Pediatric Infant & Family Personal Care Special

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the quality assurance and performance improvement (QAPI) program focused on patients’ hospitalizations rate of 29% in October 2025, 7% in November 2025, and 7% in December 2025. Findings include: A Patient Hospitalization Sheet indicated Patient #16 was hospitalized 10/10/2025 to 10/12/2025 and 10/22/2025 to 10/28/2025, Patient #4 was hospitalized 10/21/2025 to 11/09/2025, Patient #10 was hospitalized 10/26/2025 to 11/07/2025 and 12/16/2025 to 12/17/2025, and Patient #6 was hospitalized 11/16/2025 to 11/24/2025. The Patient Hospitalization Sheet was left blank for reason for hospitalization. A Client Census List for October 2025, November 2025, and December 2025 indicated an active patient census of 14. During an interview, on 01/02/2025, beginning at 12:40 PM, the non-clinical Alternate Administrator indicated she was responsible for the QAPI program. The Alternate Administrator indicated the agency was tracking hospitalizations, did not know reason for patients’ hospitalizations and the QAPI program did not identify patients’ hospitalizations for an improvement opportunity.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure: the comprehensive assessment reflected patients’ health/psychosocial/cognitive status (see G0528); the comprehensive assessment included patients’ strengths/goals (see G0530); the comprehensive assessment included review of medication (see G0536); the comprehensive assessment included patients’ primary caregiver availability/willingness (see G0538); and the comprehensive assessment incorporated Outcome Assessment and Information Set (see G0542). The cumulative effect of these systemic problems has resulted in the home health agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 484.55 Comprehensive Assessment of Patients.”

“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: skilled services were provided as ordered (See G0572); the plan of care included all required information / elements for the treatment of the patient (See G0574); all orders were recorded in the plan of care (See G0576); verbal orders were written and authenticated (See G0584); the plan of care integrated all physician orders (See G0604); and patient care was coordinated based on patient’s needs (See G0608). The cumulative effect of these systemic problems has resulted in the home health agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42CFR 484.60 Care Planning, Coordination of Care and Quality of Care.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence they had a QAPI program that measured, analyzed, and tracked quality indicators (G0642); utilized data to identify opportunities for improvement (G0644); improvement activities focused on high risk or problem prone areas (G0646); performance improvement activities analyze patient adverse events and implement preventative actions (G0654); performance improvement project had documented reason and measured progress (G0656); and that the Governing Body approved the data detail and frequency of collection (G0660). The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR §484.65 Condition: Quality Assessment/Performance Improvement. Findings include: An OASIS Agency Patient-Related Characteristic Report for 06/2024 to 05/2025, and prior observation dates of 06/2023 to 05/2024, indicated under section Elimination home health agency patient urinary tract infections were at 25.53%, prior observation urinary tract infections were at 26.67%, and the national observation was at 10.13%. The OASIS Agency Patient Related Characteristic Report under section General Health Status indicated patients’ multiple hospitalizations were at 45.71%, prior observation multiple hospitalizations were at 41.18%, and the national observation was at 40.03%. Quality Improvement and Infection Control Reports for Patient #6 indicated hospitalization with wound infection on 02/27/2025, and 03/25/2025. Quality Improvement and Infection Control Reports for Patient #3 indicated hospitalization with antibiotics on 06/01/2025. Quality Improvement and Infection Control Reports for Patient #10 indicated a urinary tract infection with antibiotics on 02/25/2025, 03/03/2025; and urinary tract infection with hospitalization and antibiotics on 03/17/2025 and 05/11/2025. Quality Improvement and Infection Control Reports for Patient #11 indicated urinary tract infection with hospitalization and antibiotics on 05/06/2025; and hospitalization for seizures on 04/12/2025. During an interview on 09/15/2025, beginning at 2:50 PM, the Alternate Administrator indicated the agency does not utilize quality indicator data derived from OASIS to identify opportunities for improvement. The Alternate Administrator indicated the frequency and detail of data collection was not approved by the agency’s governing body, the agency did not have performance improvement activities that would lead to opportunities for improvement. The Alternate Administrator indicated the agency did not analyze adverse patient events to implement preventative action. 410 IAC 17-12-2(a)”

“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 patients’ comprehensive assessment included an individualized emergency plan in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7). Findings include: 1. The clinical record for Patient #1 evidenced the most recent recertification assessment, dated 09/08/2025; the assessment indicated Patient had a self-care deficit due to seizure disorder and reduced mobility. The updated Comprehensive assessment, failed to evidence a patient specific individualized emergency plan. 2. The clinical record for Patient #2 included a recertification assessment, dated 09/07/2025, which revealed Patient required wound care. The updated Comprehensive assessment, failed to evidence a patient specific individualized emergency plan. 3. The clinical record for Patient #3 included the Initial Comprehensive Assessment, dated 07/18/2025, indicated Patient was bed bound, had a tracheostomy (surgical hole in the windpipe for breathing), had a portable ventilator (machine to support or replace breathing for a person), was quadriplegic (weakness in all extremities), and had a foley catheter (tube into bladder to drain urine). The Comprehensive Assessment, failed to evidence a patient specific individualized emergency plan. 4. The clinical record for Patient #4 included the Recertification Comprehensive Assessment, dated 08/11/2025, which indicated Patient had atrial fibrillation (irregular heartbeat) and Pulmonary arterial hypertension (elevated blood pressure affects arteries in lungs and right side of heart). The updated Comprehensive assessment, failed to evidence a patient specific individualized emergency plan. 5. The clinical record for Patient #5 included the Recertification Comprehensive Assessment, dated 09/04/2025, indicated Patient had a PICC line (intravenous catheter reaches superior vena cava of the heart), and had daily intravenous therapy. The updated Comprehensive assessment, failed to evidence a patient specific individualized emergency plan. 6. The clinical record for Patient #6 included an Initial Comprehensive Assessment, dated 07/31/2025; the assessment indicated Patient had wounds to both lower extremities and failed to evidence an individualized emergency plan. The Comprehensive assessment, failed to evidence a patient specific individualized emergency plan. 7. The clinical record for Patient #7 included an updated Recertification Comprehensive Assessment, dated 09/07/2025; the assessment revealed Patient required wound care and failed to evidence an individualized emergency plan. The updated Comprehensive assessment, failed to evidence a patient specific individualized emergency plan. 8. During an interview on 09/15/2025, beginning at 12:20 PM, the Alternate Administrator indicated emergency preparedness plans for patients were not included in the comprehensive assessments.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness training was completed and documented for new and at least every 2 years for existing staff for 1 of 1 RN, 4 of 4 Home Health Aides, 2 of 2 LPN’s, 1 of 1 Physical Therapist, and 1 of 1 Alternate Director of Nursing personnel records reviewed (RN 2, Home Health Aide 1, 3, 6, 8; Physical Therapist 1, LPN 3, 4; and Alternate Director of Nursing, Administrative Staff 3). Findings include: 1. A Personnel Record Review for RN 1, date of hire 10/15/2019, failed to evidence emergency preparedness training. 2. A Personnel Record Review for Home Health Aide 1, date of hire 2006, failed to evidence emergency preparedness training. 3. A Personnel Record Review for Home Health Aide 3, date of hire 02/09/2022, failed to evidence emergency preparedness training. 4. A Personnel Record Review for Home Health Aide, 6, date of hire of 06/18/2025, failed to evidence emergency preparedness training. 5. A Personnel Record Review for Home Health Aide 8, date of hire of 04/16/2012, failed to evidence emergency preparedness training. 6. A Personnel Record Review for Physical Therapist 1, date of contract hire of 06/01/2025, failed to evidence emergency preparedness training. 7. A Personnel Record Review for LPN 3, date of hire 01/02/2009, failed to evidence emergency preparedness training. 8. A Personnel Record Review for LPN 4, date of hire of 05/05/2010, failed to evidence emergency preparedness training. 9. A Personnel Record Review for the Alternate Director of Nursing, date of hire 04/16/2020, failed to evidence emergency preparedness training. 10. During an interview, on 09/15/2025, beginning at12:20 PM, the Alternate Administrator indicated staff should have emergency preparedness training upon hire and annually and did not have documentation of training for the staff.”

“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 ensure Outcome and Assessment Information Set (OASIS) was submitted within 30 days of completing the assessment of the patient in 2 of 4 home visits conducted (Patient #1,# 3). Findings include: 1. A policy, dated 02/12/2019, titled, “Reporting OASIS Information,” indicated the home health agency would electronically transmit each completed OASIS assessment to the Center for Medicare/Medicaid Services (CMS) within 30 days of completing the assessment of the patient. 2. The Plan of Care [POC] for the certification period 07/12/2025 to 09/09/2025, for Patient #1 indicated Patient’s start of care [SOC] date was 11/20/2023. The record included Comprehensive Assessments, with OASIS data, dated 07/07/2025 and 09/08/2025. The agency OASIS submission tracking indicated OASIS data was submitted on 09/08/2025; the agency failed to evidence OASIS data was submitted within 30 days of the completion of the 07/07/2025 assessment. 3. The POC for the certification period 07/18/2025 to 09/15/2025, for Patient #3, indicated Patient’s SOC was 07/18/2025. The record included the Comprehensive Assessment, with OASIS data, was dated 07/18/2025. The agency failed to evidence OASIS data was submitted within 30 days of the completion of the assessment dated 07/18/2025. During an interview on 09/12/2025, beginning at 2:45 PM, the Alternate Administrator indicated she would need to discover if further OASIS data was submitted for Patient #3. Upon survey exit on 09/15/2025 at 4:00 PM, no further OASIS data submission information for Patient #3 was provided. 4. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated OASIS data was to be submitted every 60 days after completion of an initial certification or recertification comprehensive assessment.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Outcome and Assessment Information Set (OASIS) data accurately reflected patients documented status at the time of the comprehensive assessment in 2 of 6 active clinical records reviewed who had OASIS data submitted to Centers for Medicare/Medicaid Services (CMS) within 30 days of the initial/recertification comprehensive assessment (Patient #1, Patient #6). Findings include: 1. A policy, dated 02/12/2019, indicated the home health agency would transmit each completed OASIS assessment within 30 days of completing the assessment of the patient. 2. An agency OASIS data submission for Patient #1 indicated data was transmitted to CMS on 09/08/2025 and indicated Patient was assessed to include but not limited to ability for patient to groom self, upper body dressing, lower body dressing, toilet transfers, transfers, ambulation, toileting hygiene, mobility and risk of hospitalization. The Recertification Comprehensive Assessment, dated 07/07/2025, failed to evidence an assessment of grooming, upper and lower body dressing, toilet transfers, transfers, ambulation and toileting hygiene and mobility and risk of hospitalization. A Recertification Comprehensive Assessment, dated 09/08/2025, failed to evidence an assessment of grooming, upper and lower body dressing, toilet transfers, transfers, ambulation and toileting hygiene and mobility and risk of hospitalization. 3. An agency OASIS data submission form for Patient #6 indicated data was transmitted to CMS on 07/31/2025 with the assessment completed on 07/31/2025; the OASIS data indicated Patient was assessed to include, but not limited to temporal orientation, self-care to include oral hygiene, toileting hygiene, shower/bath, mobility, toilet transfers, pain, wounds, risk of hospitalization, living situation, bowel/urine incontinence, high risk drug education, and drug regimen review. The Comprehensive Assessment, dated 07/31/2025, failed to evidence an assessment of orientation, self-care, transfers, wound, risk of hospitalization, living situation, shower/bath, pain, bowel/urine incontinence, and high-risk drug education. The POC for the certification period 07/31/2025 to 09/28/2025, indicated Patient was on warfarin (blood thinning medication). 4. During an interview on 09/12/2025, beginning at 2:45 PM, the Clinical manager indicated she completed and documented the OASIS data submitted; she indicated she collected the OASIS data verbally from the LPN and based on the LPN’s skilled nursing visits. She indicated the OASIS data assessments were not based on an assessment by a RN assessment; she relayed she based the OASIS assessment data collected and submitted, for the initial comprehensive assessments, the recertification comprehensive assessments, nor the updated comprehensive assessments, based on patients’ change in status from the LPN visit notes or verbally from the LPN.”

“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 agency failed to ensure each patient received the home health services that were written in the individualized plan of care that identified patient specific measurable outcomes and goals in 3 of 4 active clinical records reviewed with wound care (Patient #1 and #3). Findings include: 5. A Plan of Care, for certification period 07/18/2025 to 09/15/2025, for Patient #3 indicated skilled nurse 3 times per week, and wound care every 3 days. A Clinical Record Review indicated the following: Week of 07/19/2025, 1 skilled nurse visit completed 07/23/2025 and failed to meet the 3 skilled nurse visits per week. LPN Missed Visit Notes, dated 07/21/2025 and 07/25/2025, failed to evidence a reason for missed visit or physician notification. Week of 07/26/2025, 2 skilled nurse visits completed 07/28/2025 and 07/30/2025 and failed to meet 3 skilled nurse visits per week. A LPN Missed Visit Note, dated 08/01/2025, failed to evidence a reason for missed visit or physician notification. Week of 08/16/2025, 2 skilled nurse visits completed 08/18/2025 and 08/20/2025 and failed to meet 3 skilled nurse visits per week. A LPN Missed Visit Note, dated 08/22/2025, failed to evidence a reason for missed visit or physician notification. Week of 08/30/2025, 2 skilled nurse visits completed 09/01/2025 and 09/03/2025 and failed to meet 3 skilled nurse visits per week. A LPN Missed Visit Note, dated 09/05/2025, failed to evidence a reason for missed visit or physician notification. During an interview on 09/11/2025, beginning at 1:15 PM, LPN 4 indicated the physician would be notified if a patient had 3 or more missed visits. A Plan of Care, for certification period 07/18/2025 to 09/15/2025, indicated skilled nurse to change foley catheter (tube into the bladder to drain urine) every month. Skilled Nursing Visits dated 08/15/2025, 08/18/2025, 08/20/2025, 08/27/2025 and 08/29/2025 indicated last foley catheter change was 07/15/2025. During an interview on 09/11/2025, beginning at 1:30 PM, LPN 4 indicated Patient’s foley catheter was changed on 08/27/2025 and was not documented, LPN 4 indicated Patient’s foley catheter was not changed per physician order due to a delay in receiving supplies. A Plan of Care, for certification period 07/18/2025 to 09/15/2025, indicated skilled nurse to assess, monitor and instruct on wound care and to change dressing to wounds every 3 days. Skilled Nurse Visit Notes dated 07/23/2025, 07/28/2025, 07/30/2025, 08/04/2025, 08/06/2025, 08/08/2025, 08/11/2025, 08/13/2025, 08/15/2025, 08/18/2025, 08/20/2025, 08/25/2025, 08/27/2025, 09/01/2025, and 09/03/2025 failed to evidence weekly wounds were measured per agency policy. During an interview on 09/11/2025, beginning at 1:20 PM, LPN 4 indicated she did not measure wounds weekly, would try to measure wounds weekly and dressing changes were hectic. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated wound assessments wound include wound assessment every week on Mondays. 410 IAC 17-13-1(a) Based on record review and interview, the agency failed to ensure each patient received the home health services that were written in the individualized plan of care that identified patient specific measurable outcomes and goals in 3 of 4 active clinical records reviewed with wound care (Patient #1, #2, #3). Findings include: 1. An undated policy, titled, “Plan of Care,” indicated each patient would receive the home health services that were written in the individualized plan of care that identified patient specific measurable outcomes and goals. 2. An undated policy, titled, “Missed Visit Reports,” indicated the patient’s physician would be notified, a missed visit form would be completed and faxed to the physician’s office and be placed in the client’s file. 3. An undated policy, titled, “Wound Care,” indicated wound size would be measured once weekly on Monday and logged on the wound care flow sheet. 4. A Plan of Care, for certification period 07/12/2025 to 09/09/2025, for Patient #1, indicated skilled nurse visits 4 to 7 days per week for 8 to 16 hours per day and indicated wound care every other day. A Clinical Record Review indicated the following: Week of 07/19/2025, 3 LPN Visits completed on 07/21/2025, 07/22/2025, and 07/2025 and failed to meet the minimum 4 skilled nurse visits per week. Week of 08/02/2025, 3 LPN Visits completed on 08/04/2025, 08/05/2025, and 08/07/2025 and failed to meet the minimum 4 skilled nurse visits per week. A LPN Missed Visit Note, dated 08/06/2025, failed to evidence reason for missed visit or physician notification. Week of 08/16/2025, 2 LPN Visits completed on 08/18/2025 and 08/21/2025 and failed to meet the minimum 4 skilled nurse visits per week. A LPN Missed Visit Note, dated 08/20/2025, failed to evidence reason for missed visit or physician notification. During an interview on 09/11/2025, beginning at 1:15 PM, LPN 4 indicated the physician would be notified if a patient had 3 or more missed visits. A Plan of Care, for certification period 07/12/2025 to 09/09/2025, indicated skilled nurse to instruct on seizure precautions. Skilled Nursing Visit Notes dated 07/12/2025, 07/13/2025, 07/14/2025, 07/16/2025, 07/17/2025, 07/21/2025, 07/22/2025, 07/24/2025, 07/26/2025, 07/27/2025, 07/28/2025, 07/30/2025, 07/31/2025, 08/04/2025, 08/05/2025, 08/07/2025, 08/09/2024, 08/10/2025, 08/13/2025, 08/15/2025, 08/18/2025, 08/19/2025 and 08/21/2025 failed to evidence documentation of caregiver education on seizure precautions.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to evidence home health aides had written patient care instructions prepared by a RN in 1 of 1 active clinical record reviewed with a ventilator (Patient #3), and in 1 of 2 active clinical records reviewed with a home health aide only (Patient #4). Findings include: A Plan of Care, for certification period 08/14/2025 to 10/12/2025, for Patient #4 indicated home health aide to visit 5 to 7 times per week to perform activities of daily living. During a home visit on 09/12/2025, beginning at 8:30 AM, Home Health Aide 3 indicated she used an application to input the cares for her patient and did not have a written care plan. 1. An undated policy, titled, “Home Health Aide Services,” indicated home health aides would have written patient care instructions prepared by a RN. 2. A Plan of Care, for certification period 07/18/2025 to 09/15/2025, for Patient #3 indicated home health aide to visit 3 to 5 times per week to perform activities of daily living. During a home visit on 09/12/2025, beginning at 12:20 PM, Home Health Aide 8 indicated she used an application to view Patient’s care plan. During an interview on 09/12/2025, beginning at 3:30 PM, the Alternate Administrator indicated aides plan of care were entered into an application by a nurse, observation of the application failed to evidence the RN that created the aide plan of care or the date created, and was unable to print the aide plan of care.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the content of the comprehensive assessment accurately reflected the patient’s status and failed to include the patient’s current health, psychosocial, functional and cognitive status in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7). Findings include: 1. A Comprehensive Assessment, dated 07/09/2025, for Patient #2, indicated Patient had bilateral cellulitis (a skin infection on both legs). The comprehensive assessment failed to include an assessment of the musculoskeletal system, cardiovascular system, respiratory system, neurosensory system and pain assessment. A Comprehensive Assessment, dated 09/07/2025, failed to evidence Patient #2 had Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status. A Plan of Care, for certification period 07/10/2025 to 09/07/2025 indicated Patient had an increased risk for hospitalization, would be discharged when wounds were healed, had endurance and ambulation functional limitations, and was oriented. 2. A Comprehensive Assessment, dated 08/11/2025, for Patient #4, indicated Patient had low endurance. The comprehensive assessment failed to include an assessment of the musculoskeletal system, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence the Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status. A Plan of Care, for certification period 08/14//2025 to 10/12/2025 indicated Patient had an increased risk for hospitalization, would be discharged when health is stabilized, had endurance and ambulation functional limitations, and was forgetful. 3. A Comprehensive Assessment, dated 09/04/2025, for Patient #5, indicated Patient osteomyelitis (infection of bone) of the second right toe and a PICC line (a flexible tube inserted into a vein in the upper arm). The comprehensive assessment failed to include an assessment of the PICC line site and assessment of the second right toe. Comprehensive assessment also failed to include assessment of musculoskeletal system, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence the Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status. A Plan of Care, for certification period 09/04/2025 to 11/02/2025 indicated Patient had an increased risk for hospitalization, would be discharged when health is stabilized, had hearing as a functional limitation, and was orientated. 4. A Comprehensive Assessment, dated 08/12/2025, for Patient #7, indicated Patient had bedbound status and Dementia. The comprehensive assessment failed to include an assessment of the musculoskeletal system, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence the Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status. A Plan of Care, for certification period 08/14//2025 to 10/12/2025 indicated Patient had an increased risk for hospitalization, would be discharged when care is no longer needed, had contractures, bowel bladder incontinence and ambulation functional limitations, and was forgetful. 1. A policy, dated 02/13/2019, titled, “Comprehensive Assessment of Patients,” indicated each patient would receive a patient specific comprehensive assessment that accurately reflected the patient’s current health status, include information that may demonstrate the patient’s progress toward desired outcomes. The policy indicated the contents of the comprehensive assessment would include the patient’s current health, psychosocial, functional, cognitive status, patient’s strengths, goals, continuing need for home health, discharge planning needs, review of medications, and patient’s primary caregiver. 2. A Recertification Comprehensive Assessment, dated 09/08/2025, for Patient #1 failed to include Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status. A Plan of Care, for certification period 09/10/2025 to 11/08/2025, indicated Patient had a diagnosis of cerebral palsy (condition with impaired muscle coordination) and chronic obstructive pulmonary disease (constriction of the airway with difficulty breathing), skilled nurse was to assess changes in sputum color, had 3 liters of oxygen at night, had a feeding tube, and had increased risk for hospitalization due to seizure and respiratory issues. A Skilled Nursing Note, dated 08/24/2025, indicated Patient had a productive cough, wore 3 liters oxygen via nasal cannula at night, had a mickey button (feeding tube), had a Texas catheter (external urinary drain), had a wound to the right hip, had musculoskeletal weakness, had speech and visual impairment, and Patient able to track with eyes. A Physician/Patient Face to Face Documentation, dated 07/23/2025, indicated Patient had psychomotor retardation, dependent in all activities of daily living, was peg tube dependent and was bedbound due to quadriplegia (weakness in all extremities). The Recertification Comprehensive Assessment, dated 09/08/2025, failed to evidence documentation of a physical assessment to include but not limited to respiratory system (lungs) , digestive system, genitourinary system (bladder), cardiovascular system (heart), neurosensory system, and pain assessment. 3. An Initial Comprehensive Assessment, dated 07/18/2025, for Patient #3, indicated Patient had a foley catheter (tube into the bladder to drain urine), a tracheostomy (surgical hole into the windpipe to assist with breathing), and a ventilator (breathing apparatus that provides mechanical air movement). The comprehensive assessment failed to include an assessment of the urine, cardiovascular system, respiratory system to include tracheostomy site assessment, neurosensory system and pain assessment. A Plan of Care, for certification period 07/18/2025 to 09/15/2025, indicated Patient had oxygen at 1 to 5 liters via tracheostomy, and had a pacemaker (medical device to regulate heartbeats). 4. A Comprehensive Assessment, dated 07/31/2025, failed to evidence Patient #6 had Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status. 5. A Plan of Care, for certification period 07/31/2025 to 09/28/2025, had a start of care of 07/31/2025, and indicated Patient had a moderate risk for hospitalization, would be discharged when wounds were healed, had endurance functional limitations, and was oriented. 6. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated recertification of comprehensive assessments were updates to Patient changes and not an assessment, and indicated she relied on the assessment of the skilled nurse notes to complete comprehensive assessments. The Director of Nursing had no further documentation to provide for initial comprehensive assessments that were completed that would include current health status. 410 IAC 17-14-1(a)(1)(B)”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included patients’ strengths and goals and progress towards goals identified by measurable outcomes in 3 of 5 active clinical records reviewed with wound care (Patient #1, #3, #6). Findings include: 1. The Recertification Comprehensive Assessment, dated 09/08/2025, for Patient #1 failed to include Patient’s strength, goals and care preferences. 2. An Initial Comprehensive Assessment, dated 07/18/2025, for Patient #3, failed to include Patient’s strengths, measurable outcomes for goals, and home care preference. The Home Care Preference was blank and indicated goals were: Patient was to remain free from infection, maintain effective airway, and limit further decline of skin integrity and failed to evidence how these goals would be measured. 3. A Comprehensive Assessment, dated 07/31/2025, failed to evidence Patient #6’s strength, goals, and care preferences. 4. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated recertification of comprehensive assessments were updates to Patient changes and were not an assessment; she indicated she relied on the assessment of the skilled nurse notes to complete comprehensive assessments. The Director of Nursing indicated Patients’ goals were not on the comprehensive assessments.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications taken by the patient in order to identify significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in 1 of 1 active clinical records reviewed with a ventilator (Patient #3), and 1 of 1 active clinical records reviewed with intravenous therapy (Patient #5). Findings include: 2. An Addendum to Comprehensive Assessment Medication List, dated 09/04/2025, for Patient #5 indicated Patient was on Xtandi (medication used to treat prostate cancer), tramadol (pain medication), Plavix (blood thinner), and meloxicam (anti-inflammatory) and indicated the patient does not demonstrate noncompliance with medication use as prescribed by the physician and significant drug interactions had not been found. A review of medications on Drugs.com on 09/11/2025 indicated Major drug interactions between tramadol and Xandi, increases the risk of seizures, and Plavix and meloxicam, may cause unusual bleeding. During an interview with the Administrator on 09/12/2025, beginning at 3:40 PM, indicated that there is not a medication review regimen that is followed by the agency, but the nurses should check for side effects. 410 IAC 17-14-1(a)(1)(B) 1. An addendum to Comprehensive Assessment Medication List, dated 07/18/2025, for Patient #3 indicated Patient was on gabapentin (anticonvulsant medication primarily used to treat neuropathic pain), Ipratropium/Albuterol nebulizer (inhaled lung dilator), Lidocaine patch (pain patch), Midodrine (medication used to treat low blood pressure), pantoprazole (reduces stomach acid) and indicated the patient does not demonstrate noncompliance with medication use as prescribed by the physician. During an interview during a home visit on 09/12/2025, beginning at 12:20 PM, Person A, family member to Patient, indicated Patient does not take gabapentin and ipratropium/albuterol nebulizer, did not ever use lidocaine patch nor receive a prescription, had not used midodrine due to no issues with blood pressure, and the medication used was Tylenol (over the counter pain reliever) as needed for headaches. During an interview during a home visit on 09/12/2025, beginning at 12:20 PM, LPN 4 indicated Patient was discharged from hospital with the medications. A Plan of Care, for certification period 07/18/2025 to 09/15/2025, indicated Patient’s start of care date was 07/18/2025.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included an assessment of patient’s primary caregiver, including their willingness and ability to provide care and availability, in 1 of 1 active clinical record reviewed with a feeding tube (Patient #1), in 1 of 1 active clinical record reviewed with a ventilator (Patient #3), and in 1 of 2 clinical records reviewed with a SOC on or after 07/31/2025 (Patient #6). Findings include: 1. The policy dated 02/13/2019 titled “Comprehensive Assessment of Patients,” indicated each patient would receive a patient specific comprehensive assessment and the contents of the comprehensive assessment would include, but not limited to, patient’s primary caregiver. 2. Patient #1’s Recertification Comprehensive Assessment, dated 09/08/2025, indicated Patient had self-care deficits, immobility, had a seizure disorder, lived with family members who were overwhelmed and had health issues; the assessment failed to evidence the availability and willingness of family members to provide care. The POC for the recertification period 09/10/2025 to 11/08/2025, indicated Patient with diagnosis of cerebral palsy (condition with impaired muscle coordination), lived with family members who had medical limitations that inhibit their ability to bend and pull, had no other caregivers available, and the primary caregivers recognized they were responsible for all patient care when staff were unavailable. 3. The Initial Comprehensive Assessment for Patient #3, dated 07/18/2025, failed to include an assessment of Patient’s primary caregiver. The POC for the certification period 07/18/2025 to 09/15/2025, indicated patient had quadriplegia (weakness of all extremities), and family member was trained in the use of the ventilator and there would be situations when staff would be unavailable and Patient’s primary caregiver, they would be responsible for the Patient’s care during those times. During an interview on 09/15/2025, beginning at 1:15 PM, LPN 4 indicated Patient’s primary caregiver was Person A. 4. The Comprehensive Assessment for Patient #6, dated 07/31/2025, failed to evidence Patient’s primary caregiver. The POC for the certification period 07/31/2025 to 09/28/2025 indicated Patient resided with a family member who could not assist with care. During an interview on 09/15/2025, beginning at 1:25 PM, LPN 4 indicated Patient family members lived near Patient, not with Patient. 5. During an interview, on 09/12/2025 beginning at 2:45 PM, the Director of Nursing indicated the comprehensive assessments were updates to patient changes and were not an assessment of the patient; she indicated she relied on the assessment of the skilled nurse notes to complete comprehensive assessments. She indicated she had no further documentation to provide regarding an assessment of the primary caregiver.”

“Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included incorporation of the Outcome and Assessment Information Set (OASIS) items to include clinical record items, demographics, patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management and emergent care in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7). Findings include: 1. A Recertification Comprehensive Assessment, dated 09/07/2025, for Patient #2 failed to include Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status to include respiratory/neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 2. A Recertification Comprehensive Assessment, dated 08/14/2025, for Patient #4,the comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 3. An Initial Comprehensive Assessment, dated 09/04/2025, for Patient #5, the comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 4. 4. A Recertification Comprehensive Assessment, dated 8/12/2025. For Patient #7, the comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 1. A policy, dated 02/13/2019, titled, “Comprehensive Assessment of Patients,” indicated contents of the comprehensive assessment would include but not limited to incorporation of the current version of OASIS items to include clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management and emergency care. 2. A Recertification Comprehensive Assessment, dated 09/08/2025, for Patient #1 failed to include Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status to include respiratory/neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 3. An Initial Comprehensive Assessment, dated 07/18/2025, for Patient #3, indicated Patient had a foley catheter (tube into the bladder to drain urine), a tracheostomy (surgical hole into the windpipe to assist with breathing), and a ventilator (breathing apparatus that provides mechanical air movement). The comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system to include tracheostomy site assessment, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 4. A Comprehensive Assessment, dated 07/31/2025, for Patient #6, failed to evidence Patient’s current health status, psychosocial and cognitive status to include respiratory/neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 5. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated OASIS data transmission was based on receiving a verbal assessment from the LPN for the patients based on the LPN’s skilled nursing visits, was not based on the RN initial/recertification comprehensive assessment, and the recertification comprehensive assessments were updated based on patients’ change in status. 1. A policy, dated 02/13/2019, titled, “Comprehensive Assessment of Patients,” indicated contents of the comprehensive assessment would include but not limited to incorporation of the current version of OASIS items to include clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management and emergency care. 2. A Recertification Comprehensive Assessment, dated 09/08/2025, for Patient #1 failed to include Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status to include respiratory/neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 3. An Initial Comprehensive Assessment, dated 07/18/2025, for Patient #3, indicated Patient had a foley catheter (tube into the bladder to drain urine), a tracheostomy (surgical hole into the windpipe to assist with breathing), and a ventilator (breathing apparatus that provides mechanical air movement). The comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system to include tracheostomy site assessment, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 4. A Comprehensive Assessment, dated 07/31/2025, for Patient #6, failed to evidence Patient’s current health status, psychosocial and cognitive status to include respiratory/neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 5. A Recertification Comprehensive Assessment, dated 09/07/2025, for Patient #2 failed to include Patient’s continuing need for home health, discharge planning needs, patient’s current health, psychosocial and cognitive status to include respiratory/neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 6. A Recertification Comprehensive Assessment, dated 08/14/2025, for Patient #4,the comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 7. An Initial Comprehensive Assessment, dated 09/04/2025, for Patient #5, the comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 8. A Recertification Comprehensive Assessment, dated 8/12/2025. For Patient #7, the comprehensive assessment failed to evidence an assessment of the urine, cardiovascular system, respiratory system, neurosensory system and pain assessment. The comprehensive assessment failed to evidence neuro/emotional/behavioral status, activities of daily living, equipment management and emergency care. 9. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated OASIS data transmission was based on receiving a verbal assessment from the LPN for the patients based on the LPN’s skilled nursing visits, was not based on the RN initial/recertification comprehensive assessment, and the recertification comprehensive assessments were updated based on patients’ change in status.”

“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 agency failed to ensure the plan of care included all medications and treatments, safety measures to protect against injury, patient and caregiver education and training to facilitate timely discharge, and measurable outcomes and goals identified by the agency and the patient in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6,#7). Findings include: 7. A Plan of Care, for certification period 07/10/2025 to 09/07/2025, for Patient #2, indicated Levaquin (antibiotic) 750mg tab daily for 10 days, but failed to evidence a stop date. Addendum to Comprehensive Assessment dated 03/12/2025, 07/07/2025 and 09/07/2025 indicated that Levaquin was being taken at Start of Care 03/12/2025. Interview with Patient #2 during home visit on 09/12/2025, beginning at 11:00AM, indicated that antibiotics have not been taken since coming home from the hospital in March. Interview with Administrator on 09/12/2025, beginning at 3:45 PM, indicated that Levaquin should have been removed from the Plan of Care at Recertification. 8. A Plan of Care, for certification period 08/14/2025 to 10/12/2025, for Patient #4 indicated goals included the Patient’s health would be enhanced throughout the home care services as evidenced by no signs or symptoms of acute exacerbations (a sudden worsening of a medical condition). The Plan of Care failed to evidence the exacerbation signs and symptoms or medical condition to be monitored. 9. A Plan of Care, for certification period 09/04/2025 to 11/02/2025, for Patient #5, indicated Tylenol (over the counter pain reliever) 500mg 2 tabs PRN, and tramadol 50mg 1 tab PRN and failed to evidence a frequency for the medications. Interview with Administrator on 09/12/2025, beginning at 3:45 PM, indicated that there should be a frequency on the Plan of Care. 10. A Plan of Care, for certification period 08/16/2025 to 10/14/2025, for Patient #7 indicated goals would include the Patient’s health would be enhanced throughout the home care services as evidenced by no signs or symptoms of acute exacerbations (a sudden worsening of a medical condition). The Plan of Care failed to evidence the exacerbation signs and symptoms or medical condition to be monitored. 410 IAC 17-13-1(a)(1)(D)(ix, x) 1. An undated policy, titled, “Plan of Care,” indicated the individualized plan of care would include but not limited to all medications and treatments, safety measures to protect against injury, patient and caregiver education and training to facilitate timely discharge, measurable outcomes and goals identified by the agency and the patient. The policy indicated all patient care orders would be recorded in the plan of care and or the clinical record. 2. A Plan of Care, for certification period 09/10/2025 to 11/08/2025, for Patient #1, indicated Tylenol (over the counter pain reliever) 25 milliliters (mls) every 6 hours as needed and failed to evidence as needed reason, Lactulose (laxative) 30 ml as needed and failed to evidence an as needed reason and frequency, Imodium (anti-diarrheal) every 6 hours as needed and failed to evidence an as needed reason, Metoclopramide (medication to increase muscle contractions in digestive system) every 8 hours as needed and failed to evidence an as needed reason, and Ondansetron (anti-nausea medication) every 8 hours as needed and failed to evidence an as needed reason. During an interview, on 09/11/2025, beginning at 9:30 AM, LPN 3 indicated the lactulose was for to be once daily for constipation, the Tylenol was for pain and for fever greater than 101 degrees, and the Imodium was for diarrhea and the reason for the as needed medications. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated the plan of care should have included the reason for the as needed medications. A Plan of Care, for certification period 09/10/2025 to 11/08/2025, indicated Patient was on oxygen via nasal cannula at night and failed to evidence oxygen safety precautions. During an interview, on 09/11/2025, beginning at 9:30 AM, LPN 3 indicated she provided oxygen safety precaution education to the caregiver however she does not document when education was provided. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated oxygen safety precautions should be included on the plan of care. A Plan of Care, for certification period 07/12/2025 to 09/09/2025, indicated skilled nurse to administer tube feedings. A Skilled Nursing Visit Note, dated 08/21/2025, indicated a mickey button site (type of gastrostomy tube) (tube into the stomach to provide nutrition) had placement verified, residual (remaining amount of fluid remaining in the stomach) checked for, and mickey tube care was given. During an observation of a home visit, on 09/11/2025, beginning at 9:30 AM, LPN 3 verified placement of the mickey tube, checked for residual prior to initiating the gastrostomy tube feeding, and head of bed was elevated. During an interview, on 09/11/2025, beginning at 9:30 AM, LPN 3 indicated she performed gastrostomy site care at every skilled nursing visit by cleaning with normal saline and applying gauze. During an interview, on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated the plan of care should have included gastrostomy tube site care, positioning of head of bed, and skilled nurse to check for residual. A Plan of Care, for certification period 09/10/2025 to 11/08/2025, indicated Person C, was the plan of care physician, and skilled nursing to conduct wound care on stage 1 pressure wound to the right hip and failed to evidence the wound care that was to be provided. An Order, dated 07/17/2025, from Person B, identified as the wound care physician, indicated dressing change to right hip with xerofoam as needed. A 60 Day Summary, for certification period 09/10/2025 to 11/08/2025, indicated wound to right hip being treated by home wound doctor. The Plan of Care failed to evidence the name of the wound care doctor and the frequency of visits. During an observation of a home visit, on 09/11/2025, beginning at 9:30 AM, LPN 3 indicated Patient had a stage 1 wound to the right hip and care provided was cleanse site with normal saline and apply xerofoam. LPN 3 indicated she measured the site weekly, and a wound doctor saw Patient every Thursday. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated Patient’s wound care should have been included on the plan of care and the wound care doctor information should have been included on the plan of care. 3. A Plan of Care, for certification period 07/18/2025 to 09/15/2025, for Patient #3 indicated goals would include the Patient’s health would be enhanced throughout the home care services as evidenced by no signs or symptoms of acute exacerbations (a sudden worsening of a medical condition). The Plan of Care failed to evidence the exacerbation signs and symptoms or medical condition to be monitored. 4. A Plan of Care, for certification period 07/31/2025 to 09/28/2025, for Patient #6, indicated goals for Patient was safety to be enhanced throughout the home care service as evidenced by no signs/symptoms of acute exacerbation. The Plan of Care failed to evidence the exacerbation signs and symptoms or medical condition to be monitored. 5. During an interview, on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated Patient’s plan of care goals related to monitoring signs and symptoms of acute exacerbations were not measurable and needed a specific reason for what exacerbations to monitor. 6. A Plan of Care, for certification period 07/31/2025 to 09/28/2025, for Patient #6 indicated Patient was on Warfarin (blood thinning medication) 10 milligrams 2 tablets daily that required blood test monitoring. During an interview on 09/15/2025, beginning at 2:40 PM, LPN 4 indicated Patient was not on Warfarin and was on Eliquis (blood thinning medication).”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure all orders were recorded in the plan of care in 1 of 1 active clinical records reviewed with a feeding tube (Patient #1). Findings include: A policy, dated 12/01/2018, titled, “Plan of Care,” indicated all patient care orders are to be recorded in the plan of care. A Plan of Care, for certification period 07/12/2025 to 09/09/2025, for Patient #1 indicated wound care would include apply adaptic gauze, cover tegaderm every other day. A Physician Order, dated 07/17/2025, indicated home health to provide dressing change to right hip with xerofoam as needed. A Case Conference and Report Record, dated 09/08/2025, indicated wound was being cared for by home physician. A Patient Directives Note, dated 09/08/2025, indicated skilled nurse to provide wound care. A Plan of Care, for certification period 09/10/2025 to 11/08/2025, indicated wound care to stage 1 pressure wound to the right hip and failed to evidence the wound care orders. During an interview, on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated the wound care order from 07/17/2025 should have been incorporated onto the plan of care for certification period 09/10/2025 to 11/08/2025.”

“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 ensure physician verbal orders were documented, signed and dated in the patient’s clinical record in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7). Findings include: 7. A Plan of Care, for certification period 07/12/2025 to 08/09/2025 for Patient #1, was signed by the Director of Nursing on 07/07/2025, indicated RN spoke to the physician and received verbal orders to execute the plan of care frequency and duration; and the plan of care physician signed the plan of care on 08/07/2025. 8. A Plan of Care, received on 09/17/2025, for certification period 09/10/2025 to 11/08/2025, for Patient #4 signed by RN on 09/10/2025, and unsigned by plan of care physician indicated RN spoke to the physician and received verbal orders to execute the plan of care. A review of the clinical record failed to evidence written verbal orders with date and time received to initiate the plan of care. 9. A Plan of Care, for certification period 07/18/2025 to 09/15/2025 for Patient #3, signed by the Director of Nursing on 07/18/2025, signed by the plan of care physician on 08/13/2025 indicated RN spoke with a physician, advised of a home plan of treatment and physicians gave verbal orders to execute this plan of care. A review of the clinical record failed to evidence written verbal orders with date and time received to initiate the plan of care. 10. A Plan of Care, for certification period 07/31/2025 to 09/28/2025, for Patient #6, signed by the Director of Nursing on 07/31/2025, signed by the plan of care physician on 09/05/2025, indicated RN spoke with the physician, advised of home plan of treatment and physician gave verbal order to execute this plan of care. A review of the clinical record failed to evidence written verbal orders with date and time received to initiate the plan of care. 11. During an interview on 09/12/2025 beginning at 2:45 PM, the Director of Nursing indicated she did not write verbal orders to initiate the plan of care and orders were on the plan of care. 410 IAC 17-14-1(a)(H) Based on record review and interview, the agency failed to ensure physician verbal orders were documented, signed and dated in the patient’s clinical record in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7). Findings include: 1. A revised policy, dated 2006, titled, “Physician Orders,” indicated oral orders are put in writing, signed, and dated with date of receipt by RN responsible for supervising ordered services. The policy indicated physician services would include developing and/or authorizing the plan of care and indicated care and services would be provided according to physician orders. 3. A Plan of Care, for certification period 05/11/2025 to 07/09/2025 for Patient #2, signed by the Director of Nursing on 05/12/2025, signed by the plan of care physician on 07/11/2025, indicated RN spoke with a physician, advised of a home plan of treatment and physician gave verbal orders to execute this plan of care. A review of the clinical record failed to evidence written verbal orders with date and time received to initiate the plan of care. 4. A Plan of Care, for certification period 08/14/2025 to 010/12/2025 for Patient #4, signed by the Director of Nursing with no date, signed by the plan of care physician on 08/23/2025 indicated RN spoke with a physician, advised of a home plan of treatment and physicians gave verbal orders to execute this plan of care. A review of the clinical record failed to evidence written verbal orders with date and time received to initiate the plan of care. 5. A Plan of Care, for certification period 09/04/2025 to 11/02/2025 for Patient #5, signed by the Director of Nursing but not dated, not yet signed by the plan of care physician as of 09/15/2025 indicated RN spoke with a physician, advised of a home plan of treatment and physicians gave verbal orders to execute this plan of care. A review of the clinical record failed to evidence written verbal orders with date and time received to initiate the plan of care. 6. A Plan of Care, for certification period 08/16/2025 to 10/14/2025 for Patient #7, signed by the Director of Nursing but not dated, signed by the plan of care physician on 08/19/2025 indicated RN spoke with a physician, advised of a home plan of treatment and physicians gave verbal orders to execute this plan of care. A review of the clinical record failed to evidence written verbal orders with date and time received to initiate the plan of care.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were integrated to ensure the coordination of all services and interventions provided to the patient in 1 of 1 active clinical record reviewed with a feeding tube (Patient #1). Findings include: The POC for the certification periods 07/12/2025 to 09/09/2025 and 09/10/2025 to 11/08/2025, indicated skilled nurse visits 4 to 7 days a week, throughout the certification period. The Physician’s Patient Face to Face Documentation, dated 07/23/2025, signed by a nurse practitioner, indicated the services of a medical social worker, skilled nurse, and home health aide were medically necessary home health services. The Recertification Comprehensive Assessment, dated 07/07/2025, indicated Person E, family member, was limited due to medical issues. The 60 Day Summary for the certification period 09/10/2025 to 11/08/2025, indicated Person E was overwhelmed with Patient’s care. During an interview on 09/12/2025, beginning at 2:45 PM, the Director of Nursing indicated Patient was not offered a home health aide or a medical social worker and there was no documentation in the clinical record of the order being reviewed and it could be the document was filed without review. During an interview during a home visit, on 09/11/2025 beginning at 9:30 AM, Person E indicated he /she was not offered a social worker by the agency and would like to have for Patient. 410 IAC 17-12-2(h)”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient’s needs in 1 of 2 active clinical records reviewed that attended wound clinic (Patient #6). Findings include: The POC for the certification period 07/31/2025 to 09/28/2025, for Patient #6, indicated wound care was to cleanse bilateral lower extremities with normal saline, pat dry, apply Vaseline gauze to wound bed, cover with hydrofera blue, and wrap with kerlix 3 times per week. The record revealed a visit note dated 08/07/2025, by Entity D, a wound clinic, indicated wound care orders for the right lateral leg and left medial leg; the orders were to apply polymem to the wound bed, cover with dry gauze, ABD pad, and wrap with kerlix. Skilled Nursing Visit Notes dated August 09, 12, 15, 18, and 20, 2025 indicated the wound care provided was cleansed with normal saline, applied adaptive dressing and hydrofera blue to the wound bed, cover with ABD pad and kerlix wrap. An Entity D wound clinic note, dated 08/21/2025, indicated right lateral leg, left medial leg, and left shin wound care orders were to apply polymem to the wound bed, cover with dry gauze, ABD pad and wrap with kerlix. The Skilled Nursing Visit Notes, dated August 23, 25, 29, and September 02, of 2025 indicated the wound care provided was cleansed with normal saline, apply adaptive dressing and hydrofera blue to the wound bed, cover with ABD pad and kerlix wrap. An Entity D wound clinic note, dated 09/04/2025, indicated right lateral leg, left medial leg, and left shin wound care orders were to clean with normal saline, apply hydrofera blue to the wound bed cover with dry gauze, ABD pads, and wrap with kerlix roll. The Skilled Nursing Visit Notes, dated 09/06/2025, 09/09/2025, and 09/11/2025, indicated the wound care provided was clean with normal saline apply adaptive dressing along with hydrofera blue to wound bed, cover with ABD pads and kerlix wrap. During an interview, on 09/15/2025 beginning at 1:30 PM, the program director of Entity D indicated the 08/07/2025 wound care orders from the wound care physician did not include the use of hydrofera blue to the wound bed. During an interview, on 09/15/2025 beginning at 4:00 PM, LPN 4 indicated the skilled nurse should coordinate care with the wound care clinic and would expect to see documentation of wound care coordination with the wound clinic. 410 IAC 17-14-1(a)(1)(F)”