First Choice Home Care

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on medical record review, policy review, and staff interview, it was determined the agency failed to ensure all elements of the POC were addressed at each visit for 1 of 17 patients (Patient #11) whose records were reviewed. Failure to address depression as stated in the POC had the potential to put all patients receiving services at risk of a negative outcome due to unmet needs. Findings include: An agency policy titled, “Orders for Care,” updated May 2024 stated, “The Agency will obtain orders and provide care in accordance with physician’s...orders which are established prior to initiating patient/client care.” This policy was not followed. An example included: Patient #11 was a 66 year old female admitted to the agency on 4/29/25 with a primary diagnosis of Multiple Sclerosis. Additional diagnoses included left hemiparesis, epilepsy, optic neuritis and unspecified mood disorder. She received PT and OT services. Patient #11’s record was reviewed for the certification period of 4/29/25 to present. Patient #11’s POC orders included: “Physical therapy to monitor plan for current treatment of depression such as effects of medication and/or need for referral for other treatment.” POC goals included: “Verbalize/demonstrate ability to properly manage depression by DC. Depression was not addressed during the PTA visits of 5/08/25, 5/06/25, 5/13/25, or 5/15/25. The Clinical Supervisor was interviewed on 5/22/25 at 11:30 AM and Patient #11’s record was reviewed in her presence. She confirmed Patient #11’s POC included an order to address depression, but depression was not addressed in any of the above visits. The agency failed to address all orders in the POC. m”

“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 medical record review, policy review, incident report review, and staff interview, it was determined the agency failed to ensure the comprehensive assessment included a patient’s nursing needs for 1 of 2 patients (Patient #9) whose records were reviewed and who died. Failure to recognize all relevant needs for all patients had the potential to put all patients receiving services at risk of a negative outcome due to unmet needs. Findings include: An agency policy titled, “Initial Patient/Client Comprehensive Assessment,” updated May 2024, stated, “The comprehensive assessment will include, but not be limited to the following: … The patient’s/client’s medical, nursing, rehabilitative, social, and discharge planning needs.” This policy was not followed. An example includes: Patient #9 was a 76 year old male admitted to the agency on 12/20/23 with a primary diagnosis of gastroenteritis with colitis. Additional diagnoses included orthostatic hypotension and end stage renal disease. He received PT services. His record for the certification period 12/20/23 to his death on 1/27/24 was reviewed. Patient #9’s SOC note dated 12/20/23 completed by the Physical Therapist. The note stated, “PATIENT WAS RECENTLY HOSPITALIZED FOR GASTROENTERITIS, COLITIS, AND ORTHOSTATIC HYPOTENSION. THE PATIENT’S BLOOD PRESSURE DROPS DRASTICALLY WHEN STANDING UP AND HE HAS HAD SOME RECENT FALLS.” It was unclear how a Physical Therapist would address Patient #9’s orthostatic hypotension which was causing his falls. Patient #9’s POC was reviewed. Twenty-nine diagnoses were listed which included but were not limited to hypothyroidism, hyperlipidemia, heart attack, heart block, pacemaker, and end stage renal disease with dialysis. Additionally, 15 medications were listed which included but were not limited to aspirin, calcitrol, fludrocortisone, hydrocodone acetaminophen, and midodrine. It was unclear how a Physical Therapist would manage Patient #9’s significant medical issues. Agency incident reports were reviewed which included an incident for Patient #9 on 1/30/24 which stated, “PER SPOUSE’S REPORT: PATIENT WENT TO THE BATHROOM AND STOOD UP AND WAS DIZZY SO HE LAID ON THE FLOOR. SHE COVERED HIM UP TO KEEP HIM WARM AND HE WAS GOING TO GET UP WHEN HIS BLOOD PRESSURE CAME BACK UP. SHE CHECKED ON HIM A COUPLE OF TIMES AND HE WAS OK THEN SHE CHECKED ON HIM AND HE WAS ‘GONE’.” The incident report also stated, “DEATH AT HOME. CHART AUDIT COMPLETED. NO ISSUES NOTED” The Clinical Supervisor was interviewed on 5/22/25 at 2:57 PM and Patient #9’s record was reviewed in her presence. She confirmed Patient #9 was medically complex. She agreed Patient #9 should have had nursing services involved, but stated she was not sure if it was brought up. The agency failed to recognize nursing needs for Patient #9.”

“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, policy review, medical record review, and staff interview, it was determined the agency failed to ensure the POC included all relevant treatments and interventions for 1 of 2 patients (Patient #9) whose records were reviewed and who died and 1 of 7 patients (Patient #5) whose records were reviewed and for whom an observation was completed. Failure to recognize all relevant diagnoses and treatments put the patient at risk for unmet needs due to lack of assessment of a significant medical diagnosis. Findings include: An agency policy titled, “Plan of Care,” reviewed May 2024 stated, “The individualized Plan of Care must include the following: … The types of services, supplies, and equipment required; a. The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care … Patient/client-specific interventions and education.” This policy was not followed. An example includes: Patient #9 was a 76 year old male admitted to the agency on 12/20/23 with a primary diagnosis of gastroenteritis with colitis. Additional diagnoses included orthostatic hypotension, end stage renal disease, and renal dialysis. He received PT services. His record for the certification period 12/20/23 to his death on 1/27/24 was reviewed. His end stage renal disease was listed as a severity of 2 which meant “Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring.” The PT SOC note, dated 12/20/23 was reviewed. It stated Patient #9 was on peritoneal dialysis. There were no interventions related to dialysis or end stage renal disease. There was no assessment of his peritoneal dialysis catheter. There was no information on what dialysis equipment Patient #9 used to complete his peritoneal dialysis. The Clinical Supervisor was interviewed on 5/22/25 at 2:57 PM and Patient #9’s record was reviewed in her presence. When asked what monitoring she would expect for a patient with end stage renal disease, she stated monitoring of weight, vital signs, and monitoring of the catheter site. She confirmed this monitoring was not present in Patient #9’s POC. The agency failed to ensure the POC included all relevant treatments and interventions. Patient #5 was an 84 year old female admitted to the agency on 5/09/25 with a primary diagnosis of age related osteoporosis with current pathological fracture of the left femur. Additional diagnoses included other specified cardiac arrhythmias, and hypercalcemia. Patient #5’s medical record was reviewed. A SOC visit note report narrative dated 5/09/25 stated, “PATIENT HAS A PHM [past medical history] OF: MILD DEMENTIA, OSTEOPENIA, URINARY RETENTION AND ARRHYTHMIA.” An observation of a HHA visit was completed on 5/21/25 at 10:15 AM. During the visit the patient was helped to sit on the toilet by the HHA and stated to the HHA, “I feel like I need to pee, and I can’t.” The patient then stated “Okay body just go” while motioning to her genital area. The patient sat on the toilet for several minutes struggling to urinate. The patient did not successful urinate during the visit. The Clinical Supervisor was interviewed on 5/22/25 at 2:47 PM and Patient #5’s record was reviewed in her presence. When asked if she would expect Patient #5’s urinary retention to be on the POC and monitored she stated, “Yes, since it is something that is currently affecting her.” She confirmed that the POC did not include Patient #5’s urinary retention.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on medical record review, observations, staff interviews, and facility policies, it was determined the agency failed to ensure accurate medication reconciliation was completed for 1 of 7 patients who had observational visits by surveyors. This had the potential to affect all patients on service not receiving accurate medication reconciliation. Example included: An agency policy titled, “Medication List and Monitoring”, last reviewed May 2024, stated, “The Agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient/client.” This policy was not followed. An example included: Patient #3 was a 76 year old male admitted to the agency on 4/14/25 with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure. Additional diagnoses included acute and chronic combined systolic and diastolic heart failure, Type 2 diabetes, venous insufficiency, unspecified open wounds, and personal history of urinary tract infections. An observational visit was performed with the RN on 5/21/25 beginning at 1:30 PM. During the visit, the RN reconciled medications with the patient. The patient stated he was still taking Bactrim twice daily for his UTI. The RN noted the antibiotic was not on the medication list. The RN asked the patient when he had started the Bactrim and patient stated he had been taking it since 5/12/25 when he had signs of a UTI. The RN was interviewed outside the patient home after the visit on 5/21/25 beginning at 2:45 PM. She agreed the Bactrim was not on the medication list prior to this visit and therefore, Patient #3’s medication list had not been accurate since 5/12/25. The agency failed to ensure all patients had accurate medications listed in their medical records. An agency policy titled, “Medication List and Monitoring,” last reviewed May 2024, stated, “The Agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient/client.” This policy was not followed. An example included: Patient #3 was a 76 year old male admitted to the agency on 4/14/25 with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure. Additional diagnoses included acute and chronic combined systolic and diastolic heart failure, Type 2 diabetes, venous insufficiency, unspecified open wounds, and personal history of urinary tract infections. An observational visit was performed with the RN on 5/21/25 beginning at 1:30 PM. During the visit, the RN reconciled medications with the patient. The patient stated he was still taking Bactrim twice daily for his UTI. The RN noted the antibiotic was not on the medication list. The RN asked the patient when he had started the Bactrim and patient stated he had been taking it since 5/12/25 when he had signs of a UTI. The RN was interviewed outside the patient home after the visit on 5/21/25 beginning at 2:45 PM. She agreed the Bactrim was not on the medication list prior to this visit and therefore, Patient #3’s medication list had not been accurate since 5/12/25. The agency failed to ensure all patients had accurate medications listed in their medical records.”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on observation, medical record review, policy review, and staff interview, it was determined the agency failed to ensure the home health aides were members of the interdisciplinary team and reported changes in the patient’s condition to a registered nurse or other appropriate skilled professional and completed appropriate records in compliance with the HHA’s policies and procedures. This directly affected 1 of 7 patients (Patient #5) whose records were reviewed and for whom an observation was completed. Failure to report changes in patients condition allowed the patient’s needs to go unmet and had the potential to affect all patients receiving care through the agency. Findings include: An agency policy titled, “Implementing Care and Treatment,” updated May 2024 stated, “The duties of the home health aide include, but are not limited to:……..6.Reporting changes in the patient’s/client’s condition or needs to a registered nurse or other appropriate skilled professional; and 7. Completing appropriate documentation/records in compliance with the Agency’s policies and procedures.” This policy was not followed. An example includes: Patient #5 was an 84 year old female admitted to the agency on 5/09/25 with a primary diagnosis of Age related osteoporosis with current pathological fracture of the left femur. Additional diagnoses included other specified cardiac arrhythmias, and hypercalcemia. She received HHA and PT services. An observation of a HHA visit was completed on 5/21/25 at 10:15 AM. During the visit the patient was helped to sit on the toilet by the HHA and stated to the HHA, “I feel like I need to pee, and I can’t.” The patient sat on the toilet for several minutes struggling to urinate. The patient did not urinate during the visit. On 5/22/25 Patient #5’s visit note report for the previous observed visit was reviewed. It did not include mention of the patient having the sensation of the need to urinate but not being able to urinate successfully. The Clinical Supervisor was interviewed on 5/22/25 at 2:47 PM and Patient #5’s record was reviewed in her presence. The observation of the patient struggling to urinate was shared with her and she was asked if the HHA would be expected to document the patient struggling to urinate and report to the registered nurse or other appropriate skilled professional. The clinical supervisor stated she would expect the findings to be reported, and she acknowledge it was not documented and it was not reported to the case manager. The agency failed to ensure changes in patient condition was reported to the registered nurse or other appropriate skilled professional. m”