Adoration Home Health

“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 record review, observation, and interview, the agency failed to ensure an infection control policy was implemented appropriately to prevent cross-contamination of equipment used and ensure safety of personnel and patients with proper hand hygiene for 5 of 5 home visits. (Patients #5, #6, #7, #9 and #11) Findings include: 2. During an observation on 09/09/2026 at 8:30 AM, ST 1 placed Patient #9’s admission folder on top of a clean opened plastic container that sat on a clean barrier with disinfected vital equipment (blood pressure cuff, oximeter, thermometer). ST 1 removed the admission folder from the top of the open plastic container, placed the vital equipment in the container, and returned the container to the therapy bag. ST 1 failed to disinfect the plastic container and vital equipment after removing the admission packet from the clean barrier area and before placing the items in the therapy bag. ST 1 handed Patient #9’s family member the electronic charting device to sign at the end of the visit. The family member signed the device and returned it to ST 1. ST 1 failed to disinfect the electronic charting device before and after the family member touched it. During an interview on 09/09/2026 at 8:30 AM, ST 1 indicated staff should clean equipment after use and should not place dirty items on a clean barrier with clean supplies. 4. During an observation on 09/09/2026 at 10:34 AM, PTA 1 placed two barriers on Patient #5’s counter, then placed the therapy bag in the middle of both barriers, causing the bag to touch both the clean and dirty barrier. 5. During an observation on 09/09/2026 at 12:45 PM, LPN 1 placed three barriers on Patient #7’s couch, overlapping all three, then placed the nursing bag, clipboard, and electronic charting device on the barriers. LPN 1 removed vital equipment from the nursing bag and placed it on the barrier next to the nursing bag, then used the vital equipment on Patient #7 and placed it back on the barriers. LPN 1 cleaned the equipment and placed it back on the barriers to dry. LPN 1 failed to prevent the three barriers from touching and failed to prevent clean equipment from touching the dirty barrier. LPN 1 gloved, took Patient #7’s temperature and oxygen reading, wrote the vitals in the admission packet, then placed the stethoscope around her neck; she placed the blood pressure cuff around Patient #7’s arm, removed the stethoscope from her neck, and used it on the patient. LPN 1 failed to perform hand hygiene before gloving, failed to remove gloves after touching the patient and before using the writing utensil to document vitals, and failed to clean the stethoscope before and after removing it from her neck and before and after using it on Patient #7. LPN 1 handed the electronic charting device to Patient #7; Patient #7 signed the device and returned it to LPN 1. LPN 1 failed to clean the electronic charting device before and after Patient #7 touched it. During an interview on 09/09/2026 at 12:45 PM, LPN 1 indicated staff should keep clean and dirty equipment and supplies separate. LPN 1 indicated staff should clean the stethoscope before and after using it on a patient. 7. During an interview on 09/10/2026 at 10:56 AM, the Administrator confirmed staff must clean the stethoscope before and after using it on a patient. He indicated staff should perform hand hygiene before gloving and that barriers should not touch, and therapy/nursing bags should not touch a clean barrier. 1.A review of Super Sani-Cloth Germicidal Disposable Wipes manufacturer’s guidelines and recommendations written on the package provided by OT 1, indicated “To achieve effective disinfection, hard non-porous surface must remain visibly wet for a full two (2) minutes, using additional wipes if necessary. Let air dry.” 3.During a home visit with Patient #6 on 09/27/2026 at 10:00 AM, OT 1 was observed disinfecting vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, and thermometer) after use with a Super Sani-Cloth Germicidal Disposable Wipe. OT 1 failed to ensure the surface of each piece of equipment remained wet for two (2) minutes then laid out to dry before returning to the nursing bag. An interview after the home visit indicated OT 1 was not aware of the proper use of the sanitation wipe being used. OT 1 said the equipment had to be cleaned thoroughly after use and put away but didn’t mention that each piece of equipment had to remain wet for 2 minutes and air dried. 6.During a home visit with Patient #11 on 09/09/2026 at 3:51 PM, RN 1 was observed disinfecting vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, and thermometer) after use with a Super Sani-Cloth Germicidal Disposable Wipe. RN 1 failed to ensure the surface of each piece of equipment remained wet for two (2) minutes before it was laid out to dry before returning to the nursing bag. An interview with RN 1 after the home visit indicated RN 1 was not aware of the proper use of the sanitation wipe being used. RN 1 said the equipment had to be cleaned completely with the wipe, laid out to dry before then it could be put away. RN 1 was not aware the equipment had to remain wet for two (2) minutes for appropriate disinfection. 410 IAC 17-12-1(m)”

“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 complete an initial assessment within 48 hours of a referral and failed to document the reason for the delayed start of care for 2 of 7 active record reviews. (Patients #9, #12 ) Findings include: 1. A review of Patient #9’s record included a Patient Information Report with a referral date of 07/10/2026 and a plan of care for certification dates 07/18/2026 to 09/15/2026. The plan of care indicated a start‑of‑care date of 07/18/2026. The agency failed to perform an initial assessment within 48 hours of receiving the referral. During an interview on 09/10/2026 at 11:21 AM, the Administrator reviewed Patient #9’s record and confirmed the referral date of 07/10/2026 and the start‑of‑service date of 07/18/2026. He indicated there was no documentation showing when the patient was discharged from the facility and confirmed the agency does initial assessment and SOC on the same date. 2. A review of Patient #12’s record included a Patient Information Report with a referral date of 07/14/2026 and a plan of care for certification dates 07/18/2026 to 09/15/2026. The plan of care indicated a start‑of‑care date of 07/18/2026. The agency failed to perform an initial assessment within 48 hours of receiving the referral. During an interview on 09/10/2026 at 11:21 AM, the Administrator reviewed Patient #12’s record and confirmed the referral date of 07/14/2026 and the start‑of‑service date of 07/18/2026. He indicated there was no documentation explaining the reason for the delayed start of care. 410 IAC 17-14-1(a)(1)(A)”

“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 obtain a signed POC or a detailed verbal POC order from the primary physician before providing services and treatments to patients for 3 of 7 active records reviewed with skilled nursing (Patient #9, #12, #14). Findings include: 1. A review of Patient #9’s record included a Home Health Certification and Plan of Care for certification period 07/18/2026 to 09/15/2026. The record showed the agency provided skilled nursing services on 07/18/2026, 07/23/2026, 07/30/2026, 08/06/2026, 08/13/2026, 08/19/2026, 08/25/2026, and 09/03/2026 without obtaining a completed detailed verbal order or a signed POC from the physician. During an interview on 09/11/2026 at 9:19 AM, the Administrator confirmed Patient #9 did not have a signed plan of care in the record or a completed detailed verbal order for the POC. 2. A review of Patient #12’s record included a Home Health Certification and Plan of Care for certification period 07/18/2026 to 09/15/2026. The record showed the agency provided skilled nursing services on 07/29/2026, 08/05/2026, 08/12/2026, 08/18/2026, 08/24/2026, and 09/02/2026 without obtaining a completed detailed verbal order or a signed POC from the physician During an interview on 09/11/2026 at 9:19 AM, the Administrator confirmed Patient #12 did not have a signed plan of care in the record or a completed detailed verbal order for the POC. 3. A review of Patient #14’s record included a Home Health Certification and Plan of Care for certification period 08/01/2026 to 09/29/2026. The record showed the agency provided skilled nursing services on 08/01/2026, 08/03/2026, 08/04/2026, 08/06/2026, and 08/10/2026 without obtaining a completed detailed verbal order or a signed POC from the physician. During an interview on 09/10/2026 at 11:21 AM, the Administrator confirmed Patient #14’s plan of care was signed on 08/12/2026 and indicated that if a completed detailed verbal order had been obtained, it would have been documented on the plan of care. 410 IAC 17-13-1(a”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to document all required components of a verbal order on 3 of 7 records reviewed with skilled nursing services (Patient #9, #12, #14 ). Findings include: 1. A review of Patient #9’s record includes a Home Health Certification and Plan of Care for certification period 07/18/2026 to 09/15/2026. The Orders of Discipline and Treatments failed to show the time the verbal order was obtained. 2. A review of Patient #12’s record includes a Home Health Certification and Plan of Care for certification period 07/18/2026 to 09/15/2026. The Orders of Discipline and Treatments failed to show who the nurse spoke with and failed to show the date and time the verbal order was obtained. 3. A review of Patient #14’s record includes a Home Health Certification and Plan of Care for certification period 07/18/2026 to 09/15/2026. The Orders of Discipline and Treatments failed to show who the nurse spoke with and failed to show the date and time the verbal order was obtained. 4. During an interview on 09/10/2026 at 11:21 AM, the Administrator indicated the detailed verbal order for start of care is located on the plan of care and appears as the first order under the section labeled “Orders of Discipline and Treatments.” 5. During an interview on 09/11/2026 at 9:05 AM, the Administrator indicated a verbal order must include the date and time the order was received, the provider, who received the order, and who gave the order. 6. During an interview on 09/11/2026 at 11:48 AM, the Director of Home Health Clinical Practice indicated all verbal orders on the plan of care should also be documented on the verbal order form, not solely on the plan of care. 410 IAC 17-13-1(a)(2)(H)”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received a visit schedule with frequency of visits and by what personnel for 5 of 5 home visits conducted (Patients #5, #6, #7, #9, and #11). Findings include: 1. During a home visit on 09/09/2026 at 8:30 AM, the Surveyor observed a blank calendar in Patient #9’s admission packet. During an interview on 09/09/2026 at 8:30 AM, ST 1 confirmed the calendar was blank. She indicated staff provide patients with the visit frequency but not the calendar, which she also confirmed was missing from the admission packet. 2. During a home visit on 09/09/2026 at 10:34 AM, the Surveyor observed a blank calendar in Patient #5’s admission packet. During an interview on 09/09/2026 at 10:34 AM, PTA 1 confirmed the calendar in the back of the admission packet was not filled out and that no visit frequency was in the home. She indicated staff do not normally fill out the calendars; the patient is normally informed at the end of the visit when the next visit will occur, and the patient is called the night before. 4. During a home visit on 09/09/2026 at 12:45 PM, the Surveyor observed a blank calendar in Patient #7’s admission packet. 7. During an interview on 09/10/2026 at 10:56 AM, the Administrator indicated staff are to fill in the calendars in the admission packets for every patient. 3.During the home visit with Patient #6 on 09/09/2026 at 11:43 AM, a review of the agency provided patient handbook/folder showed that it did not include a visit schedule or the clinicians responsible for delivering those services. During an interview after the visit, OT 1 indicated usually a day is established for the specific therapy to be provided but the policy says a call is made to confirm the time and day of the visit the evening before. There is a two-hour window given to allow for any problems that may arise to make the appointment which is discussed with the patient during admission and then again during the initial evaluation by therapy if a nurse does SOC. OT 1 reported no schedule is given ahead of time for visits for any period of time during the cert period. 5.During the home visit with Patient #11 on 09/09/2026 at 3:43 PM, a review of the agency provided patient handbook/folder showed that it did not include a visit schedule, the services to be provided, or the clinicians responsible for delivering those services. During an interview after the visit, RN 1 indicated he/she was not sure why the information was not in the folder. RN 1 indicated it was done before the patient was put on his/her caseload and he/she had only been with the agency a short period of time, but he/she would check with office to find out why it wasn’t in the home. 6. During an interview on 09/10/2026 at 11:10 AM, the Administrator indicated the paperwork provided to the patient during admission should be completed and left with the patient that showed the services the agency plans to provide and there is a blank schedule that should be completed by clinicians to show when visits have been planned and by which clinician.”

“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 observation, record review, and interview, the agency failed to ensure staff reviewed patient medications during home visits for 1 of 1 observed PTA home visit (Patient #5) and 1 of 1 observed LPN home visit (Patient #7). Findings include: 1. During an observation on 09/09/2026 at 10:34 AM, the Surveyor reviewed medications in Patient #5’s home with PTA 1; Loperamide HCL was found in the home, but the medication was not listed on Patient #5’s medication list A review of Patient #5’s record failed to evidence Loperamide HCL (antidiarrheal) on the Patient #5’s Plan of Care, medication list or new physician orders. During an interview on 09/09/2026 at 10:34 AM, PTA 1 confirmed with Patient #5 that they currently use Loperamide. PTA 1 confirmed the medication was not on the medication list. During an interview on 09/09/2026 at 10:34 AM, the Patient indicated they have been taking Loperamide for several years and that it is not a scheduled medication, stating they only take it when needed. 2. During an observation on 09/09/2026 at 12:45 PM, the Surveyor observed a Home Health Medication Sheet Addendum in Patient #7’s admission packet indicating that on 09/08/2026, Haloperidol, Lansoprazole, Ipratropium Albuterol, and Albuterol Sulfate were added to the home medication list. During the observation, LPN 1 was unable to locate Haloperidol, Ipratropium Albuterol, or Albuterol Sulfate in the home. LPN 1 located Lansoprazole, which had an expiration date of 08/2026. A review of Patient #7’s record failed to evidence Haloperidol (treats nervous, emotional, and mental conditions), Lansoprazole (duodenal and gastric ulcers), Ipratropium Albuterol (controls symptoms of lung diseases), and Albuterol Sulfate (treats or prevents bronchospasm) were added to the patient’s medication list. During an interview on 09/09/2026 at 12:45 PM, LPN 1 indicated Patient #7 had a therapy visit on 09/08/2026 and the medication list was updated at that time. She did not have an explanation for why the medications were not in the home. 3. During an interview on 09/10/2026 at 8:35 AM, the Administrator indicated staff are to check medications during every visit, including reviewing bottles in the home. He stated the agency policy requires medication reconciliation to occur on an ongoing basis.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a verified discharge summary was sent to the physician within 5 days for 2 of 4 closed records reviewed (Patients #1 and #3). Findings include: 1. A review of Patient #1’s record showed a coordination note dated 08/07/2026 with a note type of HH Discharge Summary. The Event‑Stage History Report indicated the discharge summary was sent on 08/18/2026. The agency failed to send the discharge summary within 5 days of the patient’s discharge from the facility. During an interview on 09/10/2026 at 11:21 AM, the Administrator confirmed Patient #1 was discharged on 08/07/2026 and provided the Event‑Stage History Report for Patient #1. He confirmed the Episode Summary Report was sent on 08/18/2026. The Administrator indicated he was not aware the discharge summary had to be completed within 5 days of discharge. 2. A review of Patient #3’s record showed a coordination note dated 08/19/2026 with a note type of HH Discharge Summary. The Event‑Stage History Report indicated the Episode Summary Report was sent on 09/08/2026. The agency failed to send the discharge summary within 5 days of the patient’s discharge from the facility. During an interview on 09/10/2026 at 11:21 AM, the Administrator confirmed the discharge summary was sent to the physician on 09/08/2026, not within the required 5 days. 410 IAC 17-15-1(a)(6)”