Canary Home Healthcare of Indiana Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence a comprehensive plan that was updated every two years (see Tag E0004); failed to update delegations of authority and succession plans (see Tag E0007); failed to include a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort of collaboration and cooperative planning (see Tag E0009); failed to update an emergency preparedness communication plan (see Tag E0029); failed to update name and contact information for local emergency preparedness staff (see Tag E0031); and failed to provide emergency preparedness training to staff at least every two years (see Tag E0037). Findings include: 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 at 42 CFR 484.102 Emergency Preparedness, with the likelihood to affect all 26 current patients receiving Home Health services from this provider.”

“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 record review, observation, and interview, the agency failed to ensure services were provided as directed in the POC (see tag G0572); failed to ensure the POC included all medical equipment, patient-specific interventions, and measurable goals (see tag G0574); failed to ensure services were provided only as ordered by a physician (see tag G0580); failed to ensure physician’s verbal orders were documented in the clinical record per agency policy and signed and dated by the physician (see tag G0584); failed to notify the physician with changes in patient’s condition or needs that suggest the POC should be altered (see tag G0590); failed to update the POC with changes as needed (see tag G0592); and failed to ensure care was coordinated with all disciplines providing care (see tag G0606). 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 §484.60 Condition: Care Planning, Coordination, Quality of Care 410 IAC 17-13-1(a)”

“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 agency failed to ensure: the quality assessment and performance improvement (QAPI) program was capable of showing measurable improvement in indicators affecting health outcomes, patient safety, and quality of care (G0642); the program utilized quality indicator data to include measures from OASIS (Outcome and Assessment Information Set) data to identify opportunities for improvement (G0644); the performance improvement activities focused on high risk and high volume areas (G0646); the program tracked adverse events, analyzed their causes, and implemented preventative actions (G0654); performance improvement actions are tracked and measured to ensure improvements are sustained (G0656); and the reason the improvement project was chosen and the measurable progress achieved was documented (G0568). 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. The findings include: Review of the agency’s hospitalization log indicated the following hospitalizations: 1 (5%) for Quarter 1 2024, 2 (10%) for Quarters 2 and 3 2024, 1 (5%) for Quarter 4 2024, 4 (20%) for Quarter 1 2025, 6 (30%) for Quarter 2 2025, 7 (35%) for Quarter 3 2025, 1 (5%) for Quarter 4 2025, and 7 (35%) for Quarter 1 2026. The hospitalization log did not include relevant data to track and trend data such as length of stay and admitting diagnosis. Review of the agency’s infection log indicated the following infections: 0 for Quarters 1, 2, and 3 2025, 1 (5%) for Quarter 4 2025, 4 (20%) for Quarter 1 2026, and 3 (15%) for the month of April 2026. The infection log was missing information for tracking and trending data such as type of infection for patient infections with a date of onset of 11/18/2024 and 04/03/2026. A review of the incident log indicated the following falls: 1 (5%) for Quarters 3 and 4 2024 and Quarter 1 2025, 2 (10%) Quarters 2 and 3 2025, 5 (25%) for Quarter 4 2025, and 4 (20%) for Quarter 1 2026. Review of the QAPI program and meeting minutes dated 06/26/2024, 09/25/2024, 12/30/2024, 03/26/2025, and 12/31/2025 failed to evidence indicators and documented improvements affecting health outcomes, patient safety, and quality of care. The program failed to evidence quality indicator data from OASIS and failed to evidence data, data analysis, and performance improvement activities related to hospitalizations, falls, and infections. The program failed to evidence the reason why the improvement project was chosen and measurable progress achieved. On 04/09/2026 beginning at 1:40 PM, the Administrator indicated the average census for 2024 and 2025 was 18-22. The Administrator indicated the QAPI program did not have any data compiled related to OASIS data outcomes. The Administrator indicated there were no performance improvement actions set in place, because the agency did not go over a threshold value of more than 10% variance in any comparison and indicated there was no data included in the program for the comparison of the variance in threshold value. The Administrator indicated the reason the improvement project was chosen was not documented. The Administrator indicated the QAPI program did not include data related to falls, hospitalizations, and infections. 410 IAC 17-12-2(a)”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to: follow standards of practice, including the use of standard precautions, to prevent the transmission of infections (See tag G0682); maintain program for the surveillance, prevention, control, and investigation of infections (See tag G0684); and follow agency policy to provide infection control education to staff (See tag G0686). The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care for the Condition of Participation 42 CFR 484.70 Infection Prevention and Control. Other unrelated conditions of participation and findings will be cited.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure: the home health aide provide services that were included in the plan of care (see tag G0800); the RN completed a supervisory assessment of HHA services every 14 days (see tag G0808); and the home health aide supervision ensured the care provided followed the plan of care (see tag G0818). The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care for the Condition of Participation 42 CFR 484.80 Home Health Aide Services.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and observation, the agency failed to evidence a comprehensive plan that was updated every two years in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan evidenced a document, titled “Introduction to the Emergency Preparedness Plan”, which indicated that the emergency preparedness plan should be reviewed and updated at least every two years. A document, titled “Administrator Approval & Attestation”, indicated that the agency emergency preparedness policy had been reviewed on 10/30/2025, by the administrator. A review of the agency emergency preparedness plan evidenced the following items: A person identified as the administrator who is no longer employed at the agency.An employee identified as the alternate administrator who no longer holds that position.A person identified as the director of clinical services who is no longer employed at the agency.A person identified as the clinical supervisor who is no longer employed at the agency.An incorrect person listed as the Emergency Management County Coordinator with coordinating incorrect contact information. A person identified in the succession of command who is no longer employed at the agency. A person identified as an official spokesperson for issues pertaining to the emergency preparedness planning who is no longer employed at the agency.A person no longer employed by the agency was identified as a person responsible for providing and/or coordinating education efforts relating to emergency preparedness and planning. During an interview on 04/08/2026 beginning at 1:40 PM, the administrator indicated that the review of the emergency preparedness plan should include updating of contact information and other areas, and this was overlooked during the last review on 10/30/2025.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on record review and interview, the agency failed to update delegations of authority and succession plans for emergency preparedness in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan evidenced a document, titled “Introduction to the Emergency Preparedness Plan”, which indicated that the emergency preparedness plan should be reviewed and updated at least every two years. A document, titled “Administrator Approval & Attestation”, indicated that the agency emergency preparedness policy had been reviewed on 10/30/2025, by the administrator. A review of the emergency preparedness plan evidenced a document titled “Succession of Command”, that identified a person who is no longer employed by the agency as the administrator and director of clinical services, as well as a current employee listed as the alternate administrator who no longer holds this title. During an interview on 04/08/2026 beginning at 1:40 PM, the administrator indicated that the review of the emergency preparedness plan should include updating of contact information and other areas, and this was overlooked during the last review on 10/30/2025.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to include a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort of collaboration and cooperative planning at least every two years in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan failed to evidence documentation of communication, cooperation, or collaboration with local, regional, state, or federal emergency planning authorities, including documented attempts at contacting officials within the last two years. A document, titled “Coordination with Local Emergency Responders and Resources”, indicated that the agency will maintain working relationships with the following agencies: Fire DepartmentLaw enforcement agencyEmergency medical servicesLocal disaster task forceLocal health departmentLocal flood control agencyLocal utility companies During an interview on 04/09/2026 beginning at 11:24 AM, the administrator indicated that there have been no documented attempts to contact emergency officials regarding emergency preparedness cooperation and collaboration since 08/21/2023.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to update the emergency preparedness communication plan in 1 of 1 agency. Findings include: A review of the agency emergency preparedness communication plan indicated the plan should be reviewed and updated every two years and that contact information for incoming new staff and departing staff will be updated throughout the year as necessary. A document, titled “Communication Plan: Staff Contact Information”, evidenced names and contact information for 2 employees who were no longer employed by the agency and names and contact information for 5 of the 16 employees currently employed by the agency. During an interview on 04/08/2025 beginning at 1:40 PM, the administrator indicated that contact information should be updated every two years and that the incorrect and omitted contact information for current employees was an oversight at the time of review on 10/30/2025.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to update name and contact information for local emergency preparedness staff in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan indicated that contact information is updated every 2 years and throughout the year for changes to information for entities listed on the contacts list. A document, titled “Key Contacts Information”, evidenced an incorrect contact name and contact number for the emergency management county coordinator. The name and contact number is for a coordinator in a neighboring city and not affiliated with the county. During an interview on 04/09/2026 beginning at 11:24 AM, the administrator indicated that the emergency contacts information for state, regional, and local emergency staff is gathered from searching on google, and calls are not made to verify or confirm contact information.”

“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 provide emergency preparedness training to staff at least every two years in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan indicated that staff training on the emergency preparedness plan would occur during orientation and at least every two years. A review of training records for staff of the agency evidenced that employees had received emergency preparedness training during orientation, but failed to evidence that any employee had received emergency preparedness training every two years thereafter for the four employees that had been employed greater than two years. During an interview on 04/08/2026 beginning at 3:20 PM, the administrator indicated that every employee is trained in emergency preparedness upon hire, and training is only repeated unless there has been a change in the emergency preparedness plan or procedures.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on record review and interview, the agency failed to update the comprehensive assessment with changes in the patient’s condition in 1 of 1 active clinical record reviewed with an onset of a new wound after the SOC in a total sample. (Patient #4) The findings include: A clinical record review for Patient #4 evidenced a SN visit note dated 04/02/2026 completed by the CM which indicated new pressure ulcers (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) to the buttocks. The record failed to evidence an update to the comprehensive assessment for the change in status due to the new wounds. On 04/07/2026 at 4:23 PM, the CM indicated the comprehensive assessment was not updated for the new wounds. 410 IAC 17-14-1(a)(1)(B)”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on record review, the agency failed to implement its transfer/discharge policy in 1 of 2 closed clinical records reviewed. (Patient #6) The findings include: A 2022 policy titled “Transfer/Referral Criteria and Process” indicated the agency will document all communication with the receiving provider and patient/caregiver in the clinical record and complete a transfer summary within 48 hours of notification of transfer. A clinical record review for Patient #6 indicated a comprehensive assessment for transfer/discharge dated 02/27/2026 which indicated the patient was transferred to the hospital for shortness of breath and was admitted for congestive heart failure (chronic weakening of heart causing fluid overload in lungs). The clinical record failed to evidence documentation of how and when it was notified of the patient’s transfer and failed to evidence any communication with the hospital and patient’s caregiver related to discharging patient due to caregiver’s request to seek an alternative place of residence for the patient upon discharge from the hospital. On 04/09/2026 at 12:40 PM, the CM indicated there was no documentation of how and when the agency was notified of patient’s transfer to the hospital. The CM indicated once the agency found out about the patient’s transfer to the hospital, the agency communicated with the caregiver who indicated they were going to seek an alternative place of residence for the patient such as a skilled nursing facility upon discharge from the hospital. The CM indicated there was no documentation of the communication with the patient’s caregiver related to the discharge and need to find alternative living arrangements for the patient and no communication documented with the receiving facility on the agency’s plan to discharge and not resume home health care upon hospital discharge. 410 IAC 17-12-2(i)”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to send all necessary information pertaining to patient’s current course of illness and post-discharge goals of care to the practitioner (or receiving facility) upon discharge within 48 hours of notification of transfer in 2 of 2 closed clinical records reviewed. (Patient #6, Patient #7) The findings include: 2.A clinical record review for Patient #7 indicated a comprehensive assessment for transfer/discharge dated 03/02/2026 which indicated that Patient #7 was transferred to the hospital for acute respiratory failure and was admitted. During an interview on 04/09/2026 beginning at 2:14 PM, the CM indicated that there was no documentation or record of how, when, and by whom the agency was notified of Patient #7’s transfer to the hospital. Additionally, the CM indicated that while a transfer summary should be sent to the receiving facility within 48 hours of the comprehensive assessment completion, a transfer summary was never sent to the receiving facility for Patient #7. A 2022 policy titled “Transfer Summary” indicated the transfer summary including medications will be sent to the receiving facility within 2 business days of becoming aware of an unplanned transfer. A clinical record review for Patient #6 indicated a comprehensive assessment for transfer/discharge dated 02/27/2026 which indicated the patient was transferred to the hospital for shortness of breath and was admitted On 04/09/2026 at 12:40 PM, the CM indicated the agency was not notified of the transfer to the hospital until 03/02/2026 when the comprehensive assessment at discharge was created in the electronic medical record. The CM indicated the transfer summary was not sent to the receiving facility until 03/13/2026. 410 IAC 17-13-2(a)(b)(9)”

“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 services were provided as directed in the POC in 2 of 5 active clinical records reviewed. (Patient #4, 5) The findings include: 410 IAC 17-13-1A 1. A clinical record review for Patient #4 evidenced a PT POC for the initial certification period 03/08/2026-05/06/2026 signed by the PT on 03/11/2026 which indicated the agency was to provide PT services 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks. The clinical record failed to evidence the agency provided PT services during week 2 beginning 03/15/2026 and week 3 beginning 03/22/2026. On 04/07/2026 at 4:25 PM, the CM indicated the agency did not provide PT services as directed in the POC. 2. A clinical record review for Patient #5 evidenced a POC for the recertification period 02/14/2026-04/14/2026 which indicated the agency would provide SN services 1 time a week for 8 weeks to include a complete physical assessment and wound care to the pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) on the right buttock. Record review failed to evidence the agency provided a SN visit during the week of 02/15/2026. The SN visit note dated 02/26/2026 indicated wound care was already provided by the caregiver and failed to evidence an assessment of the wound. The record failed to evidence an assessment of the wound to the right buttock from 02/13/2026 until 03/06/2026. SN visit notes completed by the CM dated 03/12/2026, 03/19/2026, 03/26/2026, and 04/03/2026 evidenced the patient had non-blanching areas to the right buttocks and failed to evidence the assessment of the wound to include measurements and surrounding skin appearance. During the entrance conference on 04/06/2026 beginning at 12:20 PM, the Administrator indicated the nurse would assess and measure the wounds at every visit. On 04/08/2026 beginning at 1:40 PM, the CM indicated the agency did not provide a SN visit during the week of 02/15/2026 and there was no wound assessment between 02/13/2026 and 03/06/2026. The CM indicated the wound to the right buttocked was no longer open but was non-blanching which was a pressure ulcer stage 1 (pressure-related tissue damage with intact, non-blanching skin) and indicated there were no measurements of the Stage 1 pressure ulcer on 03/12/2026, 03/19/2026, 03/26/2026, and 04/03/2026.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on record review, observation, and interview, the agency failed to follow standards of practice including the use of environmental cleaning and disinfection to prevent the transmission of infections and communicable diseases in 2 of 2 home visit observations with a RN. (Patient #2, Patient #3) The findings include: 2.During a home visit for Patient #3 on 04/07/2026 beginning at 11:36 AM, RN 2 was observed using a stethecope, blood pressure cuff, and pulse oximeter (medical device to measure oxygetn saturation and pulse). RN 2 was observed to wipe the equipment with wipes from an unmarked, plastic bag that she obtained from the nursing bag. No label that stated disinfection solution for the wipes or directions for use was present on the plastic bag. RN 2 was observed wiping the equipment and placing it directly in the nursing bag without a saturation time or dry time. During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that she provides her own disinfecting wipes and does not use agency provided disinfection wipes. RN 2 additionally indicated that she places them in a small plastic bag because the original container is too large for the nursing bag and that she was unaware of the directions for use in regard to saturation and dry time for effective disinfection. A 2022 policy titled “Standard Precautions” indicated that non-disposable equipment used by the clinician would be disinfected by an approved disinfectant. During a home visit observation for Patient #2 on 04/07/2026 beginning at 11:33 AM, RN 1 was observed using a stethoscope, blood pressure cuff, and pulse oximeter (medical device to measure oxygen saturation and pulse). RN 1 was observed wiping the equipment with a disposable wipe from a container which noted the cleaned surfaces must remain wet for 4 minutes and allowed to air dry for disinfection. RN 1 was observed wiping the equipment and immediately placing it in the nursing bag without allowing the surfaces to remain wet for 4 minutes or allowing equipment to air dry. On 04/07/2026 at 11:34 AM, when queried what the dry time was for the disinfecting wipes, RN 1 asked “Is there anything special I’m supposed to do?” RN 1 indicated she probably should have left the equipment out before putting it right back into the nurse bag. 410 IAC 17-12-1(m)”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a program was developed for the surveillance, identification, prevention, and control of infectious and communicable diseases specific to care and services provided in the home setting and was included in the agency’s Quality Assurance and Performance Improvement (QAPI) program. The findings include: 1. A clinical record review for Patient #1 evidenced the patient was admitted to the hospital on 03/23/2026 for a complex urinary tract infection per the hospital admission documents. 2. A clinical record review for Patient #2 evidenced a SN visit note dated 03/17/2026 which indicated the patient had a urinary tract infection and started antibiotics. The infection was not logged on the infection log. 3. A clinical record review for Patient #8 evidenced a comprehensive assessment for recertification dated 12/16/2025 which indicated the patient had cellulitis (bacterial infection affecting deep tissue layers of the skin). 4. Review of the agency’s infection log failed to evidence the infections for Patient #1, #2, and #8. The infection log was missing information for tracking and trending data such as type of infection for logged patient infections with a date of onset of 11/18/2024 and 04/03/2026. The infection log indicated 5 patient infections in 2024, 1 in 2025, and 7 for year-to-date 2026. The agency failed to evidence an infection control program to include the surveillance of infections to include the aggregations of data to track and trend the patient infections. 5. A review of the QAPI program failed to evidence the data related to the patient infections. 6. On 04/09/2026 at 2:17 PM, the Administrator indicated there was no data aggregation of infections and no infections data was included in the QAPI program.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide infection control education to staff annually per its policy in 3 of 3 personnel records reviewed of licensed personnel that have been hired for greater than 1 year (CM, RN 1, PT 3) and failed to provide infection control education at time of hire in 1 of 2 personnel records reviewed of licensed personnel that have been hired for under 1 year (PT 1). The findings include: 1. A 2022 policy titled “Training/Inservice Education” indicated mandatory inservices would be attended by all disciplines and would include annual training for infection control. 2. A 2022 policy titled “Infection Control Plan” indicated new personnel receive a copy of the standard precautions at time of orientation and staff will receive infection control training no less than annually. The policy indicated attendance would be documented and maintained in the personnel files. 3. A personnel record review for the CM, date of hire 12/26/2022, failed to evidence infection control education since hire. 4. A personnel record review for RN 1, date of hire 08/19/2024, failed to evidence infection control education since hire. 5. A personnel record review for PT 3, date of hire 04/25/2024, failed to evidence infection control education since hire. 6. A personnel record review for PT 1, date of hire 02/06/2026, failed to evidence infection control education. 7. Review of the agency inservice binder failed to evidence any education other than OASIS (Outcome and Assessment Information Set) dated 03/25/2026. 8. On 04/08/2026 at 2:06 PM, the CM indicated there was no specific annual inservice provided to staff and infection control education was only provided at time of hire. 9. On 04/08/2026 beginning at 2:39 PM, the Administrator indicated the agency had not yet provided refresher training related to hand hygiene and bag technique. The Administrator indicated there was not any infection control training for PT 1.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical records were accurate in 1 of 3 active clinical records reviewed with an infection. (Patient #2) The findings include: 410 IAC 17-15-1 (a)(7) A 2022 policy titled “Clinical/Service Data Collection” indicated documentation in the clinical record would be accurate and reflect the care provided. A clinical record review for Patient #2 evidenced SN visit notes dated 03/17/2026 and 03/31/2026 which indicated the patient had a urinary tract infection and started antibiotics “today” on 03/17/2026. On 04/07/2026 at 2:09 PM, the CM indicated the SN visit note dated 03/31/2026 was not accurate but a carry-over from the SN visit note dated 03/17/2026.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete the comprehensive assessment in a timely manner in 1 of 2 clinical record reviews of new admission patients. (Patient #1) Findings include: A policy, titled “Initial and Comprehensive Assessment”, indicated that a comprehensive patient assessment should be completed within 5 calendar days of the patient’s SOC. A clinical record review, for Patient #1, evidenced that the SOC comprehensive assessment was performed on 03/12/2026. The PT comprehensive assessment and the OT comprehensive assessment were both completed 7 days later on 03/19/2026. During an interview on 04/08/2026 beginning at 11:31 AM, the CM indicated that the PT and OT comprehensive assessment should be performed within 24 to 48 hours of SOC. The CM indicated that if the family of Patient #1 had refused the PT and OT comprehensive assessment, there was no documentation as such.”

“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 the physical, mental, and psychosocial status in 2 of 3 active clinical records reviewed with a wound present at time of the comprehensive assessment. (Patient #2, 5) The findings include: 1. A clinical record review for Patient #2 evidenced a comprehensive assessment for recertification dated 03/26/2026 which indicated the patient had a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (a pressure ulcer with partial thickness loss of skin) to the right side of the sacrum (lower back above the buttocks). The assessment failed to evidence the assessment of the depth of the wound. The assessment indicated the patient complained of “achy” legs and failed to evidence an assessment of the pain to include intensity, duration, frequency, character, aggravating and alleviating factors, and impact on function. On 04/07/2026 at 2:03 PM, the CM indicated the comprehensive assessment did not include the depth of the wound and a complete pain assessment. 2. A clinical record review for Patient #5 evidenced a comprehensive assessment at the recertification dated 02/13/2026 completed by the CM which indicated the patient had a stage II pressure ulcer to the right buttocks and failed to evidence an assessment of the wound depth. The assessment indicated patient had a gastrostomy (GT, a type of feeding tube surgically inserted through the abdomen and into the stomach) and failed to evidence the assessment included the size of the GT. On 04/08/2026 and 1:34 PM, the CM indicated the wound was open and the assessment did not include the depth. The CM indicated the assessment did not include the size of the GT. 410 IAC 17-14-1(a)(1)(B)”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the need for nursing services in 1 of 2 active clinical records reviewed with a feeding tube. (Patient #5) The findings include: A clinical record review for Patient #5 evidenced a POC for the recertification period 02/14/2026-04/04/14/2026 which indicated the agency was to provide SN services 1 time a week for 8 weeks to include instructing the caregiver on the management of the feeding tube. A comprehensive assessment at recertification dated 02/13/2026 indicated patient received care by caregiver who managed the tube feeding. The assessment failed to evidence the need for nursing services related to the feeding tube. On 04/08/2026 at 1:34 PM, the CM indicated the caregiver was able to manage the tube feeding and the need for SN to educate the caregiver on the feeding tube was not documented. 410 IAC 17-14-1(a)(1)(B)”

“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 reconciliation of medications in 3 of 5 active clinical records reviewed. (Patient #2, 4), and failed to ensure the reconciliation of medications included notification of major drug interactions to the provider in 2 of 2 active clinical record reviews of patients who had major drug interactions identified. (Patient #1, Patient #8) The findings include: 1. A clinical record review for Patient #2 evidenced a referral document from the attending nurse practitioner dated 02/02/2025 which indicated a medication list which included Gabapentin (to treat seizure and/or nerve pain), Diazepam (to treat anxiety and/or seizures), and Atorvastatin (to treat high cholesterol). The POC for the initial certification period 02/04/2025-04/04/2025 failed to evidence the patient’s medications included Gabapentin, Diazepam, and Atorvastatin. A comprehensive assessment at the SOC dated 02/04/2025 failed to evidence the review of the medication discrepancy between what was included in the attending physician’s list of ordered medications and what was included in Patient’s POC. On 04/07/2026 at 1:57 PM, the CM indicated the comprehensive assessment did not document the discrepancy of the medications between the medication list on the referral and on the POC. 2. A clinical record review for Patient #4 evidenced an agency document dated 04/07/2026 and titled “Drug-Drug Interactions” which indicated there were 6 drug interactions between Levothyroxine (for underactive thyroid) and Sertraline (for depression); Cyanocobalamin (Vitamin B) and Omeprazole (for reflux); Aspirin (for pain, fever, and/or prevention of blood clots) and Sertraline; Aspirin and Spironolactone (for high blood pressure, heart failure, and/or fluid retention); Aspirin and Furosemide (for fluid retention); and Levothyroxine and Omeprazole. The POC for the initial certification period 03/08/2026-05/06/2026 indicated the patient’s medications included Levothyroxine, Sertraline, Cyanocobalamin, Omeprazole, Aspirin, Spironolactone, and Furosemide. The comprehensive assessment at SOC dated 03/08/2026 completed by the CM indicated no issues were found during the drug review and failed to evidence the review of the drugs to include the drug interactions. On 04/08/2026 at 1:59 PM, the CM indicated the agency only reviews medications for severe interactions and indicated the moderate and minor drug reactions were not included in the drug review at the time of the comprehensive assessment. 1.A policy, titled “Ongoing Assessment”, indicated that the provider should be notified of medications which might interact. 2. A clinical record review for Patient #2 evidenced a referral document from the attending nurse practitioner dated 02/02/2025 which indicated a medication list which included Gabapentin (to treat seizure and/or nerve pain), Diazepam (to treat anxiety and/or seizures), and Atorvastatin (to treat high cholesterol). The POC for the initial certification period 02/04/2025-04/04/2025 failed to evidence the patient’s medications included Gabapentin, Diazepam, and Atorvastatin. A comprehensive assessment at the SOC dated 02/04/2025 failed to evidence the review of the medication discrepancy between what was included in the attending physician’s list of ordered medications and what was included in Patient’s POC. On 04/07/2026 at 1:57 PM, the CM indicated the comprehensive assessment did not document the discrepancy of the medications between the medication list on the referral and on the POC. 2. A clinical record review for Patient #4 evidenced an agency document dated 04/07/2026 and titled “Drug-Drug Interactions” which indicated there were 6 drug interactions between Levothyroxine (for underactive thyroid) and Sertraline (for depression); Cyanocobalamin (Vitamin B) and Omeprazole (for reflux); Aspirin (for pain, fever, and/or prevention of blood clots) and Sertraline; Aspirin and Spironolactone (for high blood pressure, heart failure, and/or fluid retention); Aspirin and Furosemide (for fluid retention); and Levothyroxine and Omeprazole. The POC for the initial certification period 03/08/2026-05/06/2026 indicated the patient’s medications included Levothyroxine, Sertraline, Cyanocobalamin, Omeprazole, Aspirin, Spironolactone, and Furosemide. The comprehensive assessment at SOC dated 03/08/2026 completed by the CM indicated no issues were found during the drug review and failed to evidence the review of the drugs to include the drug interactions. On 04/08/2026 at 1:59 PM, the CM indicated the agency only reviews medications for severe interactions and indicated the moderate and minor drug reactions were not included in the drug review at the time of the comprehensive assessment. 3.A clinical record review for Patient #1, evidenced a referral document from the attending provider dated 03/11/2026 that included a list of current medications to include Metformin (to treat diabetes) and Carvedilol (to treat high blood pressure). The POC for the initial certification period of 03/12/2026 to 05/10/2026 failed to evidence that Patient #1’s medications included Metformin and Carvedilol. Additionally, medications listed on the POC but not listed on the referral document included Aspirin (for anticoagulation), Cardizem (to treat high blood pressure), Mirtazepine (to treat depression), Wound wash (for wound care), Manuka honey (for wound care), and Desitin Paste (to protect skin). A comprehensive assessment at the SOC dated 03/12/2026 failed to evidence the review of the medication discrepancy between what was included on the attending provider’s list of medications and what was included in Patient #1’s POC. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that there was no documentation of medication discrepancies identified at the SOC, or that the discrepancies were discussed with the provider. #.A clinical record review for Patient #1 evidenced a document, titled “Drug-Drug Interactions”, that indicated a major drug interaction between the medications Sertraline (to treat depression) and Mirtazepine (to treat depression). The record failed to evidence that the physician was notified of the major drug-drug interaction. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that there was no documentation of a conversation with the provider regarding the major drug interactions. #.A clinical record review for Patient #8 evidenced a document, titled “Drug-Drug Interactions”, that indicated two major drug interactions: between the medications Clopidogrel (used as an anticoagulant) and Esomeprazole (used to decrease stomach acid), and Trelegy Elipta (to treat chronic obstructive pulmonary disease) and Carvedilol (to treat blood pressure). During an interview on 04/09/2026 beginning at 9:25 AM, RN 1 indicated that there was no conversation with the provider to discuss the major drug interactions, and that the only communication with the provider is the faxed medication reconciliation.”

“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 included all medical equipment, patient-specific interventions, and measurable goals in 4 of 7 clinical records reviewed. (Patient #2, 4, 5 ,6) The findings include: 410 IAC 17-13-1 (a)(1)(D)(i-xiii) 1. During an observation of care at the home of Patient #2 on 04/07/2026 beginning at 11:05 AM, the patient was observed lying on an air mattress. A comprehensive assessment for recertification dated 03/26/2026 indicated the patient took an Ensure supplement (nutritional supplement) at breakfast and dinner daily. A clinical record review evidenced a POC for recertification period 03/31/2026-05/29/2026 which failed to include the air mattress and Ensure supplement. The POC indicated the patient’s medications included a lidocaine (pain relieving medication) patch topically to the affected area daily and failed to evidence what area was affected. The POC indicated blood sugar parameters for when to notify the physician, and the POC failed to evidence blood sugars were supposed to be checked and a diagnosis for diabetes (a chronic disease affecting blood sugar). The POC indicated goals that the patient would reach optimal effectiveness of pain and maintain appropriate body weight and would reach optimal nutrition and hydration. The POC did not include the patient-specific optimal level of pain, nutrition, and hydration and failed to evidence what was the appropriate body weight. On 04/07/2026 at 11:22 AM, the patient’s caregiver indicated the lidocaine patches were applied as needed to the patient’s neck and forehead. On 04/07/2026 beginning at 1:57 PM, the CM indicated the POC did not include the air mattress and Ensure supplement. The CM indicated the affected area for the lidocaine patch was not included on the POC. The CM indicated the patient was not diabetic and the blood sugar parameter was not patient-specific but a generic intervention. The CM indicated the goals on the POC were generic and not patient specific. 2. A clinical record review for Patient #4 evidenced a comprehensive assessment at SOC dated 03/08/2026 and completed by the CM which indicated the patient had an acute exacerbation of congestive heart failure (chronic, progressive condition where the heart cannot pump efficiently and causes fluid to back-up in the lungs and body) and had difficulty breathing with minimal exertion. The patient had a recent increase of Furosemide (medication to decrease the swelling caused by fluid overload in the tissues) and had swelling to both legs. The POC for the initial certification period 03/08/2026-05/06/2026 failed to evidence interventions and goals for the swelling. On 04/07/2026 at 4:23 PM, the CM indicated specific interventions such as educating the patient to elevate legs and measuring legs were not included as patient-specific interventions in the POC. The CM indicated there was no patient-specific goal for the patient’s edema. 3. A clinical record review for Patient #5 evidenced a comprehensive assessment for the recertification dated 02/13/2026 which indicated the patient used a purewick (an external catheter that uses suction and a tube to drain urine away from the body) for bladder incontinence. A SN visit dated 03/26/2026 indicated the patient had heel protectors and an air mattress. The POC for the recertification 02/14/2026-04/14/2026 failed to evidence the external catheter. The POC indicated the patient had a gastrostomy (GT, a type of feeding tube surgically inserted through the abdomen and into the stomach) and had a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (a pressure ulcer with partial thickness loss of skin) to the right buttock. The POC indicated the goals included patient was to have effective tube feeding management and optimal wound healing. The POC failed to include measurable goals related to tube feeding management and wound healing. The POC failed to evidence the size of the GT. The POC failed to evidence the heel boots and air mattress. On 04/08/2026 beginning at 1:32 PM, the CM indicated the goals were generated by the program used to develop the POC according to the interventions, so the goals were not measurable. The CM indicated the POC did not include the size of the GT. The CM indicated the purewick external catheter, heel boots, and air mattress were not included in the POC. 4. A clinical record review for Patient #6 evidenced a comprehensive assessment for recertification dated 01/27/2026 which indicated the patient’s diagnoses included heart failure and indicated the patient had edema (swelling) to both legs. A SN visit note dated 02/11/2026 completed by LPN 1 indicated the caregiver complained the patient was becoming more short of breath and indicated the patient was assessed to have difficulty breathing. The visit note indicated LPN 1 instructed the patient to use a spirometer (a handheld medical device used to improve lung function and improve deep breathing capacity). The POC for the recertification period 01/31/2026-03/31/2026 failed to evidence the use of a spirometer and failed to evidence interventions and goals related to the edema. On 04/09/2026 at 2:53 PM, the CM indicated the spirometer and interventions related to the edema were not included in the POC.”

“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 observation, record review, and interview, the agency failed to ensure services were provided only as ordered by a physician in 4 of 5 active clinical records reviewed. (Patient #2, Patient #4, Patient #5, Patient #1) The findings include: 7. A clinical record review for Patient #1 evidenced a POC for the certification period of 03/12/2026 to 05/10/2026 which was not signed by the physician until 03/27/2026. The record evidenced that the agency provided HHA services on 03/13/2026, 03/21/2026, and 03/23/2026; SN services on 03/12/2026 and 03/19/2026. The record failed to evidence an order for home health services from the SOC until the POC was signed on 03/27/2026. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that the provider is not typically contacted for orders at the SOC unless there are immediate needs, and that the order for services is the POC that may remain unsigned initially. 1. A 2022 policy titled “Physician Participation in Plan of Care” indicated the physician would direct the patient care and care would be provided in compliance with orders. The physician orders for care would include diagnoses, treatments to include type and frequency, and medications. Verbal orders will be obtained at the time the POC is established and documented in the clinical record. 2. A 2022 policy titled “Verification of Physician Orders” indicated verbal orders would be documented on an agency form, dated and signed by the professional receiving the order, and the original of the order form would be delivered to the physician for signature. 3. A 2022 policy titled “Care Planning Process” indicated the plan of care will be based on the physician’s (or other licensed practitioner’s) orders. 4. During an observation of care at the home of Patient #2 on 04/07/2026 from 11:05 AM to 11:45 AM, RN 1 was observed providing a head-to-toe assessment, patient/caregiver education, and medication management. A clinical record review evidenced a POC for recertification period 03/31/2026-05/29/2026, which was not yet signed by the physician. The record failed to evidence an order for home health services after the physician-signed POC ending 03/30/2026. On 04/07/2026 at 1:52 PM, the CM indicated the POC was the agency’s order for recertification and continuation of home health services and the POC beginning 03/31/2026 was not yet signed by the physician. 5. A clinical record review for Patient #4 evidenced an order from the nurse practitioner dated 03/05/2026 which indicated the agency was to evaluate and treat for SN, HHA, PT, and OT. The comprehensive assessment at SOC dated 03/08/2026 and completed by the CM indicated the patient had rashes to both legs and under both breasts that required topical medication. The assessment indicated the patient had an acute exacerbation of congestive heart failure (chronic, progressive condition where the heart can not pump efficiently and causes fluid to back-up in the lungs and body) and had difficulty breathing with minimal exertion. The patient had a recent increase of Furosemide (medication to decrease the swelling caused by fluid overload in the tissues) and had swelling to both legs. The record indicated the agency provided PT services on 03/11/2026; HHA services on 03/12/2026, 03/14/2026, and 03/17/2026, and SN services on 03/18/2026. The clinical record indicated the POC for the initial certification period 03/08/2026-05/06/2026 was not signed until 03/20/2026 and no other orders for care were provided before 03/20/2026. On 04/07/2026 at 4:19 PM, the CM indicated the POC is order for care. The CM indicated she did not speak to the nurse practitioner at SOC and was unsure of the name of the person she spoke to at the nurse practitioner’s office when she left a message regarding the SOC. The CM indicated the nurse practitioner did not return the phone call regarding the SOC. 6. A clinical record review for Patient #5 evidenced a POC for recertification period 02/14/2026-04/14/2026, which was not by the physician until 02/25/2026. The record evidenced the agency provided HHA services on 02/16/2026, 02/20/2026, and 02/23/2026. The record failed to evidence an order for home health services after the physician-signed POC ending 02/13/2026. On 04/08/2026 at 1:29 PM, the CM indicated there was no additional orders from the physician after the ending of the certification period on 02/13/2026 and before the POC for the certification beginning 02/14/2026 was signed by the physician on 02/25/2026. The CM indicated she did not recall speaking to the physician to get verbal orders for the recertification of the patient at the time of the comprehensive assessment on 02/13/2026. 410 IAC 17-13-1(a)”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician’s verbal orders were documented in the clinical record per agency policy and signed and dated by the physician in 1 of 1 clinical record with a change in attending physicians. (Patient #5) The findings include: A clinical record review for Patient #5 evidenced a referral order from Person 1 (physician) for home health services for SN, PT, and HHA services dated 08/20/2024. The comprehensive assessment at SOC dated 08/23/2024 completed by the CM which indicated the CM contacted Person 1 regarding the SOC and the SN and HHA services. A communication note dated 09/03/2024 completed by the CM indicated the patient’s caregiver requested to change the attending physician from Person1 to Person 2 (physician). The POC for the initial certification period 08/23/2024-10/21/2024 was signed by Person 2. The record failed to evidence a verbal order was written and signed by the physician for home care services as discussed at the comprehensive assessment with the CM on 08/23/2024. On 04/08/2026 at 4:32 PM, the CM indicated there was no documentation of the verbal order or the SOC by Person 1. 410 IAC 17-14-1(a)(H)”

“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 notify the physician with changes in patient’s condition or needs that suggest the POC should be altered in 5 of 8 clinical records reviewed. (Patient #2, Patient #4, Patient #5, Patient #6, Patient #3) The findings include: 6. A policy, titled “Scope of Services”, indicated that nursing services provided to patients includes informing the physician and other staff of changes in the patient’s needs. A clinical record review for Patient #3, evidenced the following: A SN visit note, dated 03/20/2026, by RN 2, indicated that Patient #3 was in need of refills of medications and that RN 2 attempted to call refills into the pharmacy, but the pharmacy was closed due to power outage. The note failed to evidence that the physician was notified of the pharmacy unable to refill the medications.A SN visit note, dated 03/27/2027, indicated that the pharmacy was closed due to power outage for the day. The note failed to evidence that the physician was notified of the pharmacy unable to refill the medications.A SN visit note, dated 04/03/3036, indicated that RN 2 attempted to reorder medications into the pharmacy, but the pharmacy was closed. The record failed to evidence that the physician was notified of the pharmacy unable to refill the medications.During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that the pharmacy was closed and she was unable to have medications refilled for 4 weeks. Additionally, she indicated that the physician was not notified of the inability to have Patient #3’s medications refilled. During an interview on 04/09/2026 beginning at 12:45 PM, the pharmacy manager at Patient #3’s pharmacy confirmed that Patient #3 has their medications filled through this pharmacy and that the only closure in the last 60 days had been on 03/13/2026 due to a power outage. 1. A 2022 policy titled “Admission Documents” indicated the agency will notify the physician or other licensed practitioner of refusal of services. 2. A clinical record review for Patient #2 evidenced a referral order from the ordering nurse practitioner dated 02/02/2025 for OT services. The clinical record failed to evidence OT services were provided. The referral document evidenced a medication list which included Gabapentin (to treat seizure and/or nerve pain), Diazepam (to treat anxiety and/or seizures), and Atorvastatin (to treat high cholesterol). The POC for the initial certification period 02/04/2025-04/04/2025 failed to evidence the patient’s medications included Gabapentin, Diazepam, and Atorvastatin. On 04/07/2026 beginning at 12:37 PM, the CM indicated the agency did not provide OT services, because the agency did offer OT services at the time of referral. The CM indicated there was no documentation the agency notified the ordering nurse practitioner that the agency was not able to provide the OT services as ordered. The CM indicated there was no documentation the agency notified the attending nurse practitioner of the discrepancy in medications. 3. A clinical record review for Patient #4 evidenced a referral order from the ordering nurse practitioner dated 03/05/2026 which indicated the agency was to provide OT services. The clinical record failed to evidence the agency provided OT services and failed to evidence the agency notified the nurse practitioner that OT services were not provided. On 04/07/2026 at 4:17 PM, the CM indicted the patient refused OT and there was no documentation the agency notified the ordering nurse practitioner that the patient refused OT services as ordered. 4. A clinical record review for Patient #5 evidenced a referral order from the physician dated 08/20/2024 which indicated the agency was to provide SN, HHA, and PT services. The consent form dated 08/23/2026 and signed by the patient’s caregiver indicated the patient/caregiver refused PT services. The clinical record failed to evidence the agency notified the physician the patient/caregiver refused PT services as ordered. On 04/08/2026 at 4:25 PM, the CM indicated there was no documentation the physician was notified the patient/caregiver refused PT services. 5. A clinical record review for Patient #6 evidenced the POC for the recertification period 01/31/2026-03/31/2026 which indicated patient’s diagnoses included heart failure. The POC failed to evidence the use of a spirometer. A SN visit note dated 02/11/2026 completed by LPN 1 indicated caregiver complained the patient was becoming more short of breath and indicated the patient was assessed to have difficulty breathing. The visit note indicated LPN 1 instructed the patient to use a spirometer (a handheld medical device used to improve lung function and improve deep breathing capacity) and indicated the patient’s weight increased by 6 pounds from the previous visit on 02/04/2026. A SN visit note dated 02/19/2026 completed by LPN 1 indicated the patient complained of being short of breath with just sitting and indicated the patient was assessed to have difficulty breathing. A PT visit note dated 02/24/2026 completed by PT 2 indicated the patient complained of dizziness, had a blood pressure higher than usual of 170/80, and a reported blood sugar of over 200. A SN visit note dated 02/24/2026 completed by LPN 1 indicated the patient’s caregiver was more short of breath and was assessed to have difficulty breathing. A discharge summary dated 02/27/2026 indicated the patient was transferred to the hospital due to shortness of breath and admitted for congestive heart failure (weakness of the heart causing fluid to back up in the lungs and other parts of the body). The record failed to evidence the agency notified the physician related to the patient’s complaints of shortness of breath and dizziness, weight gain, difficulty breathing, spirometer use, and elevated blood pressure and blood sugar prior to the patient’s transfer to the hospital. On 04/09/2026 at 2:28 PM, the CM indicated the agency did not notify the physician related to the changes in the patient’s condition.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to update the POC with changes as needed in 1 of 2 home visits with a RN. (Patient #2) The findings include: During an observation of care at the home of Patient #2 with RN 1 on 04/07/2026 at 11:25 AM, a dry dressing was observed to the patient’s sacrum (lower back above the buttocks). The patient’s caregiver was observed to remove the dressing, and the patient’s sacrum and buttocks were observed without an open area. A clinical record review evidenced a POC for the recertification period 03/31/2026-05/29/2026 which indicated a diagnosis of a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (a pressure ulcer with partial thickness loss of skin) to the sacral region. The POC failed to evidence it was updated to reflect the wound was healed and pure honey and a dry dressing was applied daily to the sacral area. On 04/07/2026 at 11:25 AM, RN 1 indicated the wound to the coccyx/buttocks was healed. On 04/07/2025 at 11:28 AM, the patient’s caregiver indicated they were still applying “pure honey” to the wound and covering with a dry dressing daily for protection to the area. On 04/07/2026 at 2:55 PM, RN 1 indicated the wound to the sacrum was healed in the last few weeks and the family was applying honey to the wound for 3 months. RN 1 indicated she did not update the POC to reflect the healed wound and use of honey.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated with all disciplines providing care in 1 of 2 active clinical records reviewed with PT services (Patient #4) and in 1 of 2 closed clinical record reviewed. (Patient #6) The findings include: 1. A clinical record review for Patient #4 evidenced a PT POC for the initial certification period 03/08/2026-05/06/2026 which indicated the agency was to provide PT services 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks. A missed visit note dated 03/17/2026 and completed by PT 1 indicated the patient was not feeling well and cancelled PT. The record failed to evidence PT 1 notified the RN case manager the patient was not feeling well. Missed visit notes dated 03/20/2026, 03/24/2026, and 03/27/2026 completed by PT 1 indicated PT services were cancelled. The clinical record failed to evidence PT services were provided week 2 beginning 03/15/2026 and week 3 beginning 03/22/2026, and the record failed to evidence PT 1 coordinated care with the RN case manager regarding the PT frequency directed by the POC was not able to be met. On 04/07/2026 at 4:25 PM, the CM (and RN case manager) indicated PT 1 did not inform her of the patient’s report of not feeling well. The CM indicated there was no documentation the PT notified the CM of the missed PT visits prior to 04/01/2026. 2. A clinical record review for Patient #6 evidenced the POC for the recertification period 01/31/2026-03/31/2026 which indicated patient’s diagnoses included heart failure. The POC failed to evidence the use of a spirometer. A SN visit note dated 02/11/2026 completed by LPN 1 indicated caregiver complained the patient was becoming more short of breath and indicated the patient was assessed to have difficulty breathing. The visit note indicated LPN 1 instructed the patient to use a spirometer (a handheld medical device used to improve lung function and improve deep breathing capacity) and indicated the patient’s weight increased by 6 pounds from the previous visit on 02/04/2026. A SN visit note dated 02/19/2026 completed by LPN 1 indicated the patient complained of being short of breath with just sitting and indicated the patient was assessed to have difficulty breathing. A PT visit note dated 02/24/2026 completed by PT 2 indicated the patient complained of dizziness, had a blood pressure higher than usual of 170/80, and a reported blood sugar of over 200. A SN visit note dated 02/24/2026 completed by LPN 1 indicated the patient’s caregiver was more short of breath and was assessed to have difficulty breathing. A discharge summary dated 02/27/2026 indicated the patient was transferred to the hospital due to shortness of breath and admitted for congestive heart failure (weakness of the heart causing fluid to back up in the lungs and other parts of the body). The record failed to evidence LPN 1 and PT 2 notified the RN case manager in efforts to coordinate care related to the patient’s complaints of shortness of breath and dizziness, weight gain, difficulty breathing, spirometer use, and elevated blood pressure and blood sugar prior to the patient’s transfer to the hospital. On 04/09/2026 at 2:28 PM, the CM indicated LPN 1 and PT 2 did not notify the RN case manager related to the changes in the patient’s condition. 410 IAC 17-12-2(g)”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the SN provided services ordered by the provider as indicated in the plan of care in 1 of 4 active clinical record reviews of patients who had received services for greater than 60 days. (Patient #1) Findings include: A policy, titled “Care Planning Process”, indicated that the POC should contain patient specific interventions. A clinical record review for Patient #3, evidenced a POC, dated 02/26/2026, that indicated the physician should be notified of a diastolic blood pressure less than 60mmhg. A SN visit note, by RN 2, dated 03/06/2026, evidenced a blood pressure reading of 92/56mmhg. The visit note failed to evidence communication that the physician had been notified of the diastolic blood pressure of less than 60mmhg. During an interview on 04/09/2026 beginning at 9:42 AM, RN 1 indicated that she did not notify the physician of the blood pressure of Patient #3 that was outside of parameters because the patient was not symptomatic, and would have notified the physician if the patient was symptomatic. 410 IAC 17-14-1(a)(1)(C)”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency filed to ensure accurate preparation of clinical notes in 1of 4 active clinical record reviews of patients who received services more than 60 days. (Patient #8) Findings include: A policy, titled “Contents of Clinical Record”, indicated that the clinical record will be maintained for each patient and that each clinical record should accurately documented. A clinical record review for Patient #8 evidenced the following: A comprehensive assessment dated 02/11/2026, that indicated that Patient #8 uses a nasal cannula for oxygen administration and did not indicate an assessed need for occupational therapy.A SN visit note, dated 02/17/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services.A SN visit note, dated 03/03/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services.A SN visit note, dated 03/17/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services.A SN visit note, dated 03/31/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services. During an interview on 04/09/2026 beginning at 9:25 AM, RN 1 indicated that she uses a copy and paste feature to prepare the clinical notes and the documentation of a need for occupational therapy and simple mask use for oxygen was an error and oversight to be placed on multiple SN notes. 410 IAC 17-14-1(a)(1)(E)”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHA provided the tasks as directed in the POC in 3 of 4 active clinical records reviewed with HHA services. (Patient #4, Patient #5, Patient #3) The findings include: 3. A clinical record review for Patient #3, evidenced an HHA care plan, dated 03/01/2026, that indicated the HHA tasks to be performed by the HHA every visit included combing of hair, oral care, assisting with bedside commode use, and meal preparation. The HHA care plan additionally indicated that the HHA was to report refusal of care. HHA visit notes indicated Patient #3 refused combing of hair on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; refused oral care on 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; assistance with bedside commode on 03/03/2026, 03/10/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; and meal preparation on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that she was the primary RN for Patient #3 and had not been notified of refusals from Patient #3 by the HHA. 1. A clinical record review for Patient #4 evidenced a HHA care plan dated 03/09/2026 which indicated the HHA was to provide oral care, nail care, comb hair, and shampoo the patient at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused oral care on 03/12/2026, 03/17/2026, 03/20/2026, 03/23/2026, 03/27/2026, 03/30/2026, 04/02/2026, and 04/06/2025; refused shampoo on 03/20/2026, 04/02/2026, and 04/06/2026; refused comb hair on 03/20/2026, 04/02/2026, and 04/06/2026; and refused nail care on 04/02/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. On 04/07/2026 at 4:32 PM, the CM indicated there was no documentation the HHA reported the refusals of care. 2. A clinical record review for Patient #5 evidenced a HHA care plan dated 02/14/2026 which indicated the HHA was to provide visits 2 times a week to include provide a shampoo at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused a shampoo at 13 HHA visits dated from 02/16/2026 and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. On 04/08/2026 at 1:54 PM, the CM indicated the HHA should provide the tasks as directed on the care plan and there was not any documentation the HHA reported the refusals of care.”

“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 the RN completed a supervisory assessment of HHA services every 14 days in 3 of 4 active clinical records reviewed with HHA and skilled services. (Patient #2, Patient #1, Patient #3) The findings include: A clinical record review for Patient #2 evidenced POCs for recertification periods of 01/30/2026-03/30/2026 and 03/31/2026-05/29/2026 which indicated the agency would provide SN and HHA services. The record failed to evidence a supervisory assessment of HHA services since 03/17/2026. On 04/07/2026 at 1:34 PM, the CM indicated there was not a supervisory assessment for HHA services since 03/17/2026. A policy, titled “Home Health Aide Plan of Care”, indicated that the RN will complete a supervisory assessment of the home health aide no less frequently than every 14 days. 2.A clinical record review, for Patient #3, evidenced a POC for the episode period of 03/03/2026 to 05/01/2026 that indicated the agency would provide SN and HHA services. The clinical record evidenced an HHA supervisory visit was performed on 03/17/2026, with the next HHA supervisory visit performed 17 days later on 03/28/2026. During an interview on 04/09/2026 beginning at 12:05 PM, the CM indicated that HHA supervisory visits should be conducted no less than every 14 days. 3.A clinical record review, for Patient #1, evidenced a POC for the episode period of 03/12/2026 to 05/10/2026 that indicated the agency would provide SN, HHA, PT, and OT services. The clinical record failed to evidence that any HHA supervisory visit was performed as of survey date of 04/09/2026. During an interview on 04/08/2026 beginning at 11:31 AM, the CM indicated that while Patient #1 was hospitalized from 03/23/2026 to 04/01/2026, an HHA supervisory visit should have been completed upon Patient #1’s resumption of care on 04/02/2026 and was not completed at that time.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHA was supervised to ensure the aides furnished care that followed the patient’s plan of care in 3 of 4 active clinical records reviewed with HHA services. (Patient #4, Patient #5, Patient #3) The findings include: 3. A clinical record review for Patient #3, evidenced an HHA care plan, dated 03/01/2026, that indicated the HHA tasks to be performed by the HHA every visit included combing of hair, oral care, assisting with bedside commode use, and meal preparation. Tasks to be performed weekly included changing linen, shampooing hair, and cleaning/filing nails. The HHA care plan additionally indicated that the HHA was to report refusal of care. HHA visit notes indicated Patient #3 refused combing of hair on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; refused oral care on 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; assistance with bedside commode on 03/03/2026, 03/10/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; and meal preparation on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. HHA visit notes indicated that the weekly tasks of changing linen, shampooing hair, and cleaning/filing nails had been completed with on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026 which was twice weekly. A review of the HHA supervisory visit notes dated 03/03/2026, 03/17/2026, and 04/03/2026, completed by RN 2, indicated the HHA followed the patient’s plan of care for completion of tasks assigned. The review failed to evidence the RN provided HHA supervision to ensure the HHA followed the care plan as directed. During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that she had not been notified by the HHA of refusals by Patient #3, but if tasks were not completed, completed more often than ordered, and refusals were not reported, then it would have been incorrect to document that the patient plan of care was being followed by the HHA. 1. A clinical record review for Patient #4 evidenced a HHA care plan dated 03/09/2026 which indicated the HHA was to provide oral care, nail care, comb hair, and shampoo the patient at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused oral care on 03/12/2026, 03/17/2026, 03/20/2026, 03/23/2026, 03/27/2026, 03/30/2026, 04/02/2026, and 04/06/2025; refused shampoo on 03/20/2026, 04/02/2026, and 04/06/2026; refused comb hair on 03/20/2026, 04/02/2026, and 04/06/2026; and refused nail care on 04/02/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. Review of the HHA supervisory visits dated 03/23/2026 and 04/02/2026 completed by the CM indicated the HHA followed the patient’s plan of care for completion of tasks as assigned. Review failed to evidence the RN provided HHA supervision to ensure the HHA followed the care plan as directed. On 04/07/2026 at 4:32 PM, the CM indicated there was no documentation the RN provided supervision of the HHA regarding the POC not being followed. 2. A clinical record review for Patient #5 evidenced a HHA care plan dated 02/14/2026 which indicated the HHA was to provide visits 2 times a week to include provide a shampoo at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused a shampoo 13 times at HHA visits dated from 02/16/2026 and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. Review of the HHA supervisory visits dated 02/26/2026, 03/12/2026, and 03/26/2026 completed by the CM indicated the HHA followed the patient’s plan of care for completion of tasks as assigned. Review failed to evidence the RN provided HHA supervision to ensure the HHA followed the care plan as directed. On 04/08/2026 at 1:55 PM, the CM indicated there was no documentation the RN provided supervision of the HHA regarding the POC not being followed. 410 IAC 17-14-1(n)”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to coordinate patient care with other agencies servicing patients in 1 of 2 clinical record reviews of active patients on service less than 60 days. (Patient #1) Findings include: A policy, titled “Scope of Services”, indicated that the agency will be responsible for coordination of services to meet patient needs. During an observation of a home visit on 04/07/2026, for Patient #1, a staff member from Entity 3 was present. The staff member indicated that Entity 3 provides services including bathing, positioning, feeding, meal preparation, incontinent care, and housekeeping 6 days per week. The staff member indicated that when the agency HHA comes twice weekly, on the days that Entity 3 is scheduled. Entity 3 indicated that there was no communication with Entity 3 regarding duties performed or scheduling. A clinical record review for Patient #1 failed to evidence communication or coordination of care with Entity 3. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that care coordination with other agencies should be performed upon knowledge of other entities in the home. The CM indicated that there was no care coordination with Entity 3 at the time of record review.”