Sunrise Home Health Care Services Inc.

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to include in its policies the use of volunteers in an emergency and the role for integration of State and Federally designated health care professionals to address needs during an emergency. The findings include: Review of the emergency preparedness plan and its policies failed to evidence the use of volunteers and the integration of State and Federally designated health care professionals to address needs during an emergency. On 01/23/2026 at 3:08 PM, the Administrator indicated the use for emergency staffing was a hypothetical situation and the use of the phone tree was the plan to activate emergency staffing. The Administrator indicated there was no emergency staff included in the phone tree.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency training program. The findings include: An undated policy titled “Emergency Disaster Plan Orientation and Training” indicated the agency would provide emergency preparedness training to all staff initially and then annually. Review of the emergency preparedness binder, training binder, and personnel files failed to evidence emergency preparedness training for staff. On 01/23/2026 at 3:19 PM, the Administrator indicated there was no training offered for emergency preparedness.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct a community or facilty -wide exercise to test the emergency plan at least every 2 years. The findings include: Review of the emergency preparedness plan failed to evidence a community or facility-wide exercise since the last recertification survey of 02/02/2023. On 01/23/2026 at 3:08 PM, the Administrator indicated the agency had not conducted a community or facility-wide exercise as the agency was informed they did not have to conduct a facility-wide exercise if the agency was not allowed to be included in the community-wide exercise.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency’s Quality Assessment and Performance Improvement (QAPI) Program failed to track quality indicators to include all documented Patient infections in 1 of 1 active clinical records reviewed with a suprapubic catheter (Patient #1). Findings include: An undated policy, titled, “Quality Assurance and Performance Improvement,” indicated the QAPI Program Components would include infection prevention integration. The policy indicated the QAPI Committee would be responsible for identifying performance issues and reviewing data. The policy indicated the agency’s QAPI program would focus on improving clinical care and patient outcomes. A Plan of Care, for certification period 11/16/2025 to 01/14/2026, indicated Patient #1 had a suprapubic catheter (device used to drain urine from the bladder through an incision in the abdominal wall), and was sent to urgent care on 11/07/2025 for blood and sediment in the urine, a urinalysis and culture was performed and a new antibiotic cefpodoxime for 7 days was started on 11/10/2025 for the bacteria that the bacteria was sensitive to on the culture. A RN Skilled Nursing Visit Note, dated 01/07/2026, indicated Patient #1 was started on an antibiotic cefpodoxime on 01/02/2026 for a urinary tract infection. A review of the Infection Logs failed to include Patient #1’s urinary tract infections for 11/07/2025 and 01/02/2026. During an interview on 01/23/2026, beginning at 2:40 PM, the Alternate Administrator indicated the agency was tracking infections for quality indicators for their QAPI program. The Alternate Administrator indicated Patient #1’s urinary tract infections should have been and were not on the tracked infection logs. 410 IAC 17-12-2(a)”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a complete patient’s health status in 1 of 1 active clinical records reviewed of a patient with a suprapubic catheter (Patient #1). Findings include: An undated policy, titled, “Comprehensive Client Assessment,” indicated the comprehensive assessment would include but not limited to a general health status and system assessment, and integumentary (skin) status. A Comprehensive Assessment, dated 01/14/2026, indicated Patient #1 had a suprapubic catheter (device used to drain urine from the bladder through an incision in the abdominal wall), and required skilled nursing visits to assess urine output, evaluate catheter patency and stoma (skin opening) site, and monitor for signs and symptoms of infection. The Comprehensive Assessment failed to include an assessment of the suprapubic catheter stoma site. During an interview on 01/23/2026, beginning at 1:45 PM, the Administrator indicated there was not an assessment of the suprapubic catheter stoma site on the comprehensive assessment and should have been assessed and documented. 410 IAC 17-14-1(a)(1)(B)”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure all treatments were included on the plan of care in 1 of 3 active clinical records reviewed with a diagnosis of diabetes (Patient #3). Findings include: A policy, revised 01/26/2024, titled, “Plan of Care,” indicated the plan of care should include the care and services necessary to meet patient’s specific needs as identified in the comprehensive assessment. A Start of Care Comprehensive Assessment, dated 12/12/2025, indicated Patient #3, start of care 12/12/2025, had a diagnosis of type 2 diabetes with hyperglycemia (elevated blood sugar), Patient was not on hypoglycemic medications, and Patient and caregiver required instruction on use of the glucometer (device to check blood sugar).The Comprehensive Assessment indicated Patient’s fasting blood sugar was 111 at the time of the visit. A Plan of Care, for certification period 12/12/2025 to 02/09/2026, indicated skilled nursing once weekly for 9 weeks to instruct Patient and caregiver on use of glucometer and to record blood sugar readings. The Plan of Care indicated to notify the physician if fasting blood sugar was greater than 300 or less than 60. The Plan of Care was completed by the Alternate Director of Nursing. The Plan of Care failed to evidence a blood sugar testing frequency order. During an interview on 01/23/2026, beginning at 2:30 PM, the Alternate Director of Nursing indicated Patient was to have blood sugar checked weekly, the frequency of blood sugar monitoring should have been and was not on the plan of care. 410 IAC 17-13-1(a)(1)(D)(ix)”

“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 verbal orders for start of care or recertification were obtained or documented in the patient’s clinical record in 2 of 4 active clinical records reviewed with skilled nursing care ordered (Patient #3,Patient #8), and in 1 of 2 active clinical records reviewed with occupational therapy ordered (Patient #6). Findings include: 1.An undated policy, titled, “Verbal Order Policy,” indicated verbal orders would be documented by the clinician into the electronic medical record system on the day they were received and include date, time, name of ordering physician and clinician that received the order. 2.A Plan of Care, for certification period 12/12/2025 to 02/09/2026, indicated skilled nursing frequency was to be one time per week for 8 weeks to instruct Patient #3 on daily blood pressure monitoring and blood sugar monitoring device use. The Plan of Care physician signed the plan of care on 12/22/2025. The Plan of Care was completed by the Alternate Director of Nursing. A review of the clinical record failed to evidence a verbal order from the plan of care physician to start care on 12/12/2025. During an interview on 01/23/2026, beginning at 2:30 PM, the Alternate Director of Nursing indicated she did not obtain verbal orders to start care on Patient. 3.A Plan of Care, for certification period 12/03/2025 to 01/31/2026, indicated Patient #8, start of care 06/06/2025, was to have skilled nursing visits one time per week for 8 weeks to test fasting blood sugar and report results to the physician if blood sugar was less than 60 or greater than 250, and monitor for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (elevated blood sugar). The Plan of Care physician signed the plan of care on 12/04/2025. A Recertification Comprehensive Assessment, dated 12/01/2025, indicated Patient’s random blood sugar was tested with a result of 138, and the skilled nurse instructed Patient on symptoms of hyperglycemia, and to drink more water to remove excess sugar from the blood through urine, and the skilled nurse was to perform blood sugar testing due to Patient was unable to perform. A review of orders failed to evidence a verbal order from the plan of care physician to continue care for certification period 12/03/2025 to 01/31/2026. During an interview on 01/23/2026, beginning at 2:00 PM, the Administrator confirmed the agency did not obtain verbal orders to continue care for the certification period of 12/03/2025 to 01/31/2026. 4. A Plan of Care, for certification period 01/09/2026 to 03/09/2026, indicated Patient #6, start of care 01/09/2026, was to receive occupational therapy once per week for 8 weeks. The Plan of Care physician signed the plan of care on 01/15/2026. The Plan of Care was completed by RN 1. A Missed Visit Order Form, dated 01/13/2026, indicated the plan of care physician was notified Patient requested the initial occupational therapy evaluation for the week of 01/22/2026. A Referral, dated 01/07/2026, indicated disciplines ordered were physical therapy and occupational therapy. During an interview, on 01/23/2026, beginning at 12:45 PM, RN 1 indicated she completed the plan of care and included the occupational therapy frequency based on the referral received, the occupational therapist would complete the plan of care orders and frequency after the evaluation. RN 1 indicated she did not contact the plan of care physician to obtain verbal orders for the occupational therapy frequency. 410 IAC 17-14-1(a)(F)”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aide supervisory assessments were conducted onsite in 1 of 2 active clinical records reviewed with home health aide services (Patient #4). Findings include: A Plan of Care, for certification period 11/11/2025 to 01/09/2026, indicated Patient #4 had Physical Therapy once a week for 9 week, and Home Health Aide (HHA) services twice a week for 9 weeks. An Aide Care Plan, for certification period 11/11/2025 to 01/09/2026, indicated HHA was to complete pulse, respiration and temperature assessment every visit; provide incontinent care, record bowel movement every visit; assist with transfer and positioning every visit; perform shower and shampoo hair every visit. Aide Supervisory Visits, dated 11/21/2025, 12/05/2025, 12/19/2025, and 01/02/2026 indicated RN 1 completed supervisory visits on HHA 1, and HHA 1 was not present at time of visits. The Aide Supervisory Visits indicated HHA 1 demonstrated competency with assigned tasks, complied with infection prevention and control policies and procedures, followed plan of care as instructed and honored Patient’s Rights. During an interview on 01/23/2026, beginning at 12:45 PM, RN 1 indicated she completed HHA supervisory visits by calling Patient on the phone to assess Patient’s satisfaction with care, did not complete the visits on site, and would only go to Patient’s home for every 60 day recertifications.”