Care Plus Homehealth Care Inc.

“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 the patients received the frequency of services as ordered by physician for 1 of 2 active clinical records reviewed with only HHA services. (Patient #7) Findings Include: 1. An undated policy titled “Physician/Allowed Non-Physician Practitioner (NPP) Orders” indicated but was not limited to, “ … All medications and treatments, that are part of the client’s plan of care, must be ordered by the physician … NPP …” 2. A review of Patient #7’s active clinical record evidenced a POC with a SOC of 07/23/2025 and a recertification period from 11/20/2025 to 01/18/2026. The POC evidenced the patient received HHA services 3 to 7 hours a day, 7 days a week for personal care and assistance with ADLs. A review of the HHA visit notes failed to evidence visit notes on the following weekend dates: 11/15, 11/16, 11/22, 11/23, 11/29, 11/30, 12/06, 12/07, 12/13, and 12/14/2025. During an interview with the Administrator on 01/07/2026 at 12:30 PM, they indicated Patient #7 was receiving attendant care services and they had not received an order for the patient. The HHAs go to the patient when they need them. They explained on the POCs, they needed to better differentiate attendant care services and HHA services. During an interview with the Administrator, Alternate Administrator, and the DON on 01/07/2026 at 3:50 PM, they indicated there was no updated order to evidence the patient requested to hold services on the weekends. 410 IAC 17-13-1(a)”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure infection control practices were upheld for hand hygiene practices for 1 of 1 home visit with a HHA (HHA 1) providing care. Findings Include: 1. A review of an undated policy titled “Handwashing/Hand Hygiene” indicated but was not limited to, “ … 3. Indications for handwashing and hand antisepsis: … f. after removing gloves … Hand Hygiene Technique … 3. Multiple use cloth towels are not recommended for use in health care settings. …” 2. During a home visit at Patient #3’s residence on 01/06/2026 at 11:08 AM, HHA 1 was observed providing care for Patient #3. HHA 1 wiped the patient’s rollator with a disinfectant wipe, placed a towel on the rollator, doffed gloves, and donned new gloves without performing hand hygiene. After the HHA applied lotion to the patient’s arms and legs, they doffed their gloves and donned new gloves, and failed to perform hand hygiene after doffing gloves. The HHA was observed taking the patient’s food out of the microwave, doffed their gloves, and proceeded to adjust the patient’s hearing aid. The HHA failed to perform hand hygiene after doffing their gloves. During an interview with HHA 1 on 01/06/2026 at 12:00 PM, they indicated hand hygiene was to be performed every time they doffed their gloves. 410 IAC 17-12-1(m)”

“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 POC was individualized, included all DME and supplies, medication route and indication, hospitalization and emergency room risk, and instructions for a timely discharge for 4 of 7 active clinical records reviewed. (Patients #1, #2, #3, and #7) Findings Include: 1. A review of an undated policy titled “Plan of Care” indicated but was not limited to, “ … 2. The Plan of Care shall be completed in full to include: … m. Medications … n. Medical supplies and equipment required … r. Instructions for timely discharge or referral. s. Discharge plans … u. Other appropriate items. v. All of the above items must always be addressed on the Plan of Care. …” 2. A review of Patient #1’s active clinical record evidenced a POC with a SOC of 12/19/2025 and an initial certification from 12/19/2025 to 02/16/2026. The POC evidenced the following diagnoses: Sepsis (a medical emergency caused by an infection and causes damage to the body’s tissues and organs), Pneumonia (a lung infection with the air sacs filled with fluid or pus), Atrial Fibrillation (a rapid, irregular heart rate), Hyperglycemia (high blood sugar), and Hypertension (high blood pressure). The POC evidenced the patient’s DME included a walker and grab bars. The POC evidenced the patient took 5 milligrams (mg) of Eliquis (a blood thinner which prevents blood clots) 2 times a day orally. The section titled “Safety Measures” indicated but were not limited to, “ … Fall precautions/Transfer Safety, Universal/Infection Precautions, Keep pathways clear, Proper use of assistive device …” During a home visit at Patient #1’s residence on 01/06/2026 at 9:34 AM, it was evidenced the patient had a blood pressure cuff, an automatic blood pressure monitor, pulse oximeter, 2-wheel walker, spirometer, and a stretchy exercise band. The POC failed to evidence all of Patient #1’s DME and bleeding precautions. 3. A review of Patient #2’s active clinical record evidenced a POC with a SOC of 11/07/2023 and a recertification period from 12/26/2025 to 02/23/2026. The POC revealed the following diagnoses: Lumbar Radiculopathy (pain or weakness caused by the compression of a nerve in the lower spine), Spinal Stenosis (narrowing of spaces causing pain and numbness), Parkinsonism (a condition causing tremors, stiffness, and balance issues), chronic pain, and Nerve Root and Plexus Disorder (damage or compression to the nerves as they exit the spine). The POC evidenced the patient’s DME included a bath bench, walker, wheelchair, grab bars, and non-sterile gloves. During a home visit at Patient #2’s residence on 01/06/2026 at 1:58 PM, it evidenced the patient had an elevated toilet seat and a rollator they use with their PT. Patient #2’s POC failed to evidence all of the patient’s DME. 4. A review of Patient #3’s active clinical record evidenced a POC with a SOC of 10/02/2025 and a recertification period from 12/01/2025 to 01/29/2026. The POC included the following diagnoses: Idiopathic Pulmonary Fibrosis (a chronic disease causing difficulty with breathing), Orthostatic Hypotension (the blood pressure lowers when standing after sitting or lying down), Open-angle Glaucoma (a disease where there is build-up of fluid in the eye, causing increased pressure, causing some vision loss), physical debility, and Monoplegia of lower limb affecting unspecified side (condition where one side of the body was weaker than the other). The patient’s medications included Albuterol Sulfate (used to treat difficulty breathing, coughing, and wheezing) 2.5 milligrams (mg)/3 milliliters (ml) 4 times a day, 650 mg of Acetaminophen 3 times a day for pain relief, 81 mg of Aspirin (for pain and inflammation), 22.3mg and 6.8 mg/ml of Cosopt (used to treat high pressure in the eye) in each eye, 0.005 percent of Latanoprost (used to treat high pressure in the eye) in each eye, 2.5 mg of Midodrine (to treat Orthostatic Hypotension) 3 times a day, 17 grams (g) of Polyethylene glycol daily (used to help treat constipation), and 60 mg/ml of Prolia (used to help improve bone mass and strength)injected under the skin, in the fatty layer. The POC evidenced the patient’s DME was non-sterile gloves. The section titled “Discharge Plan(s)” indicated but was not limited to, “ … Discussed discharge plans with patient/caregiver? Yes. …” The patient’s hospitalization and emergency room visit was marked as “n/a” (sic not applicable). During a home visit at Patient #3’s residence on 01/06/2026 at 11:08 AM, it was evidenced the patient had a rollator, electric wheelchair, shower bench, elevated toilet seat, grab bars, wipes, and briefs. A review of Patient #3’s medication list evidenced the following medications: Albuterol Sulfate 2.5 milligrams (mg)/3 milliliters (ml) 4 times a day as needed for shortness of breath through a nebulizer , 650 mg of Acetaminophen 3 times a day orally for pain relief, 81 mg of Aspirin daily, 22.3mg and 6.8 mg/ml of Cosopt in each eye daily, 0.005 percent of Latanoprost in each eye daily, 2.5 mg of Midodrine 3 times a day orally, 17 grams (g) of Polyethylene glycol daily orally as needed for constipation, and 80 mg of Atorvastatin Calium (to lower cholesterol) orally once a day. Patient #3’s POC failed to include all of the patient’s medications, their routes, and indications, DME, timely discharge instruction and plan, and hospitalization and emergency room risk. 5. A review of Patient #7’s active clinical record evidenced a POC with a SOC of 07/23/2025 and a recertification period from 11/20/2025 to 01/18/2026. The POC evidenced the following diagnoses: Dislocation of internal right hip prothesis, pain in right hip, Hypertensive Chronic Kidney Disease (high blood pressure causes narrowing of the blood vessels to the kidney), and Nonrheumatic Aortic Stenosis (narrowing of the heart valve restricting blood flow). The Emergency and Hospitalization risk factors section included but was not limited to, “ … Recent Hospitalizations stays or Emergency Room visits: N/a (sic not applicable) What occurs that makes you want to or need to go to the hospital: N/a. …”. The section titled “Discharge Plan(s)” indicated but was not limited to, “ … Per patient request, Discussed discharge plans with patient/caregiver? Yes. …” Patient #7’s POC failed to include timely discharge instruction and plan and hospitalization and emergency room risk. 6. During an interview with RN 1 on 01/07/2026 at 10:56 AM and 12:59 PM, they indicated the POC should include all DME, anticoagulant precautions, discharge plan, hospitalization risk, and medications including their route and indication. 7. During an interview with the Administrator, Alternate Administrator/Alternate DON, and the DON on 01/07/2026 at 2:35 PM, they indicated all patient POCs were to include all of the patients’ DME, hospitalization risk, discharge plan, and all medications including their route, dose, frequency, and indication. They indicated Corporate Staff 7, a CM, was completing and reviewing the POCs. 8. During an interview with a CM, Corporate Staff 7 on 01/07/2026 at 3:57 PM, they indicated they completed and reviewed POCs. They explained the POC should include all medications including their route, indication, and dose, all DME, and the discharge plan. They explained they were unaware the POC should include the patients’ risk for hospitalization or emergency room visit. 410 IAC 17-13-1(a)(i-xiii)”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure they received orders from the physician to provide services before the physician signed the POC for 1 of 2 active clinical records reviewed with patients receiving HHA services. (Patient #3) Findings Include: 1. An undated policy titled “Physician/Allowed Non-Physician Practitioner (NPP) Orders” indicated but was not limited to, “ … All medications, treatments and services provided to clients must be ordered by a physician/allowed non-physician practitioner (NPP). The orders may be initiated via telephone or in writing and must be countersigned by the provider in a timely manner. …” 2. A review of Patient #3’s active clinical record evidenced a POC with a SOC of 10/02/2025 and a recertification period from 12/01/2025 to 01/29/2026. The POC evidenced the patient received HHA services 3 hours a day, 4 days a week for personal care and assistance with ADLs. Patient #3’s active clinical record failed to evidence an order for the patient’s recertification period. During an interview with HHA 1 on 01/06/2026 at 12:00 PM, they indicated they provided services to the patient 4 days a week and they were increasing the frequency this week for Patient #3. During an interview with RN 1 on 01/07/2026 at 10:56 AM, they indicated when they perform a recertification assessment, they fax the updated POC to the physician to obtain their signature. When queried regarding whether they received verbal orders for the recertification from the physician before receiving the signed POC, they indicated they had not called the physician to obtain a verbal order for the recertification. During an interview with the Administrator, Alternate Administrator/Alternate DON, and the DON on 01/07/2026 at 2:35 PM, they indicated there were no orders from the physician for Patient #3. The Alternate DON indicated they were unaware they needed orders from the physician with the patient asking the agency to receive services. 410 IAC 17-13-1(a)”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of the patient going to the hospital for 1 of 1 active clinical records reviewed with a patient going to the hospital. (Patient #2) Findings Include: 1. A review of an agency policy dated 11/10/2025 and titled “Home Health Physician Notification Process” indicated but was not limited to, “ … Care Plus Home Health requires prompt and accurate physician notification when a patient experiences a fall, incident, or any significant change in condition, status, or plan of care. Notifications must be documented and completed in accordance with clinical judgement … Physician notification is required for … Change in patient status (Improvement, decline, hospitalization, ER (sic Emergency room) visit) …” 2. A review of Patient #2’s active clinical record evidenced a document titled “Patient Communication Log”. The note dated 12/10/2025 by the DON evidenced the DON had called Patient #2 to determine if they had gone to the hospital. The note dated 12/11/2025 by the Administrator evidenced the patient had gone to the hospital, but was not hospitalized. The agency failed to ensure the physician was notified of the patient going to the hospital. During an interview with the DON on 01/07/2026 at 1:25 PM, they indicated there was no communication note evidencing they notified Patient #2’s physician of the patient’s emergency room visit. 410 IAC 17-13-1(a)(2)”

“Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This Element is not met as evidenced by: Based on observation and interview, the agency failed to ensure the HHA performed tasks within their scope for 1 of 1 home visit with a HHA. (HHA 1) Findings Include: 1. A review of a document titled “Job Description Home Health Aide” indicated but was not limited to, “ … The Home Health Aide provides personal care services under the direction of the Registered Nurse … performs services for clients as necessary to maintain their personal comfort. …” 2. During a home visit at Patient #3’s residence on 01/06/2026 at 11:08 AM, HHA 1 was observed providing care for Patient #3. HHA 1 was observed administering a drop of Latanoprost Ophthalmic Emulsion 0.005 percent (used to treat high pressure in the eye) into both of the patient’s eyes. During an interview with HHA 1 on 01/07/2026 at 10:31 AM, they indicated they administered Patient #3’s eye drops because the task was listed in the white binder provided by the patient’s caregiver, Person 1. When queried regarding who trained the HHA to administer the eye drops, they explained Person 1 showed them how to give the patient the medication. During an interview with the Administrator, Alternate Administrator/Alternate DON, and the DON on 01/07/2026 at 1:53 PM, they indicated HHAs were not allowed to administer medications to patients. 410 IAC 17-14-1 (h)(12)”