Every finding on record at Together Homecare of Jeffersonville LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 12/08/2025 - 12/11/2025 Active Census: 30 At this Emergency Preparedness Survey, Team Select Home Care was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 12/08/2025 - 12/11/2025 12-Month Unduplicated Skilled Admissions: 12 Partially Extended on 12/10/2025 at 3:05 PM This deficiency report reflects State Findings in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse POC Plan of Care HHA Home Health Aide SOC Start of Care QR compeleted on 12/16/2025 by A4MC

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 an initial RN assessment was completed within 48 hours of referral for 6 of 10 clinical records reviewed (Patient #2, #3, #4, #6, #8, #9). Findings include: 1. Review of a policy titled “Patient Admission Criteria/Scope of Services,” included but was not limited to: “Referrals may be received by phone, fax, in person, email, referral portals, or in the mail. When the Agency accepts a referral, the following information is collected and documented in the system of record…referral source… care to be provided, including frequency and duration…” 2. Review of a policy titled “Initial Assessments/Comprehensive Assessments,” included but was not limited to: “Initial Assessment and Time Frame: An RN must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home, on the physician-ordered start of care date…” 3. The clinical record for Patient #2, SOC 04/05/2022, evidenced a referral order dated 03/18/2022 and an initial/comprehensive assessment date 04/05/2022. The record failed to evidence that the RN completed the initial assessment within 48 hours of referral to the home health agency. 4. The clinical record for Patient #3, SOC date 03/24/2024, evidenced a referral order dated 03/13/2024 from the patient’s physician and an initial/comprehensive assessment dated 03/27/2024. The record failed to evidence that the RN completed the initial assessment within 48 hours of referral to the home health agency. 5. The clinical record for Patient #4, SOC date 08/27/2024, evidenced a verbal SOC order created by the agency, dated 08/26/2024 and an initial/comprehensive assessment dated 08/27/2024. The agency failed to document the date the agency received the patient referral. 6. The clinical record for Patient #6, SOC 07/12/2024, evidenced a document titled “Intake form” dated 06/25/2024 with no identifiable referral source and an initial/comprehensive assessment dated 07/12/2024. The agency failed to document the date the agency received the patient referral. 7. The clinical record for Patient #8, SOC date 03/25/2025, evidenced a verbal SOC order created by the agency, dated 03/25/2025 and an initial/comprehensive assessment dated 03/25/2025. The agency failed to document the date the agency received the patient referral. 8. The clinical record for Patient #9, SOC date 07/22/2025, evidenced a document titled “Intake Form” dated 04/23/2025, which identified that the patient’s case manager had initiated a referral for home health. The record evidenced a verbal SOC order created by the agency, dated 07/22/2025, and an initial/comprehensive assessment dated 07/22/2025. The record failed to evidence that the RN completed the initial RN assessment within 48 hours of referral to the home health agency. 9. During an interview on 12/10/2025 at 1:59 PM, the Director of Nursing indicated the agency considered the intake date as the day the agency received word or found out a patient may want or need home health services. The agency does not consider the information a referral until the agency verifies the individual is eligible or able to be admitted to services. The agency does not treat the first date it receives information as a referral for home health. Instead, staff consider it a referral only when an agency RN accepts it, which usually happens later. If staff treated the first date of information or initial contact as the referral date, they generally would not use that date to ensure they completed an initial assessment within 48 hours, since that is not their process. She stated that staff assign the referral date when they determine the admission is viable. 410 IAC 17-14-1(a)(1)(A)

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 promptly alert relevant physicians and revise the POC in response to a change in patient condition for 1 of 2 closed records reviewed (Patient #9). Findings include: Review of a policy titled “Plan of Care,” included but was not limited to: “Services will be provided in accordance with a written Plan of Care based on the patient’s diagnoses and assessment of immediate and long-range needs and resources…The Agency professional staff will promptly alert the physician/allowable practitioner to any changes that suggest a need to alter the plan of care…” The clinical record for Patient #9, Certification Period 09/20/2025 – 11/18/2025, evidenced a POC with an HHA frequency and duration of 4 – 6 hours per day, 1 – 3 days per week. The record evidenced missed visits by the HHA on: 09/27/2025, 09/29/2025, 10/02/2025, 10/06/2025, 10/09/2025, 10/13/2025, 10/16/2025, 10/20/2025, 10/23/2025, 10/27/2025, 10/30/2025, 11/03/2025, 11/06/2025, 11/10/2025, 11/13/2025, and 11/17/2025 due to agency staff reports of bedbugs in the patient’s residence. The record evidenced a discharge date of 11/19/2025 and a signed discharge order from the patient’s physician on 11/25/2025. The record failed to evidence that agency staff promptly contacted the patient’s physician to report the change in POC needs. During an interview on 12/11/2025 at 11:33 AM, the Director of Nursing indicated that Patient #9’s clinical record does not include communication with the physician regarding the patient’s visit frequency not being met on the POC. She indicated there was communication with the patient, the patient’s brother, the patient’s case manager, and the patient’s apartment complex regarding the situation; however, staff did not document these communications in the clinical record. The agency’s expectation is to communicate with the physician on any changes in patient care or condition. She stated that staff failed to document notifying the physician of Patient #9’s missed visits, even though the agency expected staff to inform the physician of such visits. 410 IAC 17-13-1(a)(2)

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 the HHAs received at least 12 hours of in-service training in a 12-month period for 1 of 2 HHA files reviewed. (HHA 2) Findings include: 1. A personnel record review for HHA 2, date of hire 05/24/2025, failed to evidence at least 12 hours of in-service training in a 12-month period. 2. During an interview on 12/11/2025 at 11:00 AM, the Administrator indicated that the agency did not have documentation of HHA 2 completing in-service training hours in the past 12 months. 410 IAC 17-14-1(h)

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 agency failed to ensure documentation confirming physician notification of missed visits was included in the clinical record for 1 of 2 closed records reviewed (Patient #9). Findings include: Review of a policy titled “Visit Schedule/Missed Visits,” included but was not limited to: “Patients shall be notified as soon as practica of alterations in the visit schedule…Physician/allowable practitioner will be notified of all missed visits…” The clinical record for Patient #9, Certification Period 09/20/2025 – 11/18/2025, evidenced a POC with HHA frequency and duration of 4 – 6 hours per day, 1 – 3 days per week. The record evidenced missed visits by the HHA on: 09/27/2025, 09/29/2025, 10/02/2025, 10/06/2025, 10/09/2025, 10/13/2025, 10/16/2025, 10/20/2025, 10/23/2025, 10/27/2025, 10/30/2025, 11/03/2025, 11/06/2025, 11/10/2025, 11/13/2025, and 11/17/2025 due to agency staff reports of bedbugs in the patient’s residence. The record failed to evidence the patient’s physician was notified of the reason or frequency of missed visits by agency staff. During an interview on 12/11/2025 at 11:33 AM, the Director of Nursing indicated that Patient #9’s clinical record does not contain documentation of missed visits being sent to the physician; the agency’s expectation is that the physician be notified of missed visits. 410 IAC 17-15-1(a)(1)-(7)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 for Home Health Providers and Suppliers. Survey Dates: 03/21/2023-03/24/2023 12-Month Unduplicated Skilled Census: 20 At this Emergency Preparedness survey, Team Select Home Care was found not in compliance with Conditions of Participation 42 CFR §484.102: Emergency Requirements for Medicare and Medicaid Participating Providers and Suppliers. QR Completed 4/4/2023 A4

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to provide and document training on the review of the agency's emergency preparedness policies and procedures for 1 of 1 agencies reviewed. An undated policy titled "Emergency Management Policy B-400" was provided by the Administrator on 03/23/2023 at 12:52 PM. The policy indicated but was not limited to; "All staff members will be oriented to the emergency management plan and their associated responsibilities. Reviews will be held annually." A review of the Emergency Preparedness binder was conducted on 03/23/2023. The binder failed to evidence documentation of annual reviews of the emergency management plan. During an interview on 3/23/2023, the administrator provided a document titled Office-Wide Emergency Plan Activation After-Action Report dated 12/27/2023 and indicated this was documentation of training for the office staff. During an interview on 3/24/2023, the Administrator indicated they did not have documentation of the annual review of the Emergency Preparedness policies and procedures and did not realize that was needed in the Emergency Preparedness Binder. The Administrator stated they are still in transition from the agency's ownership change and the Emergency Preparedness Binder for the new company will contain that information.

This survey was for a Federal Recertification and State Re-Licensure of a Home Health Provider. Survey Dates: 03/21/2023-03/24/2023 12-Month Unduplicated Skilled Admissions: 20 Partially extended on 03/23/2023 at 3:00 PM. These deficiencies reflect State findings in accordance with 410 IAC 17.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and the interview the agency failed to ensure all patients were provided with a written copy of the agency's current administrator's name and the administrator's contact information in order to receive complaints for 3 of 3 home visits. (Patient #3, #7, and #8) During a home visit observation on 3/22/2023 the written information provided to patient #3 was reviewed. The information had a label with a spot for the administrator's name and the agency phone number, but the administrator's name was left blank. During a home visit observation on 3/22/2023 the written information provided to patient #7 was reviewed. The information listed a former administrator's name. During a home visit observation on 3/23/2023 the written information provided to patient #8 was reviewed. The information had a label with a spot for the administrator's name and the agency phone number, but the administrator's name was left blank. During an interview on 3/23/2023 patient #8 indicated they believed the administrator for the agency was an unknown employee. When asked if the patient knew how to file a complaint, patient #8 indicated they didn't but could probably figure it out. During an interview on 3/22/2023 at 2:00 PM. the Clinical Manager indicated the administrator listed on the information for patient #7 wasn't the administrator but used to be an intermediary below the administrator.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to include the patient's risk for an emergency room visit or risk for rehospitalization including the interventions to address the underlying risk factors for 7 of 7 clinical records reviewed. (Patient #1, #2, #3, #4, #5, #6, and #7) A policy titled "Plan of Care C-580" was provided by the Administrator on 3/23/2023 at 9:53 AM. The document indicated but was not limited to; "The Plan of Care shall be completed in full to include … l. A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risks." The clinical record for patient #1 was reviewed on 3/22/2023. The record included a Plan of Care for the certification period of 11/01/2022 through 12/30/2022. The Plan of Care failed to include the patient's risk for rehospitalization and interventions to address the underlying risk factors. The clinical record for patient #2 was reviewed on 3/22/2023. The record included a Plan of Care for the certification period of 01/14/2023 through 03/14/2023. The Plan of Care failed to include the patient's risk for rehospitalization and interventions to address the underlying risk factors. The clinical record for patient #3 was reviewed on 3/22/2023. The record included a Plan of Care for the certification period of 01/14/2023 through 03/14/2023. The Plan of Care failed to include the patient's risk for rehospitalization and interventions to address the underlying risk factors. The clinical record for patient #4 was reviewed on 3/22/2023. The record included a Plan of Care for the certification period of 02/04/2023 through 05/02/2023. The Plan of Care failed to include the patient's risk for rehospitalization and interventions to address the underlying risk factors. The clinical record for patient #5 was reviewed on 3/22/2023. The record included a Plan of Care for the certification period of 02/14/2023 through 04/14/2023. The Plan of Care failed to include the patient's risk for rehospitalization and interventions to address the underlying risk factors. The clinical record for patient #6 was reviewed on 3/23/2023. The record included a Plan of Care for the certification period of 02/28/2023 through 04/28/2023. The Plan of Care failed to include the patient's risk for rehospitalization and interventions to address the underlying risk factors. The clinical record for patient #7 was reviewed on 3/23/2023. The record included a Plan of Care for the certification period of 01/15/2023 through 3/15/2023. The Plan of Care failed to include the patient's risk for rehospitalization and interventions to address the underlying risk factors. During an interview on 3/23/2023 at 1:09 PM. the Clinical Manager stated the patient ER/Rehospitalization risk was included in the patient's comprehensive assessment. The clinical manager stated all the interventions in the care plan address risks associated with hospitalization but acknowledged the care plan did not contain a specific category for their risk level and interventions related to that risk level. 410 IAC 17-13-1(a)(1)(D)(xiii)

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the written information provided to the patient included the name and contact information for the agency's clinical manager for 3 of 3 home visits. (Patient #3, #7, and #8). 1. During a home visit observation on 3/22/2023 the written information provided to patient #3 was reviewed. The information failed to include contact information for the Clinical Manager. 2. During a home visit observation on 3/22/2023 the written information provided to patient #7 was reviewed. The information failed to include contact information for the Clinical Manager. 3. During a home visit observation on 3/23/2023 the written information provided to patient #8 was reviewed. The information failed to include contact information for the Clinical Manager. 4. During an interview on 3/22/2023 at 2:00 PM. the Clinical Manager indicated the patient binders had the phone number for the agency and often the number of the nurse caring for the patient.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the home health aide competency check-off identified which tasks were performed on an actual patient and which tasks were performed in a lab or on a pseudo patient for 2 of 2 home health aide (HHA) personnel records reviewed. (HHA 2 & HHA 3) An undated policy titled "Competency Evaluation of Homecare Staff D-220" was provided by the Administrator on 3/23/2023 at 1:40 PM. The document indicated, but was not limited to; "Skills competency is evaluated by observing the aide with a patient or pseudo patient, as part of a simulation." The policy indicated ten of the required competency evaluation topics are to be evaluated after observation of the Home Health Aide's performance of the tasks with a patient or pseudo-patient as part of a simulation. The personnel record for HHA 2 was reviewed on 3/23/2023. The aide competency evaluation for HHA 2 failed to identify which skills were performed on a pseudo-patient versus an actual patient and the competency failed to identify if the tasks were evaluated orally, through a written examination, or through observation. The personnel record for HHA 3 was reviewed on 3/23/2023. The aide competency evaluation for HHA 3 failed to identify which skills were performed on a pseudo-patient versus an actual patient and the competency failed to identify if the tasks were evaluated orally, through a written examination, or through observation. During an interview on 3/24/2023 at 11:00 AM. the Administrator stated the form should have been completed to indicate if the tasks were observed or evaluated through a written exam or oral exam. The Administrator acknowledged the forms were incomplete. 410 IAC 17-14-1(l)(2)