Caretenders

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to advise the patient nor the physician that a discharge for cause was being considered (see G464) and failed to immediately report potential neglect and unsanitary living conditions to Adult Protective Services (see G488). The cumulative effects of these systemic issues evidenced the agency failed to promote and protect all patient rights, which resulted in the agency being found out of compliance with Condition of Participation 42 CFR 484.50 Patient rights.”

“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 observation, record review, and interview, the home health agency failed to ensure all POCs were individualized to include patient-specific outcomes, goals, and interventions which addressed all patient needs (see G572), failed to include all medications on the POC (see G574),failed to perform wound care only according to physician order (see G580), failed to notify the physician of a patient fall, positive test result for urinary tract infection, and an increase in wound size (see G590), failed to ensure the revised POC included information from the patient’s updated comprehensive assessment and the patient’s progress towards his/her goals (see G592), failed to coordinate care with all outside entities providing in-home services (see G606), and failed to notify patients of the name and contact information of the clinical manager (see G622). The cumulative effect of these systemic issues evidenced the agency failed to care plan, coordinate services, and provide quality care to all patients, which resulted in the agency being found out of compliance with Condition of Participation 42 CFR 484.60 Care planning, coordination of services, and quality of care. Additional findings include: Based on observation, record review, and interview, the home health agency failed to meet all patients SN, HHA, and OT needs for 2 of 4 home visit observations (Patient #3, #4) and 4 of 7 active records reviewed (Patient #3, #4, #5, #6) Findings include: 4. Patient #6’s clinical record indicated a SOC date of 10/02/2024. The patient was admitted to the agency after suffering a heart attack and residing in a rehabilitation facility for three weeks. The patient’s other diagnoses included Type 2 diabetes, chronic respiratory failure, morbid obesity, high blood pressure, and dependence on oxygen. A PT SOC evaluation, dated 10/02/2024, indicated Patient was unable to use the toilet or shower due to Patient weighing 482 pounds. The patient would stand to have a bowel movement. Patient’s spouse would assist him/her with all ADLs, including performing a bed bath. The patient had a chronic urinary catheter which required monthly trips to the Emergency Department (ED) to be changed. Patient also had “open areas” to the buttocks, however these were not assessed during the SOC visit. The record failed to evidence Former Employee E offered HHA services to assist with ADL care at SOC. An OT evaluation visit, dated 10/03/2024, indicated Patient required moderate to maximum assistance with ADLs including dressing, grooming, hygiene, toileting, and bathing. The patient’s concerns were “limited standing tolerance/balance, [bilateral lower extremity] weakness, limited ability to ambulate, and difficulty with trunk transfers.” The record failed to evidence Former Employee F offered OT or HHA services to assist with ADL care. A POC for the initial certification period of 10/02/2024 – 11/30/2024 indicated the agency would provide PT visits once per week for five weeks then once every two weeks for four weeks and OT visits once per week for five weeks. The POC indicated PT interventions included training on bed mobility, safe transfers, and gait training, and OT interventions included instructing on safe transfers, pain control measures, energy conservation, balance training, management of diabetes, and oxygen therapy. Two COTA visits were conducted on 10/08/2024 and 10/15/2024. The visit notes indicated OT interventions included upper extremity strengthening exercises and education according to the POC. The visit notes failed to evidence the COTA offered and/or assisted Patient with completing ADL tasks during the visits. The record indicated Patient was admitted to the hospital on 10/22/2024 for altered mental status, urinary tract infection (UTI), and increased carbon dioxide levels. A PT ROC assessment was completed on 11/01/2024 by Former Employee E. The visit indicated Patient reported “increased weakness and fatigue affecting [his/her] functional mobility” and required “substantial/maximal assistance” with bathing, dressing, and toileting. The record included a verbal order, dated 11/01/2024, to conduct an OT evaluation. The record failed to evidence Former Employee E offered HHA services to assist with ADL care and failed to evidence an OT re-assessment was conducted after the patient’s return home from the hospital. The record indicated Patient was admitted to the hospital on 12/03/2024 for bronchitis, pneumonia, and COVID-19. The patient was transferred to a rehabilitation facility then was discharged home on 01/24/2025. A RN assessment was completed on 01/28/2025, which indicated the patient weighed 527 pounds and required assistance with all ADLs. The patient had two Stage 2 pressure ulcers (wound caused by prolonged pressure to a bony area), one to the right upper posterior thigh measuring 2 centimeters (cm) in length by 2 cm in width by 0 cm in depth (2 cm x 2 cm x 0 cm), and the other to the left upper posterior thigh measuring 0.5 cm x 0.5 cm x 0.2 cm. Alternate CM documented the agency would conduct PT and OT evaluations, however the record failed to evidence an OT evaluation was conducted. The record also failed to evidence Alternate CM offered HHA services to assist with ADL care. A POC for the recertification period of 01/30/2025 – 03/30/2025 indicated the agency would provide SN visits once per week for eight weeks with interventions to include performing wound care to Patient’s pressure ulcer wounds and changing Patient’s chronic urinary catheter once per month. The record evidenced the agency continued to provide SN visits once per week until the recertification period of 09/27/2025 – 11/25/2025, at which time the SN visit frequency was decreased to one visit every two weeks for two weeks, one visit every four weeks for four weeks, then one visit every three weeks for three weeks. The POC indicated SN interventions included performing wound care to Patient’s pressure ulcer wounds and changing Patient’s chronic urinary catheter once per month. PT services were continued from 01/30/2025 – 11/04/2025, at which time PT services were discontinued to due to “no progress and not participating in exercise regimen on non visit days to ensure progress.” A SN visit note, dated 10/07/2025, indicated RN 4 noted Patient’s home was cluttered with walkways obstructed “posing a fall risk.” The patient’s bed and recliner had soiled sheets. A SN visit note, dated 11/04/2025, indicated Patient’s urine was cloudy, dark, concentrated, and had a foul odor. A urine sample was obtained and laboratory results evidenced Patient tested positive for a UTI. Patient was started on Bactrim (an antibiotic). A PT visit note, dated 11/10/2025, indicated Patient was able to stand continuously for 10 minutes, however this was “very challenging for Patient.” PTA 2 documented Patient had not met all goals. The record indicated Patient missed his/her discharge PT visit on 11/24/2025 and no further PT visits were conducted. A SN recertification note, dated 11/24/2025, indicated RN 4 noted Patient appeared disheveled and the home conditions were “unsafe/unsanitary.” Patient required assistance with dressing, bathing, and toileting. The record failed to evidence agency staff offered HHA nor OT services during the certification period to assist with ADL care and failed to evidence the agency modified Patient’s POC to include interventions to address the patient’s risk for UTI. A POC for the recertification period of 11/26/2025 – 01/24/2026 indicated a SN visit frequency of once per week for one week, once every five weeks for five weeks, then once every two weeks for two weeks. The patient continued to have Stage 2 pressure ulcers to the right upper posterior thigh and left upper posterior thigh which required daily wound care. A SN visit note, dated 12/02/2025, indicated RN 4 noted Patient’s home “remains cluttered with strong garbage odor present.” A SN visit note, dated 01/07/2026, indicated RN 4 noted Patient’s home was cluttered and the cushion in Patient’s recliner was “stained with urine.” RN 4 also noted Patient had “poor hygiene.” A Coordination Note, dated 01/20/2026, indicated Patient called the agency after-hours to report signs and symptoms of a potential UTI, including abdominal pain, bladder pain, and dark cloudy red urine with sediment. A SN recertification note, dated 01/21/2026, indicated RN 4 noted Patient’s home was cluttered. Patient was noted to have a “poor appearance (i.e poor hygiene, disheveled)” and “unsafe/unsanitary home conditions.” Patient continued to require assistance with ADLs, including dressing, bathing, and toileting. Patient’s urine was cloudy and blue-tinted. Patient complained of bladder spasms, urine leaking around the catheter, and lower abdominal pain. A urine sample was obtained and laboratory results evidenced Patient tested positive for a UTI. Patient was started on a 10-day course of Bactrim. The record failed to evidence agency staff offered HHA nor OT services during the certification period to assist with ADL care and failed to evidence the agency modified Patient’s POC to include interventions to address the patient’s risk for UTI. A POC for the recertification period of 01/25/2026 – 03/25/2026 indicated a SN visit frequency of once per week for one week, once every four weeks for four weeks, then once every three weeks for three weeks. The patient continued to have Stage 2 pressure ulcers to the right upper posterior thigh and left upper posterior thigh which required daily wound care. A SN visit note, dated 02/05/2026, indicated Patient’s right posterior thigh wound measured 0.2 cm x 0.2 cm x 0 cm. The record failed to evidence further wound assessments were conducted during the certification period. A SN visit note, dated 03/04/2026, indicated Patient’s urine was dark and concentrated. A urine sample was obtained during the visit and laboratory results evidenced Patient tested positive for a UTI. On 03/13/2026, Patient was started on a 10-day course of Bactrim. A SN recertification note, dated 03/23/2026, indicated RN 4 noted Patient’s home was cluttered, Patient had “poor personal hygiene,” and Patient was wearing soiled shorts. The patient’s home was described as “unsafe/unsanitary.” Patient continued to require assistance with ADLs, including dressing, bathing, and toileting. The record failed to evidence agency staff offered HHA nor OT services during the certification period to assist with ADL care and failed to evidence the agency modified Patient’s POC to include interventions to address the patient’s risk for UTI. A POC for the recertification period of 03/26/2026 – 05/24/2026 indicated a SN visit frequency of once every two weeks for two weeks, once every four weeks for four weeks, and once every two weeks for two weeks. The patient continued to have Stage 2 pressure ulcers to the right posterior thigh and left posterior thigh requiring daily wound care. A SN visit note, dated 04/09/2026, indicated Patient’s right posterior thigh wound measured 2 cm x 2 cm x 0.1 cm, an increase of 1.8 cm in length and width from the last date of measurement (2/05/2026). The visit note also indicated Patient reported intermittent sharp abdominal pain and Patient thought he/she had another UTI. A SN visit note, dated 04/16/2026, indicated RN 4 noted Patient’s home was cluttered with a “strong odor of pet urine” and Patient appeared disheveled. Patient’s urine was dark, concentrated, and had a foul odor. Patient complained of right upper quadrant abdominal pain. A urine sample was obtained during the visit and laboratory results evidenced Patient tested positive for a UTI. The record failed to evidence Patient was started on any treatment for the UTI, including an antibiotic. A SN visit note, dated 05/06/2026, indicated Patient’s urine continued to be dark and concentrated. RN 4 noted Patient appeared disheveled and “in need of a shower.” Patient’s home was cluttered and there was a strong odor of garbage. A SN recertification note, dated 05/20/2026. indicated Patient’s urine continued to be dark and concentrated. RN 4 noted Patient’s home was cluttered and Patient appeared disheveled. Patient continued to require assistance with ADLs, including dressing, bathing, and toileting. The record failed to evidence agency staff offered HHA nor OT services during the certification period to assist with ADL care and failed to evidence the agency modified Patient’s POC to include interventions to address the patient’s risk for UTI. A POC for the recertification period of 05/25/2026 – 07/23/2026 indicated a SN visit frequency of once a week for one week, once every four weeks for four weeks, and once every three weeks for three weeks. The patient continued to have Stage 2 pressure ulcers to the right posterior thigh and left posterior thigh requiring daily wound care. A SN visit note, dated 06/03/2026, indicated RN 4 noted Patient appeared disheveled and had a “strong body odor present.” The home was cluttered with a strong pet odor. Patient’s urine was cloudy and had a foul odor. Patient reported having intermittent abdominal pain for a few days. The agency obtained an order to draw a urine analysis and culture on 06/12/2026, however the record failed to evidence the urine sample was collected until 06/17/2026. A SN visit note, dated 06/17/2026, indicated Patient’s urine continued to be cloudy and had a foul odor. RN 4 noted Patient appeared disheveled and “in need of a shower.” The home was cluttered with a strong odor of garbage. A review of the record on 6/19/2026 failed to evidence the agency had received results of the 06/17/2026 urine tests, failed to evidence agency staff offered HHA nor OT services during the certification period to assist with ADL care, and failed to evidence the agency modified Patient’s POC to include interventions to address the patient’s risk for UTI. Patient #6 declined to be interviewed on 06/22/2026 at 11:09 AM. During an interview on 06/22/2026 beginning at 12:25 PM, PT 1 reported Patient was “in a very unhygienic situation,” including having a smell of urine in the home. PT 1 stated Patient’s 10-year-old child was the primary caretaker and agency staff thought this was concerning, as the child was doing “more than a child should be doing.” PT 1 reported Patient’s poor hygiene was a concern and Patient would often be found with dirty, stained pants. The PT reported the agency did not have an aide to assist with ADL care and OT services were discontinued due to the patient not having OT needs. PT 1 also reported Patient was able to perform ADLs independently despite the record evidencing Patient required assistance with ADLs. During an interview on 06/22/2026 beginning at 1:02 PM, PTA 2 reported Patient often had an odor during the PTA’s visits and Patient’s spouse assisted with all ADLs. PTA 2 reported Patient also had a teenage child who would assist with ADLs when the spouse was not available. The PTA reported the agency did not have HHAs available to assist with ADLs. PTA 2 reported Patient was discharged from PT services due to being non-compliant with performing exercises and not progressing towards goals. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported Alternate CM and RN 4 were not available for interview. When asked how the agency helped meet Patient’s ADL needs, CM reported Patient initially had OT services at SOC, but she was unsure of the reason OT services were not resumed after Patient’s first hospitalization. CM was unsure of the reason Patient’s SN visit frequency was decreased and reported the agency should increase the visit frequency if the patient began to have complications with the urinary catheter, such as UTIs. CM was unsure if the agency had performed to address Patient’s increased frequency of UTIs. CM was unsure if Patient’s positive urine cultures from 04/16/2026 were reported to the MD or if any treatment was ordered for the UTI. CM stated concerns regarding Patient’s unsanitary home conditions should be reported to Patient’s physician but was unsure if this had been done. No further evidence was provided prior to survey exit. 6. Patient #4’s clinical record evidenced a SOC date of 5/28/2026. A SOC RN visit, dated 05/28/2026, indicated Person B, caregiver to Patient, reported Patient “has been in decline with activity and is largely bedbound or chair fast since [his/her] hospitalization.” Patient lived alone and Alternate CM noted Patient “should probably have 24 hour care.” The nurse indicated Patient required “substantial/maximal assistance” with all ADLs, including bathing, dressing, eating, toileting, transferring, and mobility. The record failed to evidence Alternate CM offered HHA services to assist with ADL care at SOC. A PT evaluation visit, dated 6/02/2026, indicated Patient lived alone and required assistance from a caregiver for ADLs and self-care. Patient was unable to ambulate during the visit. The record failed to evidence PT 1 offered HHA services to assist with ADL care. An OT evaluation visit, dated 06/02/2026, indicated Patient required maximum assistance with dressing, bathing, and toileting. OT 1 documented the agency would assist with “ADL function” including lower body bathing and upper body dressing, however the POC failed to evidence interventions to perform ADL care during visits. The record failed to evidence OT 1 offered HHA services to assist with ADL care. A POC for the initial certification period of 05/28/2026 – 7/26/2026 indicated OT interventions included ADL training for Patient and/or their caregiver for dressing, bathing, and toileting. The record failed to evidence interventions for the OT to assist Patient with performing ADL care. A PT visit note, dated 6/15/2026, indicated Patient’s family was looking into placing Patient into a skilled nursing facility “for extensive rehab.” A home visit observation with Patient #2 and COTA 2 was conducted on 6/18/2026 beginning at 10:08 AM. During the visit, COTA 2 failed to offer to assist Patient with ADLs nor perform ADL training. During an interview on 6/15/2026 beginning at 11:13 AM, COTA 2 reported she had not assisted a patient with performing ADLs “for awhile.” The COTA reported if the patient required assistance with ADLs, she would focus on performing the tasks “with clothes on.” During an interview on 6/15/2026 beginning at 11:17 AM, Person B reported he/she was a hired caregiver from Entity G, a PSA, and provided assistance with Patient’s ADLs. The caregiver was unsure if the agency had offered HHA services to assist with ADLs. During an interview on 6/24/2026 beginning at 10:32 AM, PT 1 reported Person B assisted Patient with all their ADLs. The therapist reported he did not offer HHA services to Patient through the agency. During an interview on 06/24/2026 beginning at 10:47 AM, OT 1 reported Patient required maximum assistance with all ADLs. The therapist reported Patient had been declining and Patient’s family was trying to get him/her into a residential facility for more assistance. OT 1 reported he did not offer HHA services as the agency did not have HHAs on staff. OT 1 reported he did offer OT services to assist with “lower body bathing,” however the record failed to evidence this was included in the POC’s OT interventions. 1. The agency’s admission policy stated that a patient would not be admitted unless appropriate staffing was available to meet the patient’s needs. The policy also stated that if the agency was unable to meet a patient’s needs, the patient would be referred to another agency. 2. At the entrance conference on 06/16/2026 at 09:15 AM, the Business Office Manager stated the agency intended to provide aide services, but the aide position had been vacant for over a year. The agency indicated the SN or OTA could assist with activities of daily living needs. Although the agency reported they were recruiting for an aide, they could not provide evidence of any job postings on their website or on two job search platforms. 3. During an interview on 06/24/2026 at 10:45 AM, the Business Office Manager provided employment information for Person C, a home health aide. Records showed Person C completed 18 aide visits for four patients between 04/18/2024 and 07/16/2024. The Business Office Manager reported 7/16/2024 was the last HHA visit conducted by the agency. 5. Patient #3’s clinical record identified Person A as the caregiver. At admission, Patient #3 had a fractured upper arm and required maximum assistance with lower‑body dressing, bathing, and toileting per the OT evaluation on 06/01/2026. The patient experienced falls on 06/06/2026 and 06/10/2026, requiring paramedic assistance both times because Person A was unable to lift the patient. Person A reported the 06/10/2026 fall occurred while attempting to transfer Patient #3 into the shower and stated they were uncomfortable providing shower assistance. The record failed to evidence the agency offered HHA services or OT services to assist Patient #3 and Person A with performing ADLs. The agency failed to ensure Patient #3’s care needs were met. A home visit observation occurred on 06/18/2026 at 10:15 AM. During the visit, Person A reported that Patient #3 required assistance from a home health aide for showering and dressing. Person A stated the agency did not provide an aide and that they had to pay out of pocket for a caregiver. Immediately after the visit, on 06/18/2026, PTA 1 was interviewed and stated the agency did not offer home health aide services. PTA 1 indicated she had worked for the agency for two years and that no aides had been employed during that time. 7. Patient #5’s clinical record contained a referral for home health care dated 06/15/2026 and signed by Person D, a physician. The referral included orders stating that nursing services were medically necessary. However, the record did not contain a nursing assessment to determine and plan for Patient #5’s nursing needs. The agency failed to meet Patient #5’s needs. During an interview on 06/22/2026 at 09:20 AM, OT 1 stated that Patient #5 did not have a nursing assessment and was receiving only OT and PT services. During an interview later that day at 3:45 PM, the administrator confirmed a nursing assessment should have been completed. 410 IAC 17-13-1(a)”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to include strategies for addressing emergencies identified on the risk assessment for 1 of 1 agency. Findings include: The agency’s emergency preparedness binder failed to include strategies for addressing the hazards identified in its hazard vulnerability assessment. The administrator provided a separate document that outlined definitions for various types of weather warnings; however, these definitions did not specify the actions employees should take during severe weather events. The agency failed to include strategies for addressing hazards in their emergency plan. During an interview on 06/23/2026 beginning at 12:20 PM, the administrator confirmed that the binder lacked guidance on the steps employees should follow in specific emergencies. The administrator acknowledged that the document containing weather warning definitions did not include instructions for employee response during severe weather situations.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to document attempts to contact emergency officials to perform cooperation and collaboration planning activities for 1 of 1 agency. Findings include: The agency’s emergency preparedness binder failed to evidence documentation of attempts to engage in collaborative planning with emergency officials. During an interview on 06/23/2026 beginning at 12:20 PM, the administrator indicated the agency did not have any documentation of attempts to collaborate with emergency officials.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency plan included patient specific plans that were complete and legible for 1 of 1 agency emergency plan. Findings include: 1. The agency’s emergency preparedness binder included Patient #15’s emergency plan. The plan was a poor-quality copy and was illegible. 2. Patient #16’s emergency plan failed to include the priority level for care, method of transportation, ambulatory status, and level of assistance needed. The agency failed to include a complete emergency plan for Patient #16. 3. Patient #17’s emergency plan failed to include the priority level for care, method of transportation, ambulatory status, and level of assistance needed. The agency failed to include a complete emergency plan for Patient #17. 4. Patient #18’s emergency plan was very dark and was unreadable. The agency failed to include a readable emergency plan for Patient #18. 5. The handwriting on Patient #19’s emergency plan was illegible. The agency failed to include a legible emergency plan for Patient #19. 6. During an interview on 06/23/2026 beginning at 12:20 PM, the administrator indicated the identified patient emergency plans were incomplete or illegible. She indicated the plans should be clear, complete, and legible.”

“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 28 OASIS assessments within 30 days of the assessment for 1 of 1 agency. Findings include: The agency’s iQIES (Internet Quality Improvement and Evaluation System) report for OASIS submissions identified 28 assessments that were submitted more than 30 days after the assessment date during calendar year 2025. The agency failed to submit OASIS assessments within 30 days of the assessment. On 06/24/2026, the agency provided its OASIS error report for 2025. This report documented 28 submissions that exceeded the 30‑day submission requirement. During an interview conducted on 06/22/2026 beginning at 11:10 AM, the administrator stated that OASIS assessments were automatically submitted upon completion. When questioned regarding the late submissions, the administrator indicated they were likely from errors that required correction by the agency prior to successful submission.”

“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 home health agency failed to ensure the comprehensive assessment was updated at recertification to include the patient’s current wound status for 1 of 1 record reviewed of a patient with a wound (Patient #6). Findings include: 1.Patient #6’s clinical record indicated a SOC date of 10/02/2024. An RN assessment was completed on 01/28/2025, which indicated Patient had two Stage 2 pressure ulcers (wound caused by prolonged pressure to a bony area), one to the right upper posterior thigh measuring 2 centimeters (cm) in length by 2 cm in width by 0 cm in depth (2 cm x 2 cm x 0 cm), and the other to the left upper posterior thigh measuring 0.5 cm x 0.5 cm x 0.2 cm. A POC for the recertification period of 01/30/2025 – 03/30/2025 indicated the agency would provide SN services with interventions to include performing wound care to Patient’s pressure ulcer wounds. Wound care to be performed daily included cleansing the area and applying Calazine (a medicated cream). A POC for the recertification period of 03/26/2026 – 05/24/2026 indicated a SN visit frequency of once every two weeks for two weeks, once every four weeks for four weeks, and once every two weeks for two weeks. Patient continued to have Stage 2 pressure ulcers to the right posterior thigh and left posterior thigh requiring the same daily wound care. A SN recertification note, dated 05/20/2026, failed to evidence Patient’s pressure ulcer wounds were assessed during the recertification visit. RN 4 marked the reason the wounds were not assessed as “Caregiver completed care.” 2. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported RN 4 was not available for interview. CM stated all wounds should be assessed during the SN recertification visit. CM also stated the caregiver already providing care was not an appropriate reason for the nurse to skip the wound assessment since the agency was only seeing the patient every two to four weeks. 410 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 home health agency failed to ensure all POCs were individualized to include patient-specific outcomes, goals, and interventions which addressed all patient needs for 4 of 7 active records reviewed (Patient #1, #2, #6, #7). 2. Patient #2’s clinical record indicated a SOC date of 08/16/2023. Patient’s diagnoses included a history of urinary tract infection (UTI). An RN SOC assessment, completed on 08/16/2023, indicated Patient had a chronic urinary catheter. Review of POCs for the recertification periods 04/02/2026 – 5/31/2026 and 06/01/2026 – 07/30/2026 failed to evidence patient-specific interventions to address Patient’s risk of developing a UTI. The POCs included the same interventions and goals to address the problems of edema (swelling), dietary restrictions, pain control, home safety, fall risk, prevention of pressure ulcers, and diabetic foot care. The agency failed to individualize and modify interventions and goals between certification periods to adjust for goals met or not met. During an interview on 06/22/2026 beginning at 2:26 PM, RN 2 reported Patient was primarily on services for urinary catheter changes and all other goals and interventions were carried over between certification periods to “re-educate” Patient and his/her caregivers. 3. Patient #6’s clinical record indicated a SOC date of 10/02/2024. An RN assessment, completed on 01/28/2025, indicated Patient had a chronic urinary catheter. SN visit notes on 11/04/2025, 01/21/2026, 03/04/2026, 04/16/2026, and 06/03/2026 evidenced Patient developed signs and symptoms of a urinary tract infection. Each of these infections fell during a different recertification period. Review of the POCs for the recertification periods of 09/27/2025 – 11/25/2025, 11/26/2025 – 01/24/2026, 01/25/2026 – 03/25/2026, 03/26/2026 – 05/24/2026, and 05/25/2026 – 07/23/2026 failed to evidence patient-specific interventions and goals to address Patient’s high risk of UTI. The POC for the above certification periods also included the same interventions and goals to address the problems of depression, heart failure, edema, diabetes, pressure ulcer prevention, pain management, home safety, and fall risk. The agency failed to individualize and modify interventions and goals between certification periods to adjust for goals met or not met. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported RN 4 was not available for interview. CM reported the POCs failed to evidence interventions to address Patient’s high risk for developing UTIs. CM also reported it was “difficult” to modify interventions between certification periods, as the agency “had to provide something to teach on.” 1. Patient #1’s clinical record evidenced a POC for certification period 06/01/2026 – 07/30/2026, which included a generic non- specific goal that stated, “Patient’s complications will resolve promptly with implementation of prescribed interventions through the end of episode.” The RN failed to ensure the POC included individualized and patient – specific goals. During an interview on 06/23/2026 beginning at 11:00 AM, RN 2 indicated the generic goal was to address any issue on the POC that was not related to a specific diagnosis or problem. 4. Patient #7’s clinical record evidenced a POC for certification period 04/26/2026 – 06/18/2026, included a generic non- specific goal which stated, “Patient’s complications will resolve promptly with implementation of prescribed interventions through the end of episode.” The RN failed to ensure the POC included individualized and patient – specific goals. During an interview on 06/23/2026 beginning at 11:00 AM, RN 2 indicated the generic goal was to address any issue on the POC that was not related to a specific diagnosis or problem. 410 IAC 17-13-1(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, record review and interview, the agency failed to ensure employees followed hand hygiene and bag technique procedures to reduce the risk of cross- contamination during 3 of 4 home visit observations (Patients #2, 4, and 5). Findings include: 3. During a home visit observation with Patient #2 on 06/18/2026 beginning at 7:32 AM, RN 1 failed to perform hand hygiene after removing gloves on one occasion. During an interview on 06/18/2026 beginning at 8:16 AM, RN 1 reported she should perform hand hygiene after removing gloves. 4. During a home visit observation with Patient #4 on 06/18/2026 beginning at 10:08 AM, COTA 2 failed to perform hand hygiene prior to donning gloves on two occasions. The COTA also failed to perform hand hygiene after removing gloves on one occasion. During an interview on 06/18/2026 beginning at 11:13 AM, COTA 2 reported she should perform hand hygiene prior to donning and after removing gloves. 1. The agency’s hand hygiene policy stated that hand hygiene (handwashing or use of an alcohol‑based hand sanitizer) must be performed before direct contact with a patient, before donning gloves and after removing gloves, prior to entering the home bag, and at the conclusion of the visit. 2. The agency’s bag‑technique policy outlined requirements for the use of the home bag, which is used to store equipment and supplies for home visits. The policy stated that employees must perform hand hygiene before removing items from or returning items to the bag. Employees must not wear gloves when entering the bag. The bag must remain zipped closed when not in use. Equipment must be disinfected and allowed to air dry prior to being returned to the bag. X. A home visit observation was conducted on 06/22/2026 beginning at 9:20 AM with Patient #5. OT 1 performed an initial occupational therapy evaluation. During the observation, OT 1 failed to perform hand hygiene prior to glove changes. OT 1 also failed to follow bag‑technique requirements by entering the home bag while wearing gloves, failing to zip the bag closed after use, and failing to keep clean and dirty equipment on separate barriers. OT 1 failed to follow accepted hand hygiene and bag technique practices to reduce the risk of infection. During an interview immediately following the visit, OT 1 stated he should have closed the work bag after using it. He acknowledged that hand hygiene and glove changes are required between each task. OT 1 stated he was unaware he had not used hand sanitizer before donning gloves. He confirmed that hand hygiene is required prior to entering the work bag and that gloves must not be worn when entering the bag. OT 1 also stated he should have placed dirty equipment on a separate barrier from clean equipment. 410 IAC 17-12-1(m)”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to advise the patient nor the physician that a discharge for cause was being considered for 1 of 1 closed record reviewed of a patient discharged for cause (Patient #9). Findings include: 1.Patient #9’s clinical record indicated a SOC date of 02/19/2026. A POC for the recertification period of 04/20/2026 – 06/18/2026 evidenced Patient was to receive SN and PT services. Patient’s diagnoses included alcohol cirrhosis of the liver, major depression, Type 2 diabetes, heart failure, hepatic encephalopathy (worsening of brain function due to liver disease), Chronic Obstructive Pulmonary Disease (COPD), and Post Traumatic Stress Disorder (PTSD). SN interventions included filling Patient’s pill tray. An order to conduct an OT evaluation was obtained on 05/27/2026. During the certification period, the agency conducted eight SN visits (04/20/2026, 04/27/2026, 05/06/2026, 05/15/2026, 05/20/2026, 05/27/2026, 06/01/2026, and 06/10/2026), two PT visits (04/24/2026, 05/14/2026), and one OT visit 05/20/2026). Four PT visits (04/30/2026, 05/12/2026, 05/18/2026, 06/05/2026) and two OT visits (05/12/2026, 06/04/2026) were missed due to Patient not answering his/her phone or door. Patient made three ER trips (04/20/2026, 04/26/2026, 05/31/2026) and was hospitalized on three different occasions (05/03/2026 -05/04/2026, 05/06/2026 – 05/08/2026, 05/21/2026 – 05/24/2026). A SN visit, dated 06/01/2026, indicated Patient reported issues with his/her phone. The record failed to evidence agency staff informed Patient of a potential discharge for cause due to non-compliance. This was the last visit conducted by the agency prior to Patient being discharged on 06/10/2026. A Coordination Note, dated 06/02/2026, indicated Patient was to be recertified on 06/19/2026 and SN, PT, and OT services were to continue. A written order, dated 06/05/2026, indicated Patient was to be discharged from the agency “due to noncompliance with plan of care and multiple missed/rescheduled visits.” The record failed to evidence Patient and his/her ordering provider were notified of a potential discharge for cause prior to the order being written. The order was not received as signed until 06/18/2026, which was eight days after Patient was discharged. A Coordination Note, dated 06/09/2026, indicated Patient’s spouse called the agency to report Patient was “running out of medications.” Alternate CM informed the spouse that the agency had scheduled a discharge visit on 06/10/2026 due to Patient’s non-compliance. The spouse reported Patient had lost his/her phone and had a new phone number, however Patient was discharged from the agency on 06/10/2026. 2. During an interview on 06/24/2026 beginning at 10:33 AM, PT 1 reported Patient was discharged due to the agency being unable to contact him/her to schedule visits. PT 1 reported office staff was responsible for notifying the physician of the plan to discharge a patient for cause. 3. During an interview on 06/24/2026 beginning at 10:49 AM, OT 1 could not recall the reason Patient was discharged from the agency. OT 1 reported the patient’s nurse was responsible for notifying the physician of a plan to discharge a patient for cause. 4. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported Alternate CM was not available for interview. CM confirmed Patient was discharged for cause due to multiple missed visits and noncompliance. CM stated when a discharge for cause was being considered, staff should educate the patient on the potential consequences for being noncompliant with visits, including discharge from the agency, and document this education. CM was unsure if Patient was informed of the potential for discharge for cause. CM also reported the ordering provider should be notified of a potential discharge for cause. No further evidence was provided prior to survey exit. 410 17-12-2(i)”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to immediately report potential neglect and unsanitary living conditions to Adult Protective Services (APS) for 1 of 1 record reviewed which evidenced the patient was frequently found appearing disheveled, having a body odor which indicated they had not been bathed, the patient’s sheets and clothes having urine and stool stains, and the home having an odor of urine and garbage (Patient #6), which resulted in the patient developing repeated urinary tract infections and an increase in pressure ulcer wound size. Findings include: 1.Patient #6’s clinical record indicated a SOC date of 10/02/2024. The patient was admitted to the agency after suffering a heart attack and residing in a rehabilitation facility for three weeks. The patient’s other diagnoses included Type 2 diabetes, chronic respiratory failure, morbid obesity, high blood pressure, and dependence on oxygen. A PT SOC evaluation, dated 10/02/2024, indicated Patient was unable to use the toilet or shower due to Patient weighing 482 pounds, and Patient would have to stand to have a bowel movement. Patient’s spouse would assist him/her with all ADLs, including performing a bed bath. Patient had a chronic urinary catheter which required monthly trips to the Emergency Department (ED) to be changed. Patient also had “open areas” to the buttocks, however these were not assessed during the SOC visit. The record indicated Patient was admitted to the hospital on 12/03/2024 for bronchitis, pneumonia, and COVID-19. The patient was transferred to a rehabilitation facility then was discharged home on 01/24/2025. An RN assessment was completed on 01/28/2025, which indicated Patient weighed 527 pounds and required assistance with all ADLs. The patient had two Stage 2 pressure ulcers (wound caused by prolonged pressure to a bony area), one to the right upper posterior thigh measuring 2 centimeters (cm) in length by 2 cm in width by 0 cm in depth (2 cm x 2 cm x 0 cm), and the other to the left upper posterior thigh measuring 0.5 cm x 0.5 cm x 0.2 cm. A POC for the recertification period of 01/30/2025 – 03/30/2025 indicated the agency would provide SN visits once per week for eight weeks with interventions to include performing wound care to Patient’s pressure ulcer wounds, educating Patient’s caregiver on how to perform wound care, and changing Patient’s chronic urinary catheter once per month. Wound care to be performed to Patient’s pressure ulcers included cleansing the wounds and applying Calazine (a medicated cream) daily. The record evidenced the agency continued to provide SN visits once per week until the recertification period of 09/27/2025 – 11/25/2025, at which time the SN visit frequency was decreased to one visit every two weeks for two weeks, one visit every four weeks for four weeks, then one visit every three weeks for three weeks. The record failed to evidence the reason the SN visit frequency was decreased. A SN visit note, dated 10/07/2025, indicated RN 4 noted Patient’s home was cluttered with walkways obstructed “posing a fall risk.” Patient’s bed and recliner had soiled sheets. A SN visit note, dated 11/04/2025, indicated Patient’s urine was cloudy, dark, concentrated, and had a foul odor. A urine sample was obtained and laboratory results evidenced Patient tested positive for a UTI. Patient was started on Bactrim (an antibiotic). A SN recertification note, dated 11/24/2025, indicated RN 4 noted Patient appeared disheveled and the home conditions were “unsafe/unsanitary.” Patient required assistance with dressing, bathing, and toileting. A POC for the recertification period of 11/26/2025 – 01/24/2026 indicated a SN visit frequency of once per week for one week, once every five weeks for five weeks, then once every two weeks for two weeks. Patient continued to have a urinary catheter and Stage 2 pressure ulcers to the right upper posterior thigh and left upper posterior thigh which required daily wound care. A SN visit note, dated 12/02/2025, indicated RN 4 noted Patient’s home “remains cluttered with strong garbage odor present.” A SN visit note, dated 01/07/2026, indicated RN 4 noted Patient’s home was cluttered and the cushion in Patient’s recliner was “stained with urine.” RN 4 also noted Patient had “poor hygiene.” A Coordination Note, dated 01/20/2026, indicated Patient called the agency after-hours to report signs and symptoms of a UTI, including abdominal pain, bladder pain, and dark cloudy red urine with sediment. A SN recertification note, dated 01/21/2026, indicated RN 4 noted Patient’s home was cluttered and described the home conditions as “unsafe/unsanitary.” Patient had a “poor appearance (i.e poor hygiene, disheveled).” Patient continued to require assistance with ADLs, including dressing, bathing, and toileting. Patient’s urine was cloudy and blue-tinted. Patient complained of bladder spasms, urine leaking around the catheter, and lower abdominal pain. Patient reported his/her spouse was responsible for performing his/her catheter care. A urine sample was obtained and laboratory results evidenced Patient tested positive for a UTI. Patient was started on a 10-day course of Bactrim. A POC for the recertification period of 01/25/2026 – 03/25/2026 indicated a SN visit frequency of once per week for one week, once every four weeks for four weeks, then once every three weeks for three weeks. The patient continued to have a urinary catheter and Stage 2 pressure ulcers to the right upper posterior thigh and left upper posterior thigh which required daily wound care. A SN visit note, dated 02/05/2026, indicated Patient’s right posterior thigh wound measured 0.2 cm x 0.2 cm x 0 cm. The record failed to evidence further wound assessments were conducted during the certification period. A SN visit note, dated 03/04/2026, indicated Patient’s urine was dark and concentrated. A urine sample was obtained during the visit and laboratory results evidenced Patient tested positive for a UTI. On 03/13/2026, Patient was started on a 10-day course of Bactrim. A SN recertification note, dated 03/23/2026, indicated RN 4 noted Patient’s home was cluttered, Patient had “poor personal hygiene,” and Patient was wearing soiled shorts. The patient’s home was described as “unsafe/unsanitary.” Patient continued to require assistance with ADLs, including dressing, bathing, and toileting. A POC for the recertification period of 03/26/2026 – 05/24/2026 indicated a SN visit frequency of once every two weeks for two weeks, once every four weeks for four weeks, and once every two weeks for two weeks. The patient continued to have Stage 2 pressure ulcers to the right posterior thigh and left posterior thigh requiring daily wound care and a urinary catheter. A SN visit note, dated 04/09/2026, indicated Patient’s right posterior thigh wound measured 2 cm x 2 cm x 0.1 cm, an increase of 1.8 cm in length and width from the last date of measurement (02/05/2026). The visit note also indicated Patient reported intermittent sharp abdominal pain and Patient thought he/she had another UTI. A SN visit note, dated 04/16/2026, indicated RN 4 noted Patient’s home was cluttered with a “strong odor of pet urine” and Patient appeared disheveled. Patient’s urine was dark, concentrated, and had a foul odor. Patient complained of right upper quadrant abdominal pain. A urine sample was obtained during the visit and laboratory results evidenced Patient tested positive for a UTI. A SN visit note, dated 05/06/2026, indicated RN 4 noted Patient appeared disheveled and “in need of a shower.” Patient’s home was cluttered and there was a strong odor of garbage. A SN recertification note, dated 05/20/2026, indicated RN 4 noted Patient’s home was cluttered and Patient appeared disheveled. Patient continued to require assistance with ADLs, including dressing, bathing, and toileting. A POC for the recertification period of 05/25/2026 – 07/23/2026 indicated a SN visit frequency of once a week for one week, once every four weeks for four weeks, and once every three weeks for three weeks. The patient continued to have a urinary catheter and Stage 2 pressure ulcers to the right posterior thigh and left posterior thigh requiring daily wound care. A SN visit note, dated 06/03/2026, indicated RN 4 noted Patient appeared disheveled and had a “strong body odor present.” The home was cluttered with a strong pet odor. Patient’s urine was cloudy and had a foul odor. Patient reported having intermittent abdominal pain for a few days. A SN visit note, dated 06/17/2026, indicated Patient’s urine continued to be cloudy and had a foul odor. RN 4 noted Patient appeared disheveled and “in need of a shower.” The home was cluttered with a strong odor of garbage. The record failed to evidence the agency had reported any concerns with Patient’s spouse and/or child’s potential inability to consistently perform ADL and wound care nor Patient’s unsanitary living conditions to APS, despite Patient developing frequent UTIs and worsening pressure ulcers. 2. Patient #6 declined to be interviewed on 06/22/2026 at 11:09 AM. 3. During an interview on 06/22/2026 beginning at 12:25 PM, PT 1 reported Patient was “in a very unhygienic situation,” including having a smell of urine in the home. PT 1 stated Patient’s 10-year-old child was the primary caretaker and agency staff thought this was concerning, as the child was doing “more than a child should be doing.” When asked what tasks the child caregiver was performing, PT 1 stated the child acted as a “gofer” for Patient. PT 1 reported Patient’s poor hygiene was a concern and Patient would often be found with dirty, stained pants. The PT could not recall if the agency had discussed reporting the patient’s unhygienic living conditions to APS, then stated he had advised not to contact APS, as there was “no point” since APS would not do anything. 4. During an interview on 06/22/2026 beginning at 1:02 PM, PTA 2 reported Patient often had an odor during the PTA’s visits and Patient’s spouse assisted with all ADLs. PTA 2 reported Patient also had a teenage child who would assist with “day to day needs” when the spouse was not available. 5. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported Alternate CM and RN 4 were not available for interview. CM stated concerns regarding a patient’s unsanitary home conditions should be reported to APS if it is a “safety concern,” such as if the patient was found in a dirty brief or was tripping over items in a cluttered home. CM was unsure if the agency had reported any concerns with Patient’s caregivers’ ability to provide care to Patient and/or the unsanitary home conditions to APS. No further evidence was provided prior to survey exit.”

“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 RN failed to include all medications on the POC for 1 of 4 home visit observations (Patient #3). Findings include: 1. During a home visit observation on 06/18/2026 at 10:15 AM, this surveyor compared Patient #3’s medications with the current medication list provided by the agency. Patient #3’s medications in the home included 2 bottles of omeprazole (to prevent acid reflux). The medication list failed to include omeprazole. The POC failed to include omeprazole. 2. During an interview conducted during the observation, Person A confirmed that Patient #3 took omeprazole and had been taking it for some time. 3. During an interview on 06/22/2026 beginning at 03:45 PM, the administrator indicated the medication list should include all medications the patient takes and confirmed the POC medication list failed to include omeprazole. 410 IAC 17-13-1(a)(1)(C)(ix) 1. During a home visit observation on 06/18/2026 at 10:15 AM, this surveyor compared Patient #3’s medications with the current medication list provided by the agency. Patient #3’s medications in the home included 2 bottles of omeprazole (to prevent acid reflux). The medication list failed to include omeprazole. The POC failed to include omeprazole. 2. During an interview conducted during the observation, Person A confirmed that Patient #3 took omeprazole and had been taking it for some time. 3. During an interview on 06/22/2026 beginning at 03:45 PM, the administrator indicated the medication list should include all medications the patient takes and confirmed the POC medication list failed to include omeprazole. 410 IAC 17-13-1(a)(1)(C)(ix)”

“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 RN failed to perform wound care only according to physician order, for 1 of 1 active records reviewed which evidenced the patient developed redness from a catheter (Patient #7). Findings include: 1. Patient #7’s clinical record included documentation of a SN visit performed by RN 3 on 04/24/2026. RN 3 documented she placed a mepilex dressing (a wound care bandage) to a reddened area on Patient #7’s skin. The RN provided care without a physician’s order. 2. During an interview on 06/22/2026 beginning at 03:45 PM, the administrator indicated the use of mepilex requires a physician order. 3. During an interview on 06/24/2026 beginning at 11:21 AM, RN 3 indicated she should have gotten an order to use mepilex. 410 IAC 17-13-1(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 home health agency failed to notify the physician of a patient fall for 1 of 1 active record reviewed which evidence staff were aware of a patient fall (Patient #3), failed to notify the physician of a positive test result for urinary tract infection (UTI) for 1 of 2 records reviewed which evidenced the patient tested positive for a UTI (Patient #6), and failed to notify the physician of an increase in wound size for 1 of 1 record reviewed which evidenced an increase in pressure ulcer wound size (Patient #6) Findings include: 2. Patient #6’s clinical record included an RN visit note, completed on 01/28/2025, which indicated Patient had a Stage 2 pressure ulcer (wound caused by prolonged pressure to a bony area) to the right upper posterior thigh. A SN visit note, dated 02/05/2026, indicated Patient’s right posterior thigh wound measured 0.2 centimeters (cm) in length by 0.2 cm in width by 0 cm in depth (0.2 cm x 0.2 cm x 0 cm). A SN visit note, dated 04/09/2026, indicated RN 4 measured Patient’s right posterior thigh wound for the first time since the SN visit on 02/05/2026. The wound measured 2 cm x 2 cm x 0.1 cm, an increase of 1.8 cm in length and width. The record failed to evidence the nurse notified Patient’s physician of the increase in wound measurements. A SN visit note, dated 04/16/2026, indicated Patient’s urine was dark, concentrated, and had a foul odor. Patient complained of right upper quadrant abdominal pain. RN 4 obtained a urine sample during the visit and laboratory results evidenced Patient tested positive for a urinary tract infection (UTI). The record failed to evidence Patient’s positive test results were reported to the physician nor was Patient started on treatment for the UTI. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported RN 4 was not available for interview. CM stated “any change” in a wound “to the negative” should be reported to the physician. CM reported the record failed to evidence RN 4 notified the physician of the increase in Patient’s wound measurements. CM was unsure if Patient’s positive urine test results from 04/16/2026 were reported to Patient’s physician. No further evidence was provided prior to survey exit. 3. The clinical record for Patient #3 contained documentation by PTA 1 dated 06/10/2026 describing a fall that occurred when the patient’s spouse attempted to transfer the patient into the shower. Review of the clinical record revealed no documentation that the physician had been notified of the fall. The agency failed to notify the physician of Patient #3’s fall. During an interview conducted on 06/19/2026 at 11:49 AM, PT 1 stated he would notify the physician only if the fall resulted in an injury. PT 1 indicated a change in the POC was unnecessary since fall prevention was already on the POC. 410 IAC 17-13-1(a)(2)”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the revised POC included information from the patient’s updated comprehensive assessment and the patient’s progress towards his/her goals for 4 of 4 active records reviewed of a patient with a recertification POC (Patient #2, #4, #6, #7) Findings include: 2. Patient #2’s clinical record included a POC for the recertification period 04/02/2026 – 5/31/2026 which included goals for teaching and management of edema (swelling), dietary restrictions, pain control, home safety, fall risk, prevention of pressure ulcers, and diabetic foot care. A POC for the recertification period 06/01/2026 – 07/30/2026 failed to indicate Patient’s progress towards all identified goals from the previous certification period. During an interview on 06/22/2026 beginning at 2:26 PM, RN 2 reported the POC did not indicate if all goals were met or not met. 3. Patient #6’s clinical record included a POC for the recertification period 03/26/2026 – 05/24/2026 which included goals for teaching and management of depression, heart failure, edema, diabetes, urinary catheter, skin integrity, pain control, wounds, home safety, and fall risk. A SN visit note, dated 04/09/2026, indicated Patient had two Stage 2 pressure ulcers (type of wound caused by prolonged pressure to a bony area), one to the right posterior thigh and the other to the left posterior thigh. During the visit, RN 4 measured Patient’s right posterior thigh wound for the first time since the SN visit on 02/05/2026. The wound measured 2 centimeters (cm) in length by 2 cm in width by 0.1 cm in depth (2 cm x 2 cm x 0.1 cm), an increase of 1.8 cm in length and width from the previous measurement. A SN visit note, dated 04/16/2026, indicated RN 4 noted Patient’s home was cluttered with a “strong odor of pet urine” and Patient appeared disheveled. Patient’s urine was dark, concentrated, and had a foul odor. Patient complained of right upper quadrant abdominal pain. A urine sample was obtained during the visit and laboratory results evidenced Patient tested positive for a urinary tract infection (UTI). A SN visit note, dated 05/06/2026, indicated Patient’s urine continued to be dark and concentrated. RN 4 noted Patient appeared disheveled and “in need of a shower.” Patient’s home was cluttered and there was a strong odor of garbage. A SN recertification note, dated 05/20/2026. indicated Patient’s urine continued to be dark and concentrated. RN 4 noted Patient’s home was cluttered and Patient appeared disheveled. A POC for the recertification period 05/25/2026 – 07/23/2026 included a 60-day summary of progress. The summary indicated Patient’s primary focus of care was diabetes, wound care, and urinary catheter changes. RN 4 failed to summarize the status of Patient’s diabetes, Stage 2 pressure ulcers, and urinary catheter at the time of recertification, including the increase in right posterior thigh wound measurements, development of signs and symptoms of a UTI, and hygiene and home conditions which increased Patient’s risk for developing a UTI. The RN also failed to indicate Patient’s progress towards all identified goals from the previous certification period. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported RN 4 was not available for interview. CM reported the POC’s clinical summary should indicate what the agency “accomplished” and did not accomplish during the previous certification period. CM also stated the agency had difficulty indicating Patient’s progress towards their goals as Patient was on services primarily for catheter changes. 1. Patient #1’s clinical record evidenced a POC for the recertification period 04/02/2026 -5/30/2026 which included goals for teaching and management of home safety, use and administration of medications, low sodium diet, and pain control. A POC for recertification period 06/01/2026 – 07/30/2026 included a 60-day summary of progress. The summary indicated the primary focus of care was related to chronic obstructive pulmonary disease (COPD). RN 2 failed to summarize the status of Patient #1’s COPD symptoms at time of recertification. The RN also failed to include Patient #1’s progress towards all identified goals from the previous certification period. During an interview on 06/22/2026 beginning at 02:18 PM, RN 2 indicated progress is determined by the patient’s ability to verbalize back the teaching she did. RN 2 indicated she documented progress in the SN visit note. 4. Patient #7’s clinical record evidenced a POC for the recertification period 02/25/2026 – 04/25/2026 which included goals for teaching and management of diabetic foot care, prevention of pressure ulcers, pain management, and home safety. A SN visit note, dated 5/07/26, indicated the patient had a suprapubic catheter. The note indicated the patient was a high risk for recurrent UTIs (urinary tract infections) due to poor hygiene, reusing and re-wearing dirty briefs, and not performing catheter care regularly. Patient #7’s clinical record evidenced a POC for certification period 04/26/2026 – 06/18/2026, which included a 60-day summary of progress. The summary indicated the primary focus of care was related to Patient #7’s cystostomy (an opening in the bladder with a catheter to drain urine). The RN failed to summarize the status of Patient #7’s cystostomy, including the patient’s high risk for recurrent UTIs due to his/her poor hygiene practices and inability to perform catheter care appropriately. During an interview on 06/23/2026 beginning at 02:30 PM, the administrator indicated the patient’s progress was documented in the visit note but should be noted on the POC as well.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to coordinate care with all outside entities providing in-home services for 1 of 1 active records reviewed with a SOC in 2026 and which evidenced the patient was receiving PSA services (Patient #4) Findings include: 1.Patient #4’s clinical record indicated a SOC date of 05/28/2026. An RN SOC visit note, dated 05/28/2026, indicated Patient had paid caregivers in the home and Patient “should probably have 24-hour care.” The record failed to evidence Alternate CM coordinated care with the entity providing in-home services to Patient. 2. During a home visit observation with Patient #4 and COTA 2 on 06/18/2026 beginning at 10:08 AM, Person B, paid caregiver to Patient #4, was present during the visit. 3. During an interview on 06/18/2026 beginning at 11:17 AM, Person B reported he/she was employed by Entity G, a PSA, to provide attendant care and homemaker services for Patient. 4. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported Alternate CM was not available for interview. CM reported staff should coordinate care with other entities providing in-home services to a patient at SOC and with any “significant changes.” CM was unsure if the agency had coordinated with Entity G at SOC. No further evidence was provided prior to survey exit. 410 IAC 17-12-2(h)”

“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 notify patients of the name and contact information of the clinical manager for 4 of 4 home visit observations where the patient’s home binder was reviewed (Patients #2, 3, 4, and 5). Findings include: 2. During a home visit observation with Patient #2 on 06/18/2026 beginning at 7:37 AM, Patient’s handbook was reviewed. The handbook failed to clearly identify the name and contact information for the CM. 4. During a home visit observation with Patient #4 on 06/18/2026 beginning at 10:08 AM, Patient’s handbook was reviewed. The handbook failed to clearly identify the name and contact information for the CM. 6. During an interview on 06/22/2026 beginning at 3:45 PM, when asked to show where the clinical manager’s name and contact information was listed in the patient handbook, Administrator reported the agency’s “Executive Director” title was for both administrator and clinical manager roles. When asked why the “Clinical Director” section was left blank in the handbook, Administrator stated this position was only for agencies with branch locations. 1. Review of the agency patient handbook evidenced a welcome letter to the patient. The bottom of the letter included contact information for the administrator. The section for the clinical manager was blank. 3. During a home visit observation on 06/18/2026 at 10:15 AM, this surveyor reviewed Patient #3’s patient handbook. The handbook included the welcome letter with contact information for the administrator. However, the handbook did not include the name and contact information for the clinical manager. 5. During a home visit observation on 06/22/2026 at 09:20 AM, this surveyor reviewed Patient #5’s patient handbook. The handbook included the welcome letter with contact information for the administrator. However, the handbook did not include the name and contact information for the clinical manager. 6. During an interview on 06/22/2026 beginning at 03:45 PM, the administrator indicated the welcome letter in the patient handbook did not identify the name and contact number of the clinical manager.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, record review, and interview, the RN failed to conduct a complete assessment during each visit for 1 of 1 home visit observation with an RN (Patient #2) and 1 of 1 active record reviewed of a patient with pressure ulcer wounds (Patient #6). Findings include: 1.During a home visit observation with Patient #2 on 06/18/2026 beginning at 7:37 AM, Patient remained in his/her hospital bed during the length of the visit. A Hoyer lift was observed in the home and Patient’s caregiver reported this was used to transfer Patient out of bed to an electric wheelchair. RN 1 assessed Patient’s bowel sounds by listening with a stethoscope to only two abdominal quadrants and assessed Patient’s lung sounds by listening with a stethoscope to only two lung lobes anteriorly and two lung lobes laterally. The RN failed to assess bowel sounds in all four abdominal quadrants and failed to assess lung sounds in all five lung lobes. RN 1 also failed to conduct a complete skin assessment to check for wounds or skin abnormalities on Patient’s back and buttocks. During an interview on 06/18/2026 beginning at 8:16 AM, RN 1 reported she assessed Patient’s bowel sounds by only listening to two abdominal quadrants and assessed Patient’s lung sounds by listening to lung sounds anteriorly and laterally. The nurse stated she did not assess the skin on Patient’s back or buttocks since Patient had declined to roll on his/her side when the nurse asked to listen to lung sounds posteriorly. RN 1 stated Patient “wasn’t going to want to roll” on his/her side if she would have asked Patient to roll to assess his/her skin. During an interview on 06/22/2026 beginning at 3:45 PM, CM reported the nurse should assess a patient’s bowel sounds by listening with a stethoscope to all four abdominal quadrants and should assess a patient’s lung sounds by listening with a stethoscope to all five lung lobes. CM also reported the nurse should conduct a complete skin assessment on a bedbound patient at each SN visit. 2. Patient #6’s clinical record included a POC for the recertification period of 01/25/2026 – 03/25/2026 which indicated a SN visit frequency of once per week for one week, once every four weeks for four weeks, then once every three weeks for three weeks. Patient had Stage 2 pressure ulcers (type of wound caused by prolonged pressure to a bony area) to the right posterior thigh and left posterior thigh which required daily wound care. Wound care to be provided to each wound included cleansing the wound and applying Calazine (a medicated cream). A SN visit note, dated 02/05/2026, indicated Patient’s right posterior thigh wound measured 0.2 centimeters (cm) in length by 0.2 cm in width by 0 cm in depth (0.2 cm x 0.2 cm x 0 cm). A SN visit note, dated 03/04/2026, failed to evidence RN 4 assessed Patient’s wounds during the visit. RN 4 marked the reason the wounds were not assessed as “caregiver completed care.” A SN visit note, dated 04/09/2026, indicated Patient’s right posterior thigh wound measured 2 cm x 2 cm x 0.1 cm, an increase of 1.8 cm in length and width from the last date of measurement (02/05/2026). The record failed to evidence the SN assessed Patient’s wounds during each visit. During an interview on 06/23/2026 beginning at 2:04 PM, CM reported RN 4 was not available for interview. CM stated all wounds should be assessed during each SN visit. CM also stated the caregiver already providing care was not an appropriate reason for the nurse to skip the wound assessment since the agency was only seeing Patient every two to four weeks. 410 IAC 17-12-2(g)”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on observation, record review, and interview, the RN failed to ensure all documentation was accurate for 1 of 1 home visit observation with an RN (Patient #2) Findings include: 1.During a home visit observation with Patient #2 on 06/18/2026 beginning at 7:37 AM, RN 1 failed to conduct a complete skin assessment to check for wounds or skin abnormalities on Patient’s back and buttocks. 2. During an interview on 06/18/2026 beginning at 8:16 AM, when asked how RN 1 conducted a skin assessment, the nurse stated she looked at the skin on Patient’s feet and elbows only during the visit. 3. Patient #2’s clinical record included a SN visit note, dated 06/18/2026, which indicated RN 1 assessed Patient’s skin on his/her back and buttocks by asking Patient’s caregiver if there was any redness or skin breakdown. This was not observed during the home visit observation. The record failed to evidence all SN documentation was accurate. 410 IAC 17-14-1(a)(1)(E)”

“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 agency failed to ensure the administrator was responsible for all day-to-day activities for 1 of 1 agency. Findings include: A job description for Business Office Manager, signed 02/07/2024, indicated the employee was responsible for “managing, coordinating, and directing the administrative support and non-clinical operations of the agency ....” The job description indicated the Business Office Manager’s job duties included but were not limited to “... overseeing and maintaining contracts, binders, and HR/medical files for all agency employees and contract staff ... manages clerical staff and manages all non-clinical workflow and process in the office ... responsible for processing and ensuring successful & timely onboarding and training for all new agency employees/contractors/students ... ensuring all ongoing trainings are completed timely by all staff ... reviews OASIS Validation within 7 days of receipt of report and takes appropriate action ... oversight in and participation of discharge chart reviews ....” The agency failed to ensure the administrator was responsible for the day-to-day operations of the agency. During an interview on 06/23/2026 beginning at 09:50 AM, the administrator indicated the business office manager was “… responsible for the day-to day….” During the emergency preparedness interview, the administrator indicated they did not have access to the emergency preparedness policies. 410 IAC 17-12-1(c)(1)”