Heritage Home Health Services

“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 emergency preparedness program met all requirements to meet the health, safety, and security needs of their staff and patient population (E0001), failed to ensure an Emergency Preparedness Plan was in place and reviewed every 2 years (E0004); failed to ensure a facility based and community based risk assessment utilizing an all-hazards approach (E0006); failed to ensure the emergency policy was updated every 2 years (E0013); failed to ensure the communication plan included a list of current staff, entities providing services under arrangement, patient’s physician’s, other facilities, and active patient roster (E0030); failed to ensure the emergency preparedness training and testing were reviewed and updated every 2 years (E0036); and failed to ensure an additional exercise was conducted on the opposite year of a full-scale emergency exercise (E0039). Findings Include: 1. An agency policy with a revision date of 05/2022 and titled “Emergency Management Plan” indicated but was not limited to, “ … The organization will establish an all-hazards approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capabilities. The organization shall review and update the emergency preparedness every year. … Organization leadership will conduct a hazard vulnerability analysis (HVA) … 1. The HVA is documented and evaluated at least every two (2) years to reflect changes in organization … 15. The agency maintains a hard-copy of a current patient list including contact information and categories identified for each patient in the event there is a power failure. … The organization will maintain an emergency preparedness communication plan … is reviewed and updated at least every two (2)years. … 1. Names and contact information for the following: A. Staff B. Entities providing services under arrangement C. Patients’ physician … The training and testing program is reviewed and updated at least every two (2) years. … 3. The agency conducts an additional exercise every two (2) years, opposite the year the full-scale or functional exercise is conducted …” 2. A review of the agency’s emergency preparedness binder evidenced a document titled “Hazard Vulnerability Assessment” the year listed on the document was 2018. The binder evidenced Emergency Preparedness Guide included previous Administrators, Person 4 and Person 5. An after action report was completed for their fire drill on 09/10/2025. Another “After Action Report” dated 05/23/2024 evidenced a full-scale exercise was performed for the solar eclipse. The emergency preparedness failed to include the address of their branch location. The employee list failed to evidence a date when it was last updated. The patients and physicians’ contact information was last updated in 09/2025. The emergency preparedness plan failed to evidence the current Administrator; the emergency plan, emergency policy, communication plan, and all-hazards approach were reviewed every 2 years; an additional exercise was conducted on the opposite year of the full-scale event; contact information for current employees, patients, and patients’ physicians; and the training and testing were updated and reviewed every 2 years. The Administrator provided an unsigned electronic message from their previous Administrator, Person 5. The document indicated they had a full-scale event on 08/05/2026, but failed to evidence an after action report, the specific actions taken, the start and end time, and the individuals involved. During an interview with the Administrator on 08/07/2026 at 4:09 PM, when queried regarding their Emergency Preparedness program, they reviewed the binder and confirmed the documents failed to evidence dates, documentation of their review of the plan and policy, undated employee contact list and a dated all-hazards approach. They indicated they had added the patient list on 08/07/2026, they indicated they wanted an active list in the emergency preparedness binder for the survey. They confirmed the patient list was undated. The Administrator explained they had performed an active full-scale exercise for a winter storm, but failed to document it in the emergency preparedness binder.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency’s governing body was delineated from other agency’s governing body for 1 of 1 home health agency governing body. Findings Include: 1. A policy revised in 05/2022 and titled “Governing Body” indicated but was not limited to, “ … The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations …” 2. A review of the Governing Body meeting minutes evidenced a document dated 12/02/2025 evidenced they discussed the audits and information gathered from other home health entities in another state: Entities 6, 7, 8, 9, 10, and 11). The Governing Body Meeting Minutes dated 05/14/2026 evidenced Entity 6, a home health agency, had a change in leadership. The Governing Body meeting minutes failed to ensure they discussed only the agency’s information in their minutes. During an interview with the Administrator on 08/07/2026 at 4:09 PM, they explained the agency was under a larger corporation, but indicated this agency and the branch were the entities under their license and the other entities should not be included in the Governing Body meeting minutes. 410 IAC 17-12-1(b)(1)”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments were completed and reflected the patient’s health status for 3 of 3 active clinical records reviewed with an OASIS Recertification and Resumption of Care (ROC) assessment completed by RN 1. Findings Include: 3. A review of the clinical record for Patient #2, SOC date of 06/27/2026, contained an OASIS Resumption of Care (ROC) Assessment dated 07/23/2026 and signed by RN 1. The ROC assessment noted the assessment had been completed after Patient #2 had an inpatient stay at an acute care facility. Multiple sections of the assessment were found to be incomplete as follows: The assessment section titled “Sensory Status,” listing eyes, ears, and nose assessments, had all been left blank. The assessment section titled “Community Agencies/Social Service Screening” listed community resource information needed, ability to handle finances, suspected abuse/neglect, suicidal ideation, and MSW referral needs were left blank. The section titled “Fire Assessment for Patients with Oxygen” had been left blank. The section titled “Durable Medical Equipment [DME] Provider” had been left blank. The section titled “Digestive” bowel sounds had been left blank, last bowel movement [BM] had been left blank, and Abdominal girth had been left blank. The section titled “Respiratory” lung sounds were left blank, cough had been left blank, and O2 was listed nightly via Bilevel Positive Airway Pressure (BiPAP) (a noninvasive ventilation device that helps with breathing by delivering two levels of air pressure: higher when inhaling and lower when exhaling). The section titled “Medication Follow-Up” had been left blank. During an interview on 08/11/2026 at 1:49 PM, when asked about the ROC having blanks in the sections, RN 1 stated, “There should be no blanks in the assessment. We started using an AI app to transcribe our visits, but it still needs work. We are still supposed to review our documentation to verify its transcription.” 410 IAC 17-14-1(a)(1)(B) 1. A review of a policy with a revised date of 11/2024 and titled “Initial and Comprehensive Assessment” indicated but was not limited to, “ … 4. During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record …” 2. A review of Patient #7’s active clinical record evidenced an OASIS Recertification assessment completed by RN 1 on 06/25/2026. The patient’s bowel movement was not recorded. The section titled “Respiratory” failed to evidence the lung sounds. The “Cardiovascular” section was blank. 3. A review of Patient #9’s active clinical record evidenced an OASIS recertification completed by RN 1 on 07/08/2026. The assessment evidenced a section titled “Sensory Status” was blank for the subsections “Eyes”, “Ears”, and “Nose”. The assessment revealed the patient was a Diabetic (the body is no longer able to produce enough or not use insulin appropriately to maintain blood sugar levels), but failed to evidence if the patient took insulin, used a glucometer, or knew how to use a glucometer independently. The subsection titled “Skin color” was blank. 5. During an interview with the Administrator/CM on 08/11/2026 at 11:42 AM, they indicated all sections of the comprehensive assessment were supposed to be completed. They sections were completed by the boxes being marked or a comment made in the section.”

“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 had been notified of a discharge of services for 1 of 1 inactive clinical records reviewed involving a hospitalization transfer that had not been discharged. (Patients: #11) Findings Include: 1. A review of a revised May 2023 agency policy titled “ … When the patient’s plan of care changes and this change results in discharge or reduction of services, the patient or his/her representative, as well as his/her primary physician (or other authorized licensed independent practitioner), will be notified and involved … ” 2. A review of the inactive clinical record for Patient #11 contained a transfer summary dated 05/10/2026, signed by the Administrator/CM. The transfer summary noted Patient #11 had been admitted to Entity 3, an acute care facility, and Heritage Home Health would resume care post-hospitalization for SN three times a week for wound care, assessment, and education. A review of the Communication Notes contained entries dated 04/27/2026 through 05/12/2026. The communication note dated 05/12/2026 noted the agency had spoken to Entity 3’s charge nurse and Patient #11 had been admitted for altered mental status. The record failed to evidence any further follow-up on Patient #11 or any communication to Patient #11’s primary care provider of discharge of the agency’s services. During an interview on 08/11/2026 at 12:49 PM, when asked about Patient #11’s status and notification to the primary care provider, the Administrator/CM stated, “No, there is no communication note. I know [Patient #11] went to hospice after his hospital stay. No, there is no documentation of follow-up with the physician.” 410 IAC 17-13-1(a)(2)”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RNs completed wound measurements assessment timely for 2 of 3 active clinical records reviewed of patients receiving wound care. (Patients: #2 and 5) Findings Include: 1. A review of a revised May 2022 agency policy titled “Wound Care Procedure” indicated, but was not limited to, “To provide a process for assessing, documenting, and implementing a plan of care for wound care … 3. At least every 2 weeks, the wound assessment and documentation will include measurement of length, width, depth, and undermining and tunneling if present … ” 2. During the entrance conference on 08/07/2026 at 10:26 AM, when asked about the clinical documentation required for wound measurements and assessment, the Administrator/CM stated, “Wounds are to be measured weekly and assessed every visit. There is a wound care worksheet used in the EMR to review wound measurements and assessments.” 3. A review of the active clinical record for Patient #2 with a SOC date of 06/27/2026, contained a POC for the initial certification period 06/27/2026 through 08/25/2026. The POC noted Patient #2 had orders for SN to visit two times a week for 8 weeks for wound care to Patient#2’s right below-the-knee amputation stump, and for wound care to be performed one time a week by the wound clinic. SN to assess/evaluate wounds at each dressing change and as needed (PRN). A review of the initial comprehensive assessment dated 06/27/2026, contained wound measurements for Patient #2’s wound as 9 centimeters (cm) x 10 cm x 0.2 cm. A review of the SN visit notes evidenced the following: on 07/03/2026 and 07/06/2026 no wound measurements had been documented; on 07/10/2026 and 07/13/2026 no wound measurements had been documented; on 07/13/2026 and 07/17/2026 no wound measurements had been documented; on 07/23/2026 a Resumption of Care (ROC) Assessment had been completed with wound measurements 7cm x 5cm x 0.5 cm; on 07/27/2026 and 07/31/2026 no wound measurements had been completed; and on 08/03/2026 wound measurements 5 cm x 7 cm x 0.5 cm had been completed. The clinical record for Patient #2 failed to evidence the SNs had completed wound measurements and assessments every two weeks and/or weekly, as required. During an interview on 08/10/2026 at 2:17 PM, while observing RN 1 complete wound care for Patient #2’s right below-the-knee amputation stump, RN 1 was asked how often wounds were to be measured and how often documented measurements were required. RN 1 stated, “Wounds are to be measured every week. We notify the physician and wound clinics of any changes.” 4. A review of the active clinical record for Patient #5 with a SOC date of 01/14/2026, contained a POC for the recertification period 05/14/2026 through 07/12/2026. The POC noted Patient #5 had orders for SN two visits a week for 9 weeks for wound care to Patient#5’s right and left buttocks areas. SN to assess/evaluate wounds at each dressing change and as needed (PRN). A review of the SN notes evidenced the following: on 05/14/2026 and 05/18/2026 no wound measurements had been completed; on 05/21/2026 and 05/25/2026 no wound measurements had been completed; on 05/28/2026 and 06/01/2026 no wound measurements had been completed; on 06/04/2026 and 06/08/2026 no wound measurements had been completed; on 06/11/2026 and 06/15/2026 no wound measurements had been completed; on 06/18/2026 and 06/22/2026 no wound measurements had been completed; on 06/25/2026 and 06/29/2026 no wound measurements had been completed; on 07/02/2026 and 07/06/2026 no wound measurements had been completed; on 06/04/2026 and 06/08/2026 no wound measurements had been completed; A Recertification Assessment on 07/06/2026, completed by RN 2 indicated Patient #5 buttocks wounds were scattered no measurements had been completed of the multiple open areas. During an interview on 08/10/2026 at 10:00 AM, while observing RN 2 complete wound care to 3 open areas on Patient #5’s right buttock and 1 open area on the left buttock, RN 2 was asked how often wounds were to be measured and how often documented measurements were required. RN 2 stated, “We are to measure the wounds weekly and document the obtained measurements.” During an interview on 08/11/2026 at 11:46 AM, when asked for the location of the missing wound measurements for Patient #2 and Patient #5, the Administrator/CM and Corporate Staff 3, the Director of Compliance, stated wound measurements had not been completed, based on their review of the RNs’ clinical notes, They further confirmed wound measurements should be completed weekly as required by agency policy. 410 IAC 17-14-1(a)(1)(E)”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator was appointed by the governing body for 1 of 1 governing body. Findings Include: 1. A policy revised in 05/2022 and titled “Governing Body” indicated but was not limited to, “ … 8. The Governing Body will appoint a qualified Executive Director/Administrator …” 2. A review of the Governing Body meeting minutes dated 11/17/2025, 12/02/2025, and 05/14/2026 failed to evidence the Administrator was named and appointed by the governing body. 3. A review of the Administrator’s personnel file included their signed job description for Executive Director/Administrator on 11/19/2025. 4. During an interview with the Administrator on 08/07/2026 at 2:50 PM, they indicated the governing body meeting minutes had not named and appointed them as the Administrator. 410 IAC 17-12-1(b)(3)”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Alternate Administrator was appointed by the governing body for 1 of 1 governing body. Findings Include: 1. A review of the Governing Body meeting minutes dated 11/17/2025, 12/02/2025, and 05/14/2026 failed to evidence the Alternate Administrator was named and appointed by the governing body. The Governing Body meeting minutes dated 05/14/2026 evidenced the Vice President of Operations, but had appointed the Alternate Administrator 2. A review of the Vice President’s personnel file included their signed job description for Executive Director/Administrator on 11/19/2025. 3. During the entrance conference on 08/07/2026 at 10:20 AM, they indicated the Alternate Administrator was also the Alternate CM. During an interview with the Administrator on 08/07/2026 at 2:50 PM, they indicated the governing body meeting minutes had not named and appointed them as the Administrator. During an interview with the Administrator on 08/11/2026 AM, they indicated the Vice President of Operations was the acting Alternate Administrator, while the Alternate CM was being trained to take over as Alternate Administrator. They confirmed the governing body notes failed to list the Vice President of Operations as the Alternate Administrator. 410 IAC 17-12-1(d)(8)”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview the Governing Body failed to assume full responsibility for the parent agency and its branch, failed to evidence documentation of the relocation of the agency, and failed to address the existence of a branch office, for 1 of 1 home health agency. Findings include: 1. A review of an agency policy revised May 2022, titled ‘GOVERNING BODY Policy No. 1-002.1’ indicated, “… The Governing Body will assume full legal authority, responsibility, and decision-making and accountability for the overall management and operations … The Governing Body of [Entity A] will serve as the governing authority for the home care program … 20. All actions taken by the Governing Body will be documented in meeting minutes … Minutes will minimally include … summaries of agenda items and action taken, and motions documented as stated and acted upon …” 2. A review of the Governing Body’s annual meeting minutes for January 2023 and January 2024 failed to evidenced discussion of the agency’s relocation from Indianapolis to Greenwood, and failed to be specific regarding the agency’s organization and operations to include the Martinsville branch. 3. On 09-20-2024 at 10:18 AM, the Administrator indicated the Governing Body needed to have a separate meeting for the Martinsville branch. 410 IAC 17-12-1(b)(1)”

“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 all day-to-day operations of the Home Health Agency (HHA), delegating administrative responsibilities to other, non-contracted entities, for 1 of 1 home health agency. Findings include: 1. A review of an agency policy revised May 2022, titled ‘HOME HEALTH ADMINISTRATOR Policy no. 1-009.1’ indicated, “… 3. Responsibilities of the position will include but not be limited to: A. Planning, organizing, directing and evaluating operations … B. Ensuring organizational compliance with legal, regulatory … requirements …” 2. A review of an agency policy revised May 2022, titled ‘ADMINISTRATIVE QUALIFICATIONS AND RESPONSIBILITIES Policy No. 1-006.1’ indicated, “… Authority and responsibility for administrative positions will include supervision of contracted services and branches of the parent organization … 3. [Entity A] position descriptions will clearly define specific responsibilities and will include at least: … D. Compliance with applicable law and regulation …” 3. A review of an untitled agency document dated 04-23-2024, from Palmetto GBA, indicated a change of information request had been approved. The letter was addressed to Corporate Person A at the agency’s Greenwood address. 4. On 09-19-2024 at 9:40 AM, when queried as to the letter being addressed to Corporate Person A, the Administrator indicated they were the Corporate Compliance Officer and they handled communications with the State, etc., was not an employee of the agency, but was an employee of the ‘Home Office’ located in Ohio. 5. On 09-19-2024 at 1:10 PM, the Corporate Compliance person indicated they had been the one communicating with the State and attending to the State’s requests for the agency’s updated 855 form. Indicated they had also been the one to deal with the IRS (Internal Revenue Service) in order to obtain an updated 1575 form which would be needed to update the agency’s 855 form. The Corporate Compliance person further Indicated was listed as an “authorized person” and “delegated official” through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). The Corporate Compliance person further indicated received emails from the Indiana Department of Health (IDOH) and is aware the Administrator receives these emails as well. Indicated was not an employee of the agency but was employed by Entity A and was ‘support and guidance,’ indicated did not normally work out the Greenwood office, and indicated had no contract. 6. On 09-20-204 at 10:00 AM, the Administrator indicated the Home Office performed OASIS submission for the agency, did not believe there was a contract for this but would verify. 7. On 09-20-2024 at 10:05 AM, the Administrator indicated Entity A provides the agency with support, for example: Corporate Person A for compliance, QA (Quality Assurance) for medical record review and OASIS submission. Indicated there were no contracts in place with Entity A for these services. 410 IAC 17-12-1( c)(1)”

“Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the Parent office had direct oversight of the Branch office for 1 of 1 home health agencies. Findings include: 1. A review of a policy titled ‘GOVERNING BODY 1-002.1’ revealed, “…POLICY The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations …” 2. A review of a policy titled ‘BRANCH CONTROL 1-021.1’ revealed, “PURPOSE To ensure that administration, documentation, communication, coordination and retrieval of information at branch locations is treated in the same manner as that in the patent location … 7. … The parent organization will be responsible for … issues affecting the operation of a branch location. …” 3. On 09/19/2024 a visit was made to the branch office in Martinsville, IN. The office door was locked, and was not answered when knocked on. There was a sign on the door to call the main office number if assistance was needed. 4. On 09/20/2024 during a visit to the Branch office in Martinsville, IN, Administrative Staff 4 indicated they had gone to the Greenwood office on 09/19/2024 to pick up supplies, and the Administrator had asked Administrative Staff 4 to stay since surveyors were on site to assist with the survey process but is always there during business hours. 5. On 09/19/2024 when asked if the agency could separate their Martinsville Branch patients from the Parent, the Administrator indicated they would need to go through their census and figure out which ones are at the Martinsville Branch, all patients are grouped together, there are not identifiers to separate them out. 6. On 09/20/2024 the Administrator indicated they didn’t realize the Branch should be open during operating hours, indicated they had asked Administrative Staff 4 to stay at the Greenwood location on 09/19/2024 to assist with the survey, and didn’t realize they needed to have different identifiers for their Branch patients.”