Every finding on record at Zoe Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 03/18, 03/19, 03/20, 03/23, and 03/24/2026 Active Census: 15 At this Emergency Preparedness survey, New Horizons Home Health Services 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: 03/18, 03/19, 03/20, 03/23, and 03/24/2026 12-Month Unduplicated Skilled Admissions: 2 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: POC: Plan of Care; SOC: Start of Care; CM: Clinical Manager; RN: Registered Nurse; LPN: Licensed Practical Nurse; CNA: Certified Nurse Aide; HHA: Home Health Aide QA 3/31/2026 A2

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 standard POC service frequency ranges for 1 of 1 patient with a home visit observation of HHA services (Patient #4). Findings include: 410 IAC 17-13-1(a)(1)(C)(iii) The POC for certification period 03/10/2026 – 05/08/2026, documented HHA service hours as “1–14 hours per day. The POC failed identify the number of hours required per visit. Review of HHA services provided from 01/18/2026 through 03/14/2026 showed the patient received an average of 6 hours of HHA services per day. During an interview on 03/23/2026 beginning at 02:12 PM, the Administrator indicated the agency included a broad range of hours because they were unsure whether caregivers might require additional HHA support.

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 proper infection control practices related to bag technique and clean and dirty areas of a barrier for 1 of 3 home observations of SN care (Patient #3). Findings include: 410 IAC 17-12-1(m) During a home visit observation on 03/19/2026 beginning at 03:02 PM, LPN 1had a small barrier on the table. LPN 1’s bag was on the barrier and took up most of the barrier. After LPN 1 washed her hands, she removed assessment equipment from the bag and placed it at the edge of the barrier. LPN 1 charted each vital sign on her phone immediately after she checked each vital sign. LPN 1 then placed the phone next to the barrier. As LPN 1 finished using each piece of equipment, she placed it on the edge of the barrier, on the dirty side of the barrier where it touched the nursing bag. LPN 1 cleaned each piece of equipment with a disinfecting wipe and placed the equipment in the nursing bag. LPN 1 failed to follow accepted infection control practices to limit the risk of cross contamination. During an interview after the SN visit, LPN 1 indicated she did not know if the nursing bag was clean or dirty. LPN 1 indicated the phone was clean as she disinfected it prior to beginning the assessment. LPN 1 indicated she placed it next to the barrier after each use. LPN 1 indicated the clean equipment dried in the nursing bag. LPN 1 stated that the reusable barrier was too small to adequately hold the nursing bag while also maintaining separate clean and dirty sections.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to identify the method used to evaluate HHA skills competency for 2 of 4 HHA personnel records reviewed (HHA 1 and 2). Findings include: 410 IAC 17-14-1(I)(l)(A) Review of HHA 1’s personnel record showed a competency checklist dated 08/08/2024. The checklist did not indicate whether each skill was demonstrated on a patient, a pseudo‑patient, through verbal explanation, or by written test. The agency failed to document the method of skills review. During an interview on 03/24/2026 Beginning at 10:35 AM, the Administrator stated that the competency checklist did not identify the method used to evaluate each skill. Review of HHA 2’s personnel record showed a competency checklist dated 01/31/2024. The checklist did not indicate whether each skill was demonstrated on a patient, a pseudo‑patient, through verbal explanation, or by written test. The agency failed to document the method of skills review. During an interview on 03/24/2026 beginning at 10:35 AM, the Administrator stated that the competency checklist did not identify the method used to evaluate each skill.

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Dates: September 19, 20, 21, and 22, 2023. Census: 21 At this Emergency Preparedness survey, New Horizons Home Health Services was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 3 on 09/29/2023.

This visit was for a Federal Recertification and State Relicensure survey of a Home Health Provider. This survey was partially extended on September 20, 2023. Survey Dates: September 19, 20, 21, and 22, 2023 Unduplicated skilled admissions: 12 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR by Area 3 on 09/29/2023.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency failed to ensure it provided all patients with the name, address, and telephone number of the QIO (Quality Improvement Organization that manages all beneficiary complaints and quality of care reviews) for 1 of 1 agency, with the potential to affect all patients of the agency. Findings include: On 09/19/2023, a 2018 document titled "Admission Document" for Area 4 of Indiana was provided by the administrator. The document provided to all patients of the home health agency, represented QIO services provided to Area 4 in Indiana and failed to evidence the correct information for the QIO for Area 4 in Indiana. During an interview on 09/20/2023 at 2:30 PM, the administrator indicated the agency had the incorrect QIO information in the admission documents provided to patients.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated and revised to include wound measurements in 1 of 3 active clinical records reviewed with wounds (Patient #3). Findings include: Review of an agency document dated 05/1992 and titled “Wound Assessment and Documentation” indicated a wound assessment is to include the size with measurement of the length, width, and depth. On 09/20/2023, the clinical record for Patient #3 evidenced an agency document titled “Incident Report”. The report was completed and signed by home health aide (HHA) 2 on 09/09/2023. The incident report indicated Patient #3 had an open area on the stump of the amputation site below the left knee and that registered nurse (RN) 1 was notified. On 09/09/2023, RN 1 documented actions taken. Patient #3 was going to the emergency room on 09/09/2023 to have leg evaluated and would schedule a visit with the patient on the following Monday. Review of an agency document titled “Adult Skilled Nursing Note” completed and signed by RN 1 on 09/14/2023 indicated measurements of the wound on the lateral aspect of left lower stump with length of 1 centimeter (cm) and width of .08 cm. The documentation failed to evidence measurement of the depth of the wound. During an interview on 09/22/2023 at 11:00 AM, RN 1 indicated should have obtained measurements of the length, width, and depth of the wound. 17 IAC 17-14-1(a)(1)(B)

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 home health agency failed to ensure the plan of care included the correct route of administration of medications for 1 of 3 active clinical records reviewed with home visits (Patient #1). Findings include: On 09/22/2023, the administrator provided a revised 01/2018 agency policy titled “Patient Care Plan/Medical Supervision”. The policy indicated the plan of care will include all medications. On 09/20/2023, a clinical record review for Patient #1 evidenced a plan of care (POC) for the period 07/24/2023 through 09/21/2023. The POC evidenced diagnosis, but not limited to, post traumatic seizures (seizure disorder that occurs when the brain experiences damage from physical trauma). The POC indicated the route of administration as oral (by mouth) for medications, Buspirone (to treat anxiety) was to be given two times a day by mouth and Cannabidiol (to manage seizures) two time a day by mouth. The POC indicated the skilled nurse visits were to be scheduled 1-3 times each day and were to administer medications as ordered. The POC evidenced Patient #1 had a gastrostomy tube (surgically placed tube through abdomen into the stomach used to administer feedings, hydration, and medications). The individualized POC failed to evidence the need for Buspirone and Cannabidiol to be administrered by way of a gastrostomy tube. During a home visit on 09/19/2023 at 4:00 PM, observed registered nurse (RN) 1 administer evening medications through the gastrostomy tube. During an interview on 09/19/2023 at 4:20 PM, RN 1 indicated all of patient’s medications are administered through the gastrostomy tube. 17 IAC 17-13-1(a)(1)(D)(ix)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure staff used proper hand hygiene (handwashing or use of alcohol-based hand rub) and bag technique to prevent the spread of infection in 1 of 2 home health aide (HHA) home observations, HHA 3, with the potential to affect all patients in which HHA 3 provided direct care. Findings include: On 09/20/2023, the administrator provided an undated agency policy titled “Handwashing”. The policy indicated hand washing must be completed before and after the care of patients and after removing gloves. On 09/20/2023, the administrator provided an undated agency policy titled “Bag Technique”. The policy indicated items are to be placed on a paper towel and after placement of waste in trash container in patients’ home direct care staff are to perform hand hygiene. On 09/20/2023, a home visit with HHA 3 was scheduled with Patient #2. HHA 3 was observed removing their gloves after cleaning the bathroom sink and toilet. HHA 3 removed the waste bag in the bathroom and discarded it into the garbage receptacle in the garage. HHA 3 returned to the bathroom and prepared coffee in a single serve coffee maker located on the bathroom counter. HHA 3 failed to perform hand hygiene and apply/remove gloves appropriately. HHA 3 was observed removing the fabric cover of the table device used for documentation and placed it on the patient's bed with no barrier. HHA 3 failed to protect the equipment by using a barrier before placing the tablet cover on the patient's bed. During an interview on 09/20/2023 at 11:15 AM, HHA 3 indicated hand hygiene should be done after throwing out garbage and before preparing coffee for the patient. During an interview on 09/20/2023 at 3:20 PM, the administrator indicated a paper towel or piece of paper should have been placed between the cover of the tablet and the patients’ bed. 410 IAC 17-12-1(m)

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency’s home health aide (HHA) training program failed to include training regarding adequate nutrition and fluid intake, and maintenance of a clean, safe, and healthy environment with the potential to harm all patients receiving HHA services, for 1 of 1 agency. Findings include: On 09/21/2023, the office administrative assistant, provided an undated agency document titled, “Certified Home Health/Hospice Aide Checklist”. The document failed to include the training and the evaluation of skills for adequate nutrition and fluid intake and for maintenance of a clean, safe, and health environment. During an interview on 09/22/2023 at 2:25 PM, the administrator indicated the agency’s HHA competency evaluation did not include training and evaluation of adequate nutrition and intake and maintenance of a clean, safe, and healthy environment.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient's clinical records would be made available to the patient, free of charge, upon request, at the next home visit or within 4 business days (whichever came first) for 1 of 1 agency. Findings include: On 09/19/2023, a revised 09/2013 admission document titled "Notice of Privacy Practices" was provided by the administrator. The document indicated the patient may be charged a copying fee for medical records and requests for medical records will be acted upon within 30 days after request is made. During an interview on 09/20/2023 at 11:45 AM, the administrator indicated the Notice of Privacy Practices document is not correct. 17 IAC 17-12-3(b)(3)