emergencies affecting the environment of care . . . the HHA will perform routine hazard vulnerability analysis to identify areas of vulnerability and undertake actions to lessen the severity. . . Implementation of the HHA’s Emergency Operations Plan will be conducted at least annually . . . maintains a current callback list of all staff . . . Active patient demographics and clinical data is updated and kept available for review . . . the log should be updated at least weekly and more frequently as necessary . . . Staff will attend orientation upon hire and an annual update of specific roles and responsibilities and the skills they require to perform during an emergency . . . . “ 2. A review of the agency’s emergency preparedness (EP) binder dated 2016 failed to evidence current employee or patient rosters, failed to ensure an EP plan was reviewed every 2 years at a minimum, failed to ensure a facility based and community based risk assessment utilizing an all hazards approach, failed to ensure the agency had a plan for subsistence needs for staff and patients, whether they evacuated or sheltered in place, failed to evidence a system to track the location of on-duty staff and sheltered in place patients, failed to ensure a system of medical documentation that would preserve patient information, protects the confidentiality of patient information, secures and maintains the availability of records; failed to ensure that an emergency preparedness plan included all staffing addresses and phone numbers, entities providing care services under arrangement, and failed to evidence documentation of training provided. 3. A review of the Employee records for Home Health Aides #'s 1,2,3, and 4 failed to evidence yearly in-servicing or training in Emergency Preparedness. During an interview on 05/02/2024 at 2:06 PM the administrator indicated the EP program was developed by looking at the policy and procedures. He was not sure when the EP program was last updated and reported they have not completed any community-based or facility-based risk assessments, have not conducted any drills or tabletop exercises, and could not recall when they had last done these and could not provide any proof of orientation or annual education provided to employees. The administrator reported they could not locate a more up-to-date EP binder.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 04/30/2024, 05/01/2024, and 05/02/2024 12-Month Unduplicated Skilled Admissions: 0 During this Federal Recertification Survey, D-Best Home Care was found to be out of compliance with Conditions of Participation §484.55 Comprehensive Assessment of Patients, 484.60 Care Planning, Coordination, and Quality of Care, 484.65 Quality Assessment Performance Improvement, 484.80 Home Health Aide Services, and 484.102 Emergency Preparedness. Based on the Condition-level deficiencies during the 05/02/2024 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on [date of the extended survey]. 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 May 2, 2024 and continuing through May 1, 2026 This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS (Outcome Assessment Information Set) within 30 days of assessment completion for 1 of 1 patients who received skilled services. (Patient: #1) Findings Include: 1. A review of a D-Best Home Care policy revised on 04-11-2016, titled “Reporting OASIS Information,” indicated, “Policy: D-Best Home Care HHA shall encode and electronically transmit each completed OASIS assessment to the State agency or the CMS OASIS contractor … within 30 days of completing the assessment … ” 2. A review of an agency document titled “ OASIS (The Outcome and Assessment Information Set) (a comprehensive assessment designed to collect information related to a home care recipient’s demographic, clinical, functional, and service needs) Agency Final Validation.” The document was for the reporting period of the year to date, which indicated Active Patient #5 had a section titled “RFA (Reason For Assessment) listed as 04, indicating a recertification OASIS assessments were submitted on 05-02-2024 with M0090 date of 03-12-2024. The error message indicated the 3330 warning; the record submitted had been more than 30 days after the M0090 date. The agency validations failed to report submissions for Patient 1, the only patient provided with skilled care in the past year. The Clinical Manager, Admin 2, indicated all other files were rejected. 3. A review of the active clinical record for Patient #1, with a start of care date of 05-19-2021 and a recertification assessment dated 10-24-2023, failed to be submitted. The recertification assessment was to be submitted by 04-25-2024. The record failed to provide evidence that an OASIS submission occurred within 30 days of completion and failed to provide evidence the start of care assessment was submitted from the start of care date 05-19-2021.

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, observation, and interview the agency failed to ensure that all disciplines completed the comprehensive assessment within 5 days from the start of care date, (G 514), failed to ensure that the comprehensive assessments were complete and accurately reflected the patients’ status, including current health, psychosocial, functional, and cognitive status, and (G528), failed to include the patient's strengths, goals, or care preferences, ( G530), failed to ensure a complete and accurate assessment of the patient's medical, nursing, rehabilitative, social, and discharge planning needs (G 534), and failed to identify a caregiver and their willingness to assist the patient. (G538) 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 484.55, Comprehensive Assessment of Patients. Findings include: *

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Registered Nurse (RN) conducted an initial assessment within 48 hours of referral, or on the physician-ordered start of care date in 1 of 1 newly admitted patient in the last 90 days. (Patient: #5) Findings Include: 1. A review of a D-Best Home Care policy revised on 04-11-2016, titled “Acceptance/Admission of Patients” indicated but was not limited to, “ … When a referral for care and/or services is received in the HHA, the information provided is evaluated by the supervisor …If the patient meets HHA criteria, a comprehensive assessment is performed by a Registered Nurse/Therapist … ” 2. A review of a D-Best Home Care policy revised on 04-11-2016, titled “Assessment-Nursing,” indicated but was not limited to, “ Admission assessments shall be performed by a Registered Nurse within 48 hours of referral, 48 hours of the patient’s return home, or on the physician-ordered start of care date… ” 3. A review of the clinical record for Patient #5, with a referral date of 02-21-2024, contained a physician-signed, verbal order dated 02-27-2024 for an Initial Comprehensive Assessment for home care service with no clinician signature. The record failed to evidence a revision order for the start of care date. The record contained an initial comprehensive assessment dated 03-12-2024, 8:30 AM to 10:30 AM, electronically signed by the Administrator. A review of an initial plan of care, the certification period 02-27-2024 to 04-26-2024, indicated a start of care date of 02-26-2024. However, the plan of care failed to have the correct start of care date and certification period documented. A review of the communication notes dated 02-21-2024 to 04-24-2024 failed to evidence the physician was notified of the delay in the start of care and failed to evidence Patient #5’s request to delay the start of care. During an interview on 05-02-2024 at 12:46 PM, the Administrator confirmed Patient #5’s start of care had been completed on 03-12-2024. When queried regarding the process of Patient#5's start of care, the Administrator indicated the patient delayed the start of care. When requested documentation of communication with the patient and physician, the Administrator indicated that they failed to notify the physician of the change in the start of care date, they failed to document the patient’s request, and they failed to obtain a new physician order for the delayed start of care. 410 IAC 17-14-1(a)(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 observation, record review, and interview, the agency failed to ensure the content of the comprehensive assessment was complete and accurately reflected the patients’ status including relevant medical history and diagnoses, in 6 of 6 active records reviewed. (Patients: # 1, 2, 3, 4, 5, and 7) Findings include: 8. A review of the clinical record for Patient #5 contained an initial comprehensive assessment dated 03-12-2024, and electronically signed by the Administrator. The comprehensive assessment indicated a primary diagnosis of Type 2 Diabetes Mellitus (a condition that affects the body’s inability to regulate blood sugar) and other diagnoses included; Tremors, Essential Hypertension (high blood pressure), Chronic Pain, Chronic Kidney Disease (a condition of the kidneys' inability to filter wastes), Chronic Obstructive Pulmonary Disease (a condition that causes obstructed airflow from the lungs), Seizure Disorder, Legally Blind, and Nonthrombocytopenic Purpura ( a condition that causes purple or red spots on the skin). The comprehensive assessment had multiple sections left blank, including Community Agencies/Social Services Screening, Cultural, Homebound, Safety Measures, Behavior Status, and Depression Screening. Neurological failed to address tremors and seizure history and prevention. The section Endocrine indicated Patient #5 was on insulin, and they recorded their blood sugar results; no blood sugars were documented, nor who performed the blood sugars. Nutrition was marked in normal limits, but failed to address Patient #5’s diet, appetite, weight, and nutritional health screen was left blank. Activities Permitted indicated Patient #5 had no restrictions and failed to list Patient #5 had a cane due to fear of falls. The comprehensive assessment failed to list caregiver and caregiver support. Discharge plans when wounds are healed, integumentary section indicated skin was intact, pink, and dry. During an interview on 0502-2024 at 10:28 AM, Patient #5 indicated they used the walls and furniture in their home to hold on to for balance to prevent falls and used, as stated, “a stick” outside the home. The patient further confirmed they checked their own blood sugars, which were in the 200-300 range and had not ever been on insulin. Patient #5 denied wounds, oxygen, or an intravenous catheter (IV). The patient further indicated they had difficulty sleeping at night. 9. A review of the clinical record for Patient #7, start of care 02-27-2024, contained a comprehensive reassessment dated 04-20-2024, electronically signed by the Administrator, for the recertification period 04-22-2024 to 06-20-2024. The comprehensive reassessment indicated a primary diagnosis of Multiple Sclerosis (a condition that affects the nervous system and makes it difficult for the brain to send signals to the rest of the body) and other diagnoses included; Tremors, Ataxia (poor muscle control affecting walking, balance, hand coordination, speech, swallowing and eye movements), and Paraplegia (a condition of paralysis that affects the waist down). The recertification assessment was marked Registered Nurse (RN) and was marked Physical Therapist (PT) discipline completing the assessment. The sections of the comprehensive left blank included: Vital signs and Parameters, Immunizations, Patient Caregiver and Support, Cultural, Nutritional Health Screening, Endocrine, Gastrointestinal, Fall Risk, Depression Screening, Medications, Orders for Discipline & Treatments, and Coordination of Care. The Integumentary status was marked ulcer but failed to give the location, size, appearance stage, and treatment, and who provided the wound care treatment. During an interview on 05-02-2024 at 1:57 PM, the Administrator confirmed Patient #7 did not have wounds. 10. A review of the Administrator’s employee record date of hire, 06-08-20215, indicated the Administrator's RN license was verified on the PLA online search and expired on 10-31-2025. IAC 17-14-1(a)(1)(B) A review of Patient #1’s clinical record evidenced an “OASIS-E Recertification” comprehensive assessment document dated 04-22-2024 by the Director of Nursing (DON), Admin 2). The document indicated a primary diagnosis of Vascular Dementia (a decline in memory, thinking, and behavior due to reduced blood flow to the brain), Hemiplegia affecting the right side of the body (paralysis affecting the right side of the body), Type 2 Diabetes Mellitus (a condition where the body does not regulate and use sugar appropriately) with Diabetic Polyneuropathy (a condition where multiple nerves are injured due to high sugar levels in the blood), and Hypertension (high blood pressure). The comprehensive assessment failed to evidence if the patient had any known allergies, vital signs, and vital sign parameters. The sections were left blank. The clinical record evidenced a document titled “Client Profile” with a Start of Care date of 05-19-2021 and a certification period from 04-22-2024 to 06-20-2024. The Client Profile evidenced Patient #1 was not a DNR (sic Do Not Resuscitate). The comprehensive assessment indicated the patient was a DNR, but also indicated the patient was not a DNR. The assessment failed to clearly indicate if the patient was a full code or had a DNR. During a home visit on 05-01-2024 at 8:30 AM at Patient #1’s residence, it was evidenced the patient had upper-level dentures. The comprehensive assessment failed to indicate under the section titled “Mouth” the patient’s dentures, the DON marked the patient’s mouth was within normal limits. The comprehensive assessment failed to evidence the patient’s pain was assessed during the visit. The “Pain” section was left blank. The comprehensive assessment indicated the caregiver performed glucose checks using a glucometer but failed to indicate who the patient’s caregiver was. The comprehensive assessment failed to include all of the patient’s supplies and durable medical equipment (DME) including but not limited to Diabetic supplies, including lancets and test strips. During an interview with Admin 2 on 05-02-2024 at 11:53 AM, they indicated the comprehensive assessment should have included the patient's allergies, vital signs, code status, pain assessment, and a review of all body systems. They indicated the physician was to include the parameters, and indicated they used their nursing judgment to determine when it was appropriate to call the physician regarding vital signs and blood sugar levels. A review of Patient #4’s clinical record evidenced an “OASIS-E Recertification” comprehensive assessment document, dated 03-29-2024 by the Administrator, Admin 1. The document indicated a primary diagnosis of End Stage Renal Disease (complete loss of kidney function, causing the body to be unable to remove waste and excess fluids), Lipid Storage Disorder (a genetic disorder where the body has a buildup of fatty materials in cells and tissues in the body), and other cerebrovascular (related to the brain and the blood vessels) disorders. The comprehensive assessment failed to evidence the vital sign parameters and vital signs of the patient. The comprehensive assessment evidenced under the section titled “Pain” indicated the patient had an onset of pain on 01-01-2024 in the right forearm with a pain intensity of “0 = No Pain”. The pain assessment failed to indicate what made the pain worse, and what provided relief. The section titled “Dialysis” (a procedure used to remove the waste and excess fluids in place of the kidneys) indicated the patient received Dialysis at Entity 9. During a home visit at Patient #4’s residence on 05-01-2024 at 1:00 PM, Patient # 4 indicated they received Dialysis at Entity 6. The comprehensive assessment failed to include the dialysis agency where the patient received dialysis. The section titled GI (sic Gastrointestinal) failed to evidence Admin 1 listened to the patient’s bowel sounds. The comprehensive assessment failed to include a complete assessment of the patient’s gastrointestinal tract. The comprehensive assessment failed to include a diet appropriate for a Dialysis patient. The comprehensive assessment failed to include whether psychosocial issues were identified for the patient, the section was left blank. The section titled “Activities Permitted” indicated the patient had “No Restrictions”, but the section titled “Coordination of Care” evidenced the patient used their wheelchair mostly due to frequent falls. The comprehensive assessment failed to include the patient’s discharge plans, the section was left blank. During an interview with Admin 1 on 05-02-2024 at 3:05 PM, they indicated the comprehensive assessment was to be a full head-to-toe assessment of the patient, assessing the skin, respiratory status, treatments, needs, medicine, incontinence, diet, allergies, if the patient had any fluid restrictions, vital signs, and caregiver and family involved in care. 1. A policy titled “ASSESSMENT – NURSING” dated as revised 04/11/2016 indicated but was not limited to “ Admission assessments shall be performed by a Registered Nurse within 48 hours or 48 hours of the patient’s return home, or on the physician-ordered start of care date . . . the comprehensive assessment also includes the completion of the applicable OASIS data items . . . includes the following information if applicable and appropriate: The patient’s problems, needs and strengths . . . prognosis . . . diagnosis . . . Pertinent physical findings . . . pertinent medical history . . . age-specific and gender-specific findings . . . a comprehensive review and history of prescribed, over the counter medications and herbal supplements . . . Any identified symptoms of pain . . . patient’s nutrition status and diet . . . functional status . . . psychosocial status . . . patient’s wishes regarding care, treatments, and services . . . any medical equipment in use or needed in the home . . . the patient’s family or support system and the care they are capable and willing to provide . . . . ” 2. A record review of Patient #2’s comprehensive assessment titled “OASIS-E Recertification” for the certification period beginning 02/04/2024 signed by the Director of Nursing on 02/03/2024 at 10 AM, evidenced sections titled “vital sign parameters, vital signs “ included but was not limited to blood pressure, pulse temperature, and oxygen level, as well as safety /sanitation hazards, pain assessment, GI (bowel assessment), were left blank and indicated Patient #2 had seizures. The section titled “Diagnoses” revealed multiple sclerosis (a progressive disease of the central nervous system with symptoms that may include numbness, speech impairment, muscular coordination, blurred vision, and fatigue), muscle weakness, and age-related osteoporosis. During an observation on 05/01/2024 at 10:55 AM, Patient #2 was self-administering an inhaler and had a nebulizer machine in the home. Patient #2 reported utilizing nebulizer treatments two times a day and an inhaler because of Asthma (a chronic condition that narrows airways in the lungs) and reported they never had seizures. During an interview on 05/01/2024 at 1:30 PM the Director of Nursing reported Patient #2’s comprehensive assessment was incomplete because the agency only provided Patient #2 with home health aide service. The agency failed to perform a complete comprehensive assessment accurately reflecting Patient #2’s diagnosis of Asthma, contained an incorrect diagnosis of seizures, and failed to complete an assessment of vital signs. 3. A record review of Patient #3 comprehensive assessment titled “OASIS-E Recertification” for the certification period beginning 04/09/2023 signed by the Director of Nursing on 04/08/2024 at 10 AM failed to evidence completion of assessments to include vital signs, pain assessment, GI (gastrointestinal or organs involved in digestion) an indicated Patient #3 was taking 5 or more medications. During an interview on 05/02/2024 at 10:46 AM, Patient #3's Caregiver reported Patient #3 only takes 1-2 vitamins and medication for their bowels when needed. During an interview on 05/02/2024 at 2:39 PM, the Director of Nursing reported Patient #3 was not on any medications. When asked why he had documented the patient was on 5 or more medications on the assessment, he said he would look into that.

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 identify the patient’s strengths, weaknesses, and goals in 6 of 6 records reviewed. ( Patients #1, 2, 3, 4, 5, and 7) The findings include: 6. A review of the clinical record for Patient #5, contained a comprehensive reassessment dated 04-23-2024, electronically signed by the Administrator for the recertification period 04-27-2024 to 06-25-2024. The comprehensive reassessment contained a section titled Medication goals that indicated the following: Patient #5 would remain free of medication reactions, the patient/caregiver would verbalize understanding of their medication regime, and would demonstrate understanding of flushing peripheral intravenous (IV) line(a needle or tube inserted into the vein to provide fluids, medication, or nourishment). The comprehensive assessment failed to identify patient-specific goals, failed to evidence progress towards their goals, and failed to evidence care preferences, strengths, and weaknesses. During an interview on 05-02-2024 at 3:45 PM, the Administrator pointed to the Musculoskeletal section of the patient’s comprehensive reassessment and indicated those were the patient’s strengths. The Administrator indicated they did not have patient-specific goals, care preferences, strengths, and weaknesses on their comprehensive assessments. 7. During an interview on 05-02-2024 at 10:28 AM, Patient #5 denied having a peripheral IV, and they have difficulty sleeping due to pain at night. Patient #5 further indicated they are fearful of falls, so hold on to furniture and walls while moving around in their home. 8. A review of the clinical record for Patient #7, contained a comprehensive reassessment dated 04-20-2024, electronically signed by the Administrator for the recertification period 04-22-2024 to 06-20-2024. The comprehensive reassessment contained a narrative section that indicated Patient #7, due to their disease, was able to move around, was incontinent of bowel and bladder, and required maximum assistance with Activities of Daily Living (ADLS), transfers, bathing, meals, and bedbound. The reassessment failed to evidence Patient #7’s goals and progress towards those goals and failed to evidence patient-specific goals, care preferences, and weaknesses. During an interview on 05-02-2024 at 3:59 PM, when required the Director of Nursing, regarding the location of Patient#7’s patient-specific goals, strengths, weaknesses, and care preferences, indicated they could not find those on the comprehensive reassessment. A review of Patient #1’s clinical record evidenced an “OASIS-E Recertification” comprehensive assessment document dated 04-22-2024 by the Director of Nursing (DON), Admin 2). The document indicated a primary diagnosis of Vascular Dementia (a decline in memory, thinking, and behavior due to reduced blood flow to the brain), Hemiplegia affecting the right side of the body (paralysis affecting the right side of the body), Type 2 Diabetes Mellitus (a condition where the body does not regulate and use sugar appropriately) with Diabetic Polyneuropathy (a condition where multiple nerves are injured due to high sugar levels in the blood), and Hypertension (high blood pressure). The comprehensive assessment failed to indicate the patient’s strengths. The comprehensive assessment included a section titled “Endocrine Goals”, the section indicated the caregiver would understand the importance of keeping the patient’s blood sugar levels within the desired parameters. The comprehensive assessment failed to include blood sugar parameters. The comprehensive assessment failed to evidence the patient’s progress toward the goals listed. During an interview with Admin 2 on 05-01-2024 at 2:20 PM, they indicated the patient goals were supposed to be patient-specific and their progress toward the goals were to be included in the comprehensive assessment. A review of Patient #4’s clinical record evidenced an “OASIS-E Recertification” comprehensive assessment document, dated 03-29-2024 by the Administrator, Admin 1. The document indicated a primary diagnosis of End Stage Renal Disease (complete loss of kidney function, causing the body to be unable to remove waste and excess fluids), Lipid Storage Disorder (a genetic disorder where the body has a buildup of fatty materials in cells and tissues in the body), and other cerebrovascular (related to the brain and the blood vessels) disorders. The comprehensive assessment failed to indicate the patient’s strengths. The comprehensive assessment failed to evidence the patient’s progress toward the goals listed. During an interview with Admin 1 on 05-02-2024 at 3:05 PM, they indicated the comprehensive assessment should include the patient’s goals and their progress toward the goals. 1. A policy titled “ASSESSMENT – NURSING” dated as revised 04/11/2016 indicated but was not limited to “ Admission assessments shall be performed by a Registered Nurse within 48 hours or 48 hours of the patient’s return home, or on the physician-ordered start of care date . . . the comprehensive assessment also includes the completion of the applicable OASIS data items . . . includes the following information if applicable and appropriate: The patient’s problems, needs and strengths . . . . " 2. A record review of Patient #2’s comprehensive assessment titled “Oasis Recertification” for the certification period beginning 02/04/2024 dated and signed by the Director of Nursing on 02/03/2024 indicated the goals included client’s strength, endurance, and mobility will be improved, the client caregiver will demonstrate proper ROM exercise and body alignment techniques. Patient #2’s goals failed to be measurable and failed to include Patient #2’s goals. During an observation on 05/01/2024 at 10:56 AM Patient #2 was assisted from bed to a wheelchair utilizing a mechanical lift. Patient #2 was able to utilize their left hand/arm to grab the overhead trapeze bar (a device with a bar to grip and assist in movement or repositioning while in bed) and assist in the transfer by moving to their right side so the home health aide could place a lift pad underneath the patient’s torso and buttocks to assist with the lift process. The comprehensive assessment failed to include Patient #2’s strengths including mobility in the left hand and arm and moving from side to side to assist with the transfers. 3. A record review of Patient #3 comprehensive assessment titled “OASIS-E Recertification” for the certification period beginning 04/09/2023 signed by the Director of Nursing on 04/08/2024 at 10 AM contained a section titled “Clients Strengths”, the section was left blank. The narrative indicated Patient #3 has “profound intellectual disability . . . non-verbal, cannot perform 24-hour recall, . . . of medications [gender of patient] takes . . . requires teaching/training to improve self-management.” The comprehensive assessment failed to include the patient’s strengths and failed to provide measurable outcomes related to teaching/training for self-management.

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 ensure the comprehensive assessment included discharge planning in 1 of 7 active clinical records. (Patient #4) Findings include: 1. An agency policy titled “Completion of the Comprehensive Assessment, Reference No. 10007” revised 04-11-2016 indicated but was not limited to, “ … The comprehensive assessment shall also identify … discharge planning needs …” 2. A review of Patient #4’s clinical record evidenced an “OASIS-E Recertification” comprehensive assessment document, dated 03-29-2024 by the Administrator, Admin 1. The document indicated a primary diagnosis of End Stage Renal Disease (complete loss of kidney function, causing the body to be unable to remove waste and excess fluids), Lipid Storage Disorder (a genetic disorder where the body has a buildup of fatty materials in cells and tissues in the body), and other cerebrovascular (related to the brain and the blood vessels) disorders. The comprehensive failed to evidence the patient’s discharge planning needs, the section was left blank. During an interview with Admin 1 on 05-02-2024 at 3:05 PM, they indicated the comprehensive assessment was to include discharge planning. 410 IAC 17-14-1(a)(1)(B)

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 caregivers and their willingness and availability to provide care for 2 of 4 active clinical records reviewed with home visits. (Patients #1 and 4) Findings Include: 1. An agency policy titled “Assessment – Nursing, Reference No. 10008” revised 04-11-2016 indicated but was not limited to, “ … Procedure … The patient’s family or support system and the care they are capable and willing to provide …” 2. A review of Patient #1’s clinical record evidenced an “OASIS-E Recertification” comprehensive assessment document dated 04-22-2024 by the Director of Nursing (DON), Admin 2). The document indicated a primary diagnosis of Vascular Dementia (a decline in memory, thinking, and behavior due to reduced blood flow to the brain), Hemiplegia affecting the right side of the body (paralysis affecting the right side of the body), Type 2 Diabetes Mellitus (a condition where the body does not regulate and use sugar appropriately) with Diabetic Polyneuropathy (a condition where multiple nerves are injured due to high sugar levels in the blood), and Hypertension (high blood pressure). The comprehensive assessment failed to include the patient’s primary caregiver, Person 1 (the patient’s relative), willingness and ability to provide care, and availability and schedule. During an interview with Person 1, Patient #1’s primary caregiver, on 04-30-2024 at 12:06 PM, they indicated the patient lived alone, but required continuous care because of their Dementia diagnosis. They indicated they visited the patient at least 4 times a week to check on the patient. They indicated they were Patient #1’s Power of Attorney (POA). 3. A review of Patient #4’s clinical record evidenced an “OASIS-E Recertification” comprehensive assessment document, dated 03-29-2024 by the Administrator, Admin 1. The document indicated a primary diagnosis of End Stage Renal Disease (complete loss of kidney function, causing the body to be unable to remove waste and excess fluids), Lipid Storage Disorder (a genetic disorder where the body has a buildup of fatty materials in cells and tissues in the body), and other cerebrovascular (related to the brain and the blood vessels) disorders. The comprehensive assessment failed to indicate Person 10, Patient #4’s relative, was their caregiver. The comprehensive assessment failed to indicate Person 10’s willingness to provide care. During an interview with Patient #4 during a home visit on 05-01-2024 at 1:00 PM, they indicated Person 10 was there to assist them when the agency was not with the patient. 4. During an interview with Admin 1 on 05-02-2024 at 3:05 PM, they indicated the caregiver was supposed to be listed on the comprehensive assessment.

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 the discharge summaries were sent to the health care practitioner/provider for 2 of 2 discharged records reviewed. (Patients: #6 and 8) Findings Include: 5. A review of the inactive clinical record for Patient #6 discharge date 12/05/2023, revealed a physician order for discharge dated 12/04/2023, electronically signed by the Director of Nursing. However, the record failed to provide evidence of a discharge summary being provided to the healthcare provider. 1. A review of a D-Best Home Care policy revision date of 04-11-2016, titled “Discharge Summary,” indicated, “ … A discharge summary shall be sent to the attending physician … ” 2. A review of a D-Best 3-page document titled “Skilled Nursing Discharge Summary” contained sections to be completed regarding the agency’s patient at discharge: patient identifier, start of care, last visit date, date of discharge, reason for discharge, disposition, condition at discharge, dependency Activities of Daily Living (ADLs), discharge assessment, summary of interventions, summary of goals, and referral needs. 3. A review of a D-Best document titled “Physician Discharge Summary” contained sections to be completed regarding the agency’s patient at discharge: physician name, date, patient name, a summary of care provided, goals at the time of discharge, a summary of condition from admission to discharge, services provided, and who assumed patient care needs. 4. A review of the inactive clinical record for Patient #8, discharge date 04-09-2023, revealed a physician order for discharge dated 04-08-2023, electronically signed by the Director of Nursing. However, the record failed to provide evidence of a discharge summary being provided to the healthcare provider. During an interview on 05-02-2024 at 12:46 PM, the Administrator indicated the agency could not provide documentation that the discharge summary was sent to the healthcare provider.

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 the plans of care were individualized to include all pertinent diagnoses, all equipment, accurate duration of visits, all medications, and treatments, (G0574), treatments are administered only as ordered by a physician, (G0580), and failed to coordinate the delivery or care (G0608). 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 484.60, Care Planning, Coordination of Care, and Quality of Care. Findings Include: 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the Plan of Care was individualized and included all the required elements in 6 of 6 active clinic records reviewed. (Patients: #1, 2, 3, 4, 5, and 7) Findings Include: 6. A review of the clinical record for Patient #5, start of care 03-12-2024, contained a plan of care for the incorrect date of start of care date of 02-26-2024, incorrect dated initial certification period 02-27-2024 to 04-26-2024. The plan of care indicated a primary diagnosis of Type 2 Diabetes Mellitus (a condition that affects the body’s inability to regulate blood sugar) and other diagnoses included; Tremors, Essential Hypertension (high blood pressure), Chronic Pain, Chronic Kidney Disease (a condition of the kidneys' inability to filter wastes), Chronic Obstructive Pulmonary Disease (a condition that causes obstructed airflow from the lungs), Seizure Disorder, Legally Blind, and Nonthrombocytopenic Purpura ( a condition that causes purple or red spots on the skin). The plan of care indicated Durable Medical Equipment (DME)/Supplies; the patient needed alcohol pads and exam gloves; but failed to list a glucometer, lancets, glucometer supplies, oxygen, oxygen supplies, and cane. The section titled “Safety Measures” was left blank; it failed to list infection control, seizure precautions, oxygen use, and fall risk precautions. The section titled “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” indicated Patient #5 had orders for a Home Health Aide (HHA) 10 hours a day for 7 days a week, but failed to list the duration. The narrative indicated Patient #5 was fearful of falls and needed assistance due to their limitation of activities related to their seizures and blindness. The plan of care failed to indicate seizure precaution interventions or fall interventions. The treatment further indicated Skilled Nurse (SN) to assess respiratory, teach patient safe oxygen use, and how to perform blood sugar checks. The plan of care failed to evidence SN amount, frequency, and duration. The section titled “Goal/Rehabilitation Potential/Discharge Plans” indicated but was not limited to, “… the client/caregiver will demonstrate the correct use of oxygen and equipment, absence of seizure activity … demonstrate understanding of flushing peripheral intravenous line (IV) … Discharge when goals are met. Discharge when wound (s) healed …” The plan of care failed to be individualized and list all the required elements on the plan of care. During an interview on 05-02-2024 at 10:28 AM, Patient #5 indicated they checked their own blood sugars and were not on insulin. The patient further indicated they did not have wounds or an IV and used what they called their “Stick” cane to walk outside the home. 7. During an interview on 05-02-2024 at 3:39 PM, the Administrator and Director of Nursing confirmed there were blanks on the plan of care. The Administrator further confirmed that Patient #5 did not have wounds, was not on insulin, and had not had an IV. 8. A review of the clinical record for Patient #7, start of care 02-27-2024, contained a plan of care for the recertification period 04-22-2024 to 06-20-2024. The plan of care indicated a primary diagnosis of Multiple Sclerosis (a condition that affects the nervous system and makes it difficult for the brain to send signals to the rest of the body) and other diagnoses included; Tremors, Ataxia (poor muscle control affecting walking, balance, hand coordination, speech, swallowing and eye movements), and Paraplegia (a condition of paralysis that affects the waist down). The section titled “Emergency Preparedness” indicated there was no data for this section, Allergies were left blank, “Activities Permitted” indicated the patient had no restrictions, and Hospital risk indicated none of the boxes were documented. The section titled DME/Supplies” indicated exam gloves and Abdominal Pads (ABDs) but failed to list incontinence supplies, hospital beds, scooter, and Hoyer lift. The plan of care indicated orders for HHA 12 hours daily for 7 days a week but failed to list the duration. The treatment orders were for SN to instruct the client/caregiver on turning, but the plan of care failed to list the SN amount, frequency, and duration. The section titled “Goals/Rehabilitation Potential/Discharge Plans” indicated Patient #7 wounds would heal without complications but failed to be updated individualized with all the required elements. During an interview on 05-02-2024 at 1:57 PM, the Administrator indicated that another agency had cared for Patient #7's wounds. The Administrator further indicated that the patient no longer had the wounds and confirmed that the plan of care was incorrect. 410 IAC 17-13-1(a)(1)(D)(i, ii, iii, iv, v, vi, vii, viii, ix, x, xi, xii, xiii xiv) A review of Patient #1’s clinical record evidenced a Plan of Care (POC) with a Start of Care (SOC) date of 05-19-2021 and a certification period from 02-22-2024 to 04-21-2024. The POC evidenced a primary diagnosis of Vascular Dementia (a decline in memory, thinking, and behavior due to reduced blood flow to the brain), Hemiplegia affecting the right side of the body (paralysis affecting the right side of the body), Type 2 Diabetes Mellitus (a condition where the body does not regulate and use sugar appropriately) with Diabetic Polyneuropathy (a condition where multiple nerves are injured due to high sugar levels in the blood), and Hypertension (high blood pressure). The POC failed to indicate in the section titled “Caregiver Status” the patient’s primary caregiver, their availability, and willingness to provide care. The section titled “DME (sic Durable Medical Equipment) and Supplies” indicated the patient had exam gloves. The POC failed to include the supplies observed in the patient’s home during a home visit of a Home Health Aide (HHA) on 05-01-2024 at 8:30 AM. The patient had an electric wheelchair, bedside commode, lancets, briefs, and alcohol swabs. The POC failed to indicate the patient’s allergies and their activities permitted. The patient's admission packet found in their home evidenced the patient had No Known Allergies (sic NKA). The POC indicated, under the section titled “Orders for Discipline and Treatments”, the patient received HHA services 16 hours a day, 7 days a week. The POC indicated, under the section titled “Clinical Summary”, the patient received HHA services 8 hours a day, 7 days a week. The POC failed to clearly indicate the number of hours the patient received HHA services. The POC failed to include blood sugar parameters for a patient with a diagnosis of Type 2 Diabetes Mellitus. The POC failed to evidence patient-specific and measurable goals as evidenced by, “ … Client will maintain optimal joint function, increased mobility and independence in ADLs (sic Activities of Daily Living) by the end of the care period. Client’s strength, endurance and mobility will be improved. …” The POC failed to indicate the patient received services from Entity 2, a Home Health agency, every day from 4:00 PM to 9:00 PM, to assist the patient during the hours the agency was not with the patient. During an interview with the Director of Nursing (DON, Admin 2) on 05-01-2024 at 2:20 PM, they indicated the POC was to include a holistic view of the patient, diagnoses, allergies, caregiver, activities permitted, durable medical equipment (DME), and other entities providing care for the patient. A review of Patient #4’s clinical record evidenced a POC with a SOC date of 02-27-2019 and a certification period from 04-01-2024 to 05-30-2024. The POC indicated a primary diagnosis of End Stage Renal Disease (complete loss of kidney function, causing the body to be unable to remove waste and excess fluids), Lipid Storage Disorder (a genetic disorder where the body has a buildup of fatty materials in cells and tissues in the body), and other cerebrovascular (related to the brain and the blood vessels) disorders. The POC indicated the caregiver was available to the client Monday through Friday, but failed to specify who the caregiver was. The section titled “Emergency Preparedness” indicated there was “no data”. The POC failed to include the patient’s Emergency Preparedness plan. The POC failed to indicate the patient’s diet, the section was left blank. The POC failed to include discharge planning for the patient. The POC failed to include where the patient received Dialysis (a procedure used to remove the waste and excess fluids in place of the kidneys), and the days and times they received dialysis. During an interview with the Administrator, Admin 1, on 05-02-2024 at 3:05 PM, they indicated the POC was supposed to be individualized based on the patient’s needs, develop the POC from the assessment, family willing and able to provide care, patient-specific goals, allergies, DME, diagnoses, services along with frequency and duration, tasks, and include the Dialysis center and the days the patient received care. 1. A policy titled “CARE PLANNING” dated “Revised: 04/11/1016” indicated but was not limited to “Care planning is a collaborative process that takes into consideration the patient’s wishes with regard to medical intervention, treatment choices, family involvement . . . is a dynamic process . . . includes at least the following: . . . measurable, objective goal statements . . . interventions to address the identified problems/needs . . . all pertinent diagnoses . . . types of services . . . required equipment . . . frequency of visits . . . functional limitations . . . medications and treatments . . . Other items as appropriate.” 2. A review of Patient #2’s clinical record for the certification period of 02/04/2024 through 04/03/2024 evidenced a primary diagnosis of multiple sclerosis (a chronic and progressive disease involving damage to brain cells and spinal cord resulting in numbness, impairment of muscular coordination, impaired speech, and severe fatigue) and secondary diagnoses of weakness and muscle weakness. The plan of care failed to include a diagnosis of asthma, included a diagnosis of seizures, failed to include medical supplies including an electric wheelchair, hospital bed, overbed trapeze (support bar to assist the patient in reaching and repositioning self), and nebulizer supplies. During an observation and interview with Patient #2 on 05/01/2024 at 10:55 AM, the home contained a mechanical lift, over-bed trapeze, electric wheelchair, and nebulizer equipment. While interviewing Patient #2 at this observation, they reported having a diagnosis of asthma and have never had a diagnosis of seizures or have ever had a seizure. 3. A review of Patient #3’s clinical record for the certification period of 04/09/2024 through 06/07/2024 indicated a primary diagnosis of profound intellectual disabilities. The plan of care failed to include medications and incontinent supplies. During an interview on 05/02/2024 at 10:46 AM Patient #3’s Caregiver reported Patient #3 takes vitamins daily and occasional medication for constipation.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to follow physician's orders for 1 of 6 active records reviewed. (Patient #3) Findings Include: 1. Policy titled “PLAN OF CARE (PLAN OF TREATMENT) dated revised 04/11/2016 indicated but was not limited to “All clinical services shall be implemented only in accordance with a plan of care established by a physician’s written orders.” 2. A review of Patient #3’s clinical record for the certification period of 04/09/2024 through 06/07/2024 evidenced physician orders for home health aide (HHA) services 12 hours a day for 6 days a week x 26 weeks. A review of the completed visits for the dates of 04/11/2024 through 05/01/2024 evidenced Patient #3 was receiving HHA services 8 hours 7 days a week. During an interview on 05/01/2024 at 1:38 PM the Director of Nursing reported the schedule change was due to the hours approved by Patient #3’s insurance and the physician was not notified regarding the change in plan of care or for new orders. 410 IAC 17-13-1(a)

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 ensure they coordinated care delivery to meet the patient’s needs receiving care from other health providers for 2 of 3 active patient records reviewed. (Patients: #4, and 5) Findings Include: During a home visit at Patient #4’s residence on 05-01-2024 at 1:00 PM, Patient #4 indicated they received dialysis (a procedure used to remove the waste and excess fluids in place of the kidneys), from Entity 6 on Tuesdays, Thursdays, and Saturdays during first shift. During a phone interview on 05-02-2024 at 11:22 AM with Person 7, the Clinical Manager, and Person 8, the Medical Social Worker, at Entity 6, they indicated they had never been contacted by the agency regarding Patient #4’s care. Person 8 indicated they were unaware the patient received home health services. The agency failed to evidence documentation of coordination of care with the dialysis center. 1. A review of a D-Best Home Care policy revision date 04-11-2016, titled, “Coordination of Patient Service” indicated, “ When the patient is receiving care, treatment and/or services from other organizations/providers, D-Best Home Care HHA ensures that the responsibilities of the HHA and other organizations/providers are collaborative and exclusive … ” 2. During the entrance conference on 04-30-2024 at 9:23 AM, the Administrator and Director of Nursing( DON) indicated Patient #7 was the only shared patient the agency had to coordinate care with other healthcare providers. The DON further indicated they would communicate coordination of care on the plan of care or communication notes every certification period or if their were patient concerns. 3. A review of the clinical record of Patient #5, start of care date 02-26-2024, contained a plan of care for the initial certification period from 02-27-2024 to 04-26-2024. The plan of care indicated Patient #5 had orders for a Home Health aide (HHA) for 10 hours a day, 7 days a week, for assistance with Activities of Daily Living (ADLs). The plan of care failed to evidence coordination of care with Entity 11, a Personal Care agency, who provided 49 hours a week of personal care to Patient #5. A review of agency documents titled, “Communication Notes” dated 02-26-2024 to 04-15-2024 failed to evidence coordination of care with Entity 11. During an interview on 05-02-2024 at 10:28 AM, Patient #5 indicated that Entity 11 provides them with a personal attendant during the day from 9:00 AM to 4:00 PM. Patient #5 further indicated that D-Best Home Care provides them with a HHA from 8:00 PM to 6:00 AM. 4. During an interview on 05-02-2024 at 11:57 AM, Person 12, the owner of Entity 11, confirmed that their agency provides Personal Attendant care to Patient #5. Person 12 further indicated that no one from D-Best Home Care had contacted them regarding the coordination of care for Patient #5.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to use measurable indicators to improve outcomes, patient safety, and quality of care (G 642), failed to document the agency had considered the incidence, prevalence, and high-risk/problem-prone areas to select indicators and identify performance improvement projects (G646), failed to evidence adverse patient events were tracked and analyzed and preventive actions were implemented. (G654), failed to take action at performance improvement (G656), failed to evidence documentation of quality improvement projects (G658), and failed to evidence governing body oversight of an ongoing QAPI program for quality improvement and patient safety is defined, implemented, and maintained with the potential to affect all 14 active patients. (G660) The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in non-compliance with Condition of Participation CFR 484.65 Quality Assessment/Performance Improvement. Findings include: 1. A document received from the Administrator on 05/02/2024 at 2:45 PM titled “QAPI (QUALITY ASSURANCE PERFORMANCE IMPROVEMENT D-Best Home Care QAPI MEMBERS [SIC] 2023/2024” indicated but was not limited to “ Will continue to plan, implement the following program activities to improve patient’s quality of care and staff safety . . . . “ The document contained 12 programs or activities the agency would perform including staff education (listed 2 times), fall prevention, vaccination of patients for influenza, universal precautions, medication safety and medication errors, training patients to take the Pneumovax vaccination, emergency preparedness, incident reporting, tuberculosis reporting and screening, needle stick injuries, and “ Patients and staff charts audited periodically to ensure compliance.” Under a section titled “EXECUTIVE RESPONSIBILITIES the document reported, “The QAIP [sic] committee will perform quarterly evaluation of the outcome . . . . " 2. A review of an Agency’s 2023-2024 Quality Assurance Performance Improvement (QAPI)Binder received from the Administrator on 05/02/2024 at 2:45 PM evidenced the binder contained policies and procedures last reviewed as dated 2016. Indicators listed in the binder contained categories including infection control, client safety, risk management, client satisfaction, emergency preparedness, employee files, and complaints and incidents but contained no data or details related to the categories in the binder. 3. During an interview on 05/02/2024 at 2:45 PM, the Administrator reported this was all the information he could find. When queried if there was any qualitative or quantitative data or evidence of the governing body's review of the data, he reported having some data from 2021 and was unsure when the governing body was last informed or involved and could not locate any more information or governing body meeting minutes with a discussion of the agency’s QAPI program. IAC 17-12-2(a)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure infection control practices were upheld for hand hygiene and gloving for 3 of 3 home visits with Home Health Aides (HHA) providing care. (HHA #1, 3, and 4) Findings Include: On 05-01-2024 at 8:30 AM, HHA 1 was observed providing personal care for Patient #1 during a home visit. HHA 1 was observed dumping the water used to clean the patient in the toilet and rinsed out the wash basin. HHA 1 proceeded to wipe the water off of their gloves and apply deodorant to the patient's armpits. HHA 1 proceeded to remove the dirty linens from the bed and doffed their gloves. HHA 1 failed to perform hand hygiene after doffing their gloves and before applying new gloves. During an interview with HHA 1 on 05-01-2024 at 8:30 AM, during a home visit at Patient #1's residence, they indicated they were supposed to change their gloves anytime they went to the restroom, when they eat, when they move between different tasks, after they completed a task. They indicated they were supposed to perform hand hygiene when they changed their gloves. On 05-02-2024 at 8:54 AM, HHA 4 was observed providing personal care for Patient #7 during a home visit. HHA 4 donned gloves and failed to perform hand hygiene before donning gloves. HHA 4 wiped the patient's chest down, doffed the gloves, and donned new gloves. HHA 4 failed to perform hand hygiene in between changing gloves. During an interview with HHA 4 on 05-02-2024 at 8:54 AM, during a home visit at Patient #7's residence, they indicated they were supposed to perform hand hygiene with every task involving the patient. They indicated hand hygiene was supposed to be performed when they changed gloves. 1. A policy titled “INFECTION PREVENTION AND CONTROL PROGRAM” mark as reviewed 03/21/2016 contained but was not limited to “ . . . D-Best Home Care HHA administration, with the approval of the Board of Directors, has designed and implemented and Infection Prevention and Control Program that is reflective of: . . . current scientific methods and epidemiological principles for . . . infection prevention . . . . “ 2. During an observation on 05/01/2024 at 10: 56 AM, Home Health Aide (HHA)3 was providing care to Patient # 2. HHA 3 donned gloves, positioned Patient #3 on their right side, removed a soiled pad beneath Patient # 2, removed the patient’s soiled incontinent brief, moved to the opposite of the bed, moved pill bottles on the bedside table, and manipulated the controls for the electric bed. HHA 3 continued by transferring Patient #3 into the wheelchair, touching the arms of the wheelchair, and transferring the patient to the commode. HHA 3 then returned to the bed and placed a clean pad on the mattress. HHA 3 changed their gloves and washed Patient #3’s buttocks and perineal area (area between the genitals and anus) utilizing a wet wipe and dropped the used wipes on the floor. After performing care, the aide picked up the wipes from the floor, threw them away, removed gloves, and put on another pair of gloves. HHA 3 failed to perform hand hygiene after removing soiled gloves, before applying clean gloves, failed to perform hand hygiene and change gloves after touching the soiled pad and incontinent brief, and placed soiled wipes on the floor. During an interview with the Director of Nursing on 05/01/2024 at 11:50 AM, present during the observation, he reported observing HHA 3 changing gloves “sometimes but not always.” During an interview on 05/02/2024 at 10:58 AM, HHA 3 reported they had infection control training and were not sure if they had washed their hands or changed gloves during the observation with Patient #2.

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 maintain or integrate a coordinated agency-wide infection control program in 1 of 1 agency. Findings include: 1. A review of a policy titled “INFECTION PREVENTION AND CONTROL PROGRAM” dated as reviewed 03/21/2016, indicated but was not limited to, “D-Best Home Care HHA’s Infection Prevention and Control Program ensures that this organization develops, implements and maintains an active organiztionwide [sic] program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infection in patients, visitors and staff . . . The Infection Prevention and Control Program . . . incorporates the following on a continuous cycle: Surveillance, prevention and control of infections . . . evaluation and monitoring results . . . infection prevention and control data are an integral part of the organization’s performance improvement program . . . .” 2. A review of the Agency’s infection control data evidenced 0 data collection for the years 2023-2024. 3. A review of the Agency’s Quality Assurance and Performance Improvement program failed to evidence the agency had monitored, reviewed, and or evaluated infection data for the years 2022 through April of 2024. During an interview on 05/02/2024 at 2:45 PM, the Administrator reported this was all the information he could find. When queried if there was any data related to infection surveillance, how the agency monitored infections, and a system for staff to report infections, he indicated he had some data in 2021 and staff are educated on infection control and prevention on hire and annually.

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 observation, record review, and interview, the agency failed to ensure the Home Health Aides (HHA) maintained 12- hours of in-service training yearly (G774); failed to ensure the HHA performed HHA duties within their scope of practice for each patient as ordered in 1 of 3 home visits conducted (G802); and failed to ensure HHA supervisory visits were conducted every 14 days for patients who were provided skilled services (G808). The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in non-compliance with Condition of Participation CFR 484.80 Home Health Aide Services Findings include: *

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of the Home Health Aides (HHAs) completed 12 hours of yearly in-service training in 4 of 4 HHA records reviewed. (Employees: HHA 1, 2, 3, and 4) Findings Include: 1. A review of a D-Best Home Care policy reviewed date of 03-30-2016, titled “Employee Education Programs,” indicated, “ … HHA aides shall receive a minimum of 12 hours of in-service training every 12 months … A copy of the record of in-service attendance will be retained in each aide’s personnel file … ” 2. A review of the Employee record of HHA 1, with a hire date of 05-18-2022, failed to evidence the required yearly 12 hours of in-service training for 2023. 3. A review of the Employee record of HHA 2, with a hire date of 10-03-2019, failed to evidence the required yearly 12 hours of in-service training for 2022 and 2023. 4. A review of the Employee record of HHA 3, with a hire date of 03-02-2020, failed to evidence the required yearly 12 hours of in-service training for 2022 and 2023. 5. A review of the Employee record of HHA 4, with a hire date of 08-13-2019, failed to evidence the required yearly 12 hours of in-service training for 2022 and 2023. During an interview on 05-02-2024, at 12:10 PM, the Business Office Manager, Admin 5, indicated that the HHA training was done online, and the HHAs were to bring in their certificates after they completed each training course. Admin 5 indicated they would provide documentation. 6. On 05-02-2024 at 12:10 PM, 2:03 PM, 2:53 PM, 3:39 PM, and 4:25 PM requested the documentation of the HHA’s 12-hour in-service training. 7. On 05-02-2024 at 4:30 PM, the Administrator provided a HHA in-service training education binder. The binder failed to document the HHAs' participation in the training. During an interview on 05-02-2024 at 4:30 PM, Admin 1, confirmed the agency could not provide documentation of the HHA’s in-service training. 410 IAC 17-14-1(h)

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 the Home Health Aide (HHA) performed the appropriate duties of an HHA for 1 of 1 patient receiving Skilled Nursing services. (Patient #1) Findings Include: 1. An agency polity titled “Interdisciplinary Patient Assessments and Reassessments, Reference No. 10010”, with a revision date of 04-11-2016 indicated but was not limited to, “ … Policy: … provides care, treatment and/or services consistent with the respective scopes of practice of the members of the healthcare team …” 2. A review of Patient #1’s clinical record evidenced a Plan of Care (POC) with a Start of Care (SOC) date of 05-19-2021 and a certification period from 02-22-2024 to 04-21-2024. The POC evidenced a primary diagnosis of Vascular Dementia (a decline in memory, thinking, and behavior due to reduced blood flow to the brain), Hemiplegia affecting the right side of the body (paralysis affecting the right side of the body), Type 2 Diabetes Mellitus (a condition where the body does not regulate and use sugar appropriately) with Diabetic Polyneuropathy (a condition where multiple nerves are injured due to high sugar levels in the blood), and Hypertension (high blood pressure). The POC indicated the patient had their blood glucose monitored 2 times a day. The clinical record evidenced a document titled “OASIS-E Recertification” dated 04-22-2024 by the Director of Nursing (DON), Admin 2. The document indicated the patient’s caregiver was able to perform blood glucose checks. During an interview with HHA 1 at Patient #1’s residence during a home visit on 05-01-2024 at 8:30 AM, HHA 1 indicated they were the ones to perform the blood glucose checks on the patient before the patient ate. The HHA failed to perform tasks within their scope of practice. During an interview with the Administrator, Admin 1, and Admin 2 on 05-01-2024 at 2:20 PM, they indicated HHAs were allowed to take a patient’s blood sugar. The agency failed to ensure HHAs were performing tasks within their scope of practice. 410 IAC 17-14-1(h)(13)(14)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to perform supervisory visits of a Home Health Aide (HHA) every 14 days for 1 of 1 active clinical records reviewed with a patient receiving skilled services. (Patient #1) Findings Include: 1. An agency policy titled “Skilled Staff Supervisory Visits, Reference No. 10112”, with a revision date of 04-11-2016 indicated but was not limited to, “ … A Registered Nurse … shall make onsite visits to a patient’s home no less frequently than every two (2) weeks when a patient is receiving skilled nursing care …” 2. A review of Patient #1’s clinical record evidenced a Plan of Care (POC) with a Start of Care (SOC) date of 05-19-2021 and a certification period from 02-22-2024 to 04-21-2024. The POC evidenced a primary diagnosis of Vascular Dementia (a decline in memory, thinking, and behavior due to reduced blood flow to the brain), Hemiplegia affecting the right side of the body (paralysis affecting the right side of the body), Type 2 Diabetes Mellitus (a condition where the body does not regulate and use sugar appropriately) with Diabetic Polyneuropathy (a condition where multiple nerves are injured due to high sugar levels in the blood), and Hypertension (high blood pressure). The POC indicated the patient received Skilled Nursing services 1 time a week for the certification period and HHA services 8 hours a day, 7 days a week. The clinical record of Patient #1 evidenced only 2 HHA supervisory visit notes dated 03-04-2024 and 04-04-2024. The agency failed to ensure a nurse performed onsite HHA supervisory visits every 30 days for the certification period from 02-22-2024 to 04-21-2024. During an interview with the Administrator, Admin 1, on 05-02-2024 at 1:35 PM, they indicated patients with skilled services received HHA supervisory visits every 30 days. The agency failed to follow the agency’s policies regarding HHA supervisory visits for a patient receiving skilled services.

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 be responsible for the day-to-day operations of 1 of 1 home health agency. Findings Include: In regards to Emergency Preparedness. 1. The Administrator failed to ensure the comprehensive emergency preparedness program met all requirements to meet the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to ensure an Emergency Preparedness Plan was in place and reviewed every 2 years, at minimum (E0004); failed to ensure a facility based and community based risk assessment utilizing an all-hazards approach (E0006), failed to ensure the agency had a plan for the subsistence needs for staff and patients, whether they evacuated or sheltered in place; failed to ensure access to a plan or a system / defined procedure to track the location of on-duty staff and sheltered patients under the agency’s care during an emergency (E0021) , failed to ensure a system of medical documentation that would preserve patient information, protects the confidentiality of patient information , secures and maintains the availability of records (E0023), failed to ensure that an emergency preparedness communication plan included all staffing addresses and phone numbers, entities providing services under arrangements, and patient physicians for all districts/ territories that the agency provided services to (E0030), and failed to ensure all staff providing services in all districts / territories were trained in emergency preparedness and failed to ensure the agency maintained documentation of the training provided (E0037). In regards to Comprehensive Assessments. 2. The Administrator failed to ensure that all disciplines completed the comprehensive assessment within 5 days from the start of care date, (G 514), failed to ensure that the comprehensive assessments were complete and accurately reflected the patients’ status, including current health, psychosocial, functional, and cognitive status, and (G528), failed to include the patient's strengths, goals, or care preferences, ( G530), failed to ensure a complete and accurate assessment of the patient's medical, nursing, rehabilitative, social, and discharge planning needs (G 534), and failed to identify a caregiver and their willingness to assist the patient (G538). In regards to Care planning, coordination, and quality of care. 3. The Administrator failed to ensure the plans of care were individualized to include all pertinent diagnoses, all equipment, accurate duration of visits, all medications, and treatments, (G0574), treatments are administered only as ordered by a physician, (G0580), and failed to coordinate the delivery or care (608). In regards to Quality Assessment/Performance Improvement (QAPI). 4. The Administrator failed to use measurable indicators to improve outcomes, patient safety, and quality of care (G 642), failed to document the agency had considered the incidence, prevalence, and high-risk/problem-prone areas to select indicators and identify performance improvement projects (G646), failed to evidence adverse patient events were tracked and analyzed and preventive actions were implemented. (G654), failed to take action at performance improvement (G656), failed to evidence documentation of quality improvement projects (G658), and failed to evidence governing body oversight of an ongoing QAPI program for quality improvement and patient safety is defined, implemented, and maintained with the potential to affect all 14 active patients (G660). In regards to Home Health Aide Services (HHA). 5. The Administrator failed to ensure the Home Health Aides (HHA) maintained 12- hours of in-service training yearly (G774); failed to ensure the HHA performed HHA duties within their scope of practice for each patient as ordered in 1 of 3 home visits conducted (G802); and failed to ensure HHA supervisory visits were conducted every 14 days for patients who were provided skilled services (G808). 6. A review of the Administrator’s employee record contained an agency document dated 02-29-2016 and signed by the Administrator, titled “Job Description.” The job description evidenced the job description for the Administrator and indicated but was not limited to, “Job Summary: Administers, directs and coordinates all activities of the Agency. Responsible for the overall management of the Agency. Plans, develops, directs, monitors, and supports all operational, administrative, human resources, and customer service activities for the agency’s programs so as to ensure quality and consistency with Agency standards .…” 410 IAC 17-12-1(c)(1)

This survey was for a Federal Recertification and State Re-licensure survey in conjunction with a complaint of a Home Health Provider. The survey was partially extended and the agency’s Administrator was notified on Thursday, September 3rd, 2021 at 3:47 pm. Survey dates: 8/31/21, 9/1/21, 9/2/21, and 9/7/21 Complaint # IN00294048/ 29377 - Substantiated, with findings. Facility # 013640 CNN # 15K133 Census: 8 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State findings. Quality Review Completed on 09/27/21 by Area 3

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they reconciled and identified all duplicate drug therapy and compliance with drug therapy for 1 of 7 clinical records reviewed (Patient #4). Findings include: In a review of Policies and Procedures on 9-2-21 at 2:52 pm, in a document entitled, 'Assessment - Nursing' on page 5 of 7 states, 'A comprehensive review and history of prescribed, over-the-counter medications and herbal supplements, including: ..........Duplicative drug therapy' [would be performed during nursing assessment]. The clinical record for patient #4, start of care 2-19-19, was reviewed and contained a plan of care for the certification period of 8-7-21 to 10-5-21, with orders for Home Health Aide services 10 hours per day for 7 days per week for 26 weeks. The plan of care indicated the patient's diagnoses were COPD (Chronic Obstructive Pulmonary Disease), schizoaffective disorder, congestive heart failure, diabetes mellitus, and glaucoma. The plan of care contained the following duplicated medications; A. "Brimonidine tartrate 0.15% instill one drop 3 times daily drops, gel or ointment for the eye (OPTHALMIC)" and "Brimonidine 0.15% opthalmic solution 1 drop TID drops, gel or ointment for the eye (OPTHALMIC)", (medication used to treat glaucoma) is found twice in the medication list, without instructions to administer to specific eye(s). B. "Sitagliptin 25 mg oral tablet 1 daily by mouth (PO)" and "Januvia 25 mg oral tablet 1 daily: Morning by mouth" (these are the same anti-diabetic drug, the former is the generic name, the later is the brand name). C. "Latanoprost 0.005% opthalmic solution 1 at bedtime, instill 1 drop in both eyes for the eye (OPTHALMIC)" and "Xalatan 0.005% opthalmic solution 1 drop QHS drops, gel or ointment for the eye (OPTHALMIC)" (these are the same medication used to treat increased pressure in the eye, the former is the generic name, the later is the brand name). D. "Escitalopram 10 mg oral tablet 1 daily morning by mouth (PO)" and "Escitalopram 10 mg oral tablet 1 tab daily by mouth (PO)", (medication for depression and generalized anxiety) are both found in the medication list contained within the plan of care. In an interview on 9-2-21 at 2:00 pm with Administrator and Clinical Manager were queried about the duplicate medications found in the plan of care for patient #4, both indicated that they were unaware of the duplicated medications listed. Signature of Clinical Manager appears on the Plan of Care and is dated 8-6-2021. 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 the comprehensive assessment was updated and revised as frequently as the the patient's condition warrants due to a major decline or improvement in the patients; health status but no less than the last 5 days of every 60 days beginning with the start of care date. Agency failed to perform a timely Recertification visit for 1 of 5 active records. Findings include: Clinical record for Patient #2, Start of Care 7-1-21, was reviewed on 9/2/21 and contained a plan of care for the certification period of 7-1-21 to 8-29-21, with orders for skilled nursing for 10 hours per day, 3 days a week, for 26 weeks. Further review of the record failed to evidence that a comprehensive recertification assessment was completed within the last 5 days of the 60 day certification period. In an interview on 9-7-21 at 12:02pm, Clinical Manager confirmed the Recertification visit was indeed missed, was overdue, and has not been completed. IAC 17-14-1(a)(1)(B)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the plan of care and failed to consult the physician when the orders on the plan of care were modified due to missed visits for 1 of 5 active records reviewed. Findings include: 1. On 9/7/21 at 11:00 am Administrator was queried as to location of Missed Visit Policy, as Surveyor was unable to locate this in either of the two policy binders that Administrator had presented to surveyors. Administrator stated this is likely located elsewhere and attempted to locate policy. Administrator reported later in the day that the policy could not be found. In an agency policy entitled ‘Scheduling Patient Visits’ (revised 4/11/2016), page 1 stated, “the physician shall be contacted whenever changes to the type and/or frequency of patient visits are required based on patient needs.” Page 2 stated, “Interim and/or verbal orders noting a change in visit type or frequency shall be signed and dated by the supervising Registered Nurse or Therapist and sent to physician for countersignature.” 2. On 8/31/21 clinical record review of patient #1 revealed Start of Care date of 10/24/16, and Plan of Care dated 4/12/19 – 6/10/19 with Skilled Nursing visits ordered 3 times per week, Monday through Wednesday from 7:00 am to 4:30 pm, with “Skilled Nurse to follow child to school” from 12:00 pm to 4:30 pm. Calendar revealed the following missed visits; Week of 3/24/19 - missed visit 3/25/19 Week of 3/31/19 - missed visit 4/1/19. Week of 4/7/19 – missed visit 4/8/19. Week of 4/14/19 – missed visit 4/15/19. Week of 4/21/19 missed visit 4/22/19. Further review of the clinical record for patient #1, revealed there were no notes present in the chart related to any communication between agency and staff, agency and caregiver, nor agency and physician’s office regarding missed visits for the dates in question. On 9/1/21 at 12:41 pm, in an interview with Person #A (relative of Patient #1), he/she indicated the agency often cancelled or could not cover scheduled visits, causing him/her to lose two jobs. On 9/3/21 at 2:15 pm, in an interview with Person #C, case worker with community resource agency (Agency #D), confirmed that Person #A had lost “jobs” on account of the Home Health agency’s inability to staff scheduled visits as ordered. 3. The clinical record for patient #2, start of care 7/1/21, was reviewed 9/1/21 and contained a plan of care for the certification period 7/1/21 to 8/29/21, a diagnosis cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damaged to the brain before or at birth) and feeding difficulties included order for skilled nursing with two differing frequencies: 10 hours per day, 3 times per week, then later in the same document, order indicated 10 hours daily, 5 days per week. Week of 8/8/21 – missed visits 8/11/21, 8/12/21, and 8/13/21. Week of 8/15/21 – missed visits 8/22/21 and 8/23/21. Week of 8/22/21 – missed visit 8/24/31. On 9/1/21 at 2:03 pm, Person #B (relative of patient #2) was contacted regarding the matter of missed visits; 8/11/21, 8/12/21, 8/13/21 and 8/22/21, 8/23/21 and 8/24/21. Person #B stated patient #2’s usual nurse went on vacation and person #B was subsequently informed by the agency that they could not cover the scheduled visits. When Administrator and Clinical Manager were queried on 9/7/21 @ 12:50 pm as to why visits were not able to be covered for patient #2 and have previously stated that they themselves conducted patient visits as needed, as both Administrator and Clinical Managers are Nurse Practitioners, both indicated that it was Person #B’s preference to have female nursing staff tend to his/her relative. Surveyor asked if this statement or communication was documented anywhere in the in the clinical record, neither Clinical Manager nor Administrator were able to answer this. There was no documentation found in the clinical record related to this matter. In a subsequent conversation with Person #B on 9/7/21 3:35 pm, when queried as to whether alternative nursing staff had been offered to cover missed nursing visits in question, Person #B stated “nope, nothing” had been offered. When queried as to whether the agency had offered any male nursing staff, Person #2 indicated that the agency had not made this offer either. Person #B stated further that he/she knows the two male nurses from the agency and in fact both have been in the home before and Person #B stated, “I would not have minded them coming” indicating he/she was already familiar with them. Person #B reiterated that no alternate staff had been offered to cover the missed visits for the dates in question. On 9/7/21 at 3:45pm, in a return phone call from Nurse #E, representative of Physician for Patient #2, stated that there was no record of telephone communication, nor any faxes from D-Best Home Care in relation to missed visits for Patient #2 pertaining to the dates in question. In an interview on 9/7/21 at 3:05pm, as Administrator informed surveyors he/she was not able to locate Missed Visit Policy, Clinical Manager verbalized the procedure for handling missed visits as follows; when agency is made aware of staff member not being able to keep/cover a visit, agency makes attempts to get the visit covered by another staff member, when they are not able to get coverage agency will notify caregiver/patient as well. Administrator was queried as to whom else would be contacted or notified of the missed visit, he/she indicated they were unaware that physician also needs to be notified of same. Clinical Manager stated the agency does in fact have a paper form that he/she indicated is supposed to be filled out and sent to physician to advise of missed visit, but stated twice that this form is seldom used. When queried as to where this document would be located in the electronic medical record (EMR), neither Administrator nor DON are able to answer. Referring to agency’s own policy dated 4/11/16 titled, ‘Access and Maintenance of the Electronic Health Record’ page 1 of 2, “D-Best Home Care HHA will create a complete electronic health record (EHR) for each patient. Images of the paper record are accepted into the secure electronic document system for archiving and access controls, consistent with all federal and state rules and regulations.” Further review of the electronic clinical record for patient #2 revealed there are no entries in the section of the electronic clinical record entitled ‘Communication’ neither for the current, nor previous certification period. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation and record review the agency failed to revise the plan of care to reflect current living status and information regarding updated diabetic management for 1 of 5 active records reviewed. The findings include: During a home visit on 9-2-21 at 8:00 a.m., the patient was observed to have a continuous glucose (blood sugar) monitoring device on the patient's right arm. Employee F, a home health aide, reported the patient is able to check his/ her blood sugar and that the aide writes the numbers down. A review of the patient's plan of care for the certification period of 7-8-21 through 9-5-21 contains no reference, instruction, or information related to the continuous glucose monitoring machine. 410 IAC 17-13-1(a)(1)(D)(ix)