Avant Care Home Health Care, Inc.

“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 review of Agency’s Emergency Preparedness Plan, review of In-service binder and staff interview, it was determined that in 3 of 6 (Employees #2, 3, and 5) Employees reviewed, the Agency failed to conduct staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan and In-service binder were reviewed on 06/12/25. The Agency’s Emergency Preparedness Plan and In-service binder lacked documentation that the Agency conducted Emergency Preparedness training for the following Employees: Employee #2 (Home Health Aide/Date of Hire 08/23/24). Employee #3 (Home Health Aide/Date of Hire 07/15/24). Employee #5 (Registered Nurse/Date of Hire 07/20/23). 2. During an interview with the Administrator and Director of Clinical Services on 06/12/25 at 11:00 AM, the Administrative staff confirmed the above findings.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of the Error Summary report and staff interview, it was determined that in of 345 of 848 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 05/01/24 to 05/23/25 (12 months), was reviewed on 06/11/25. The report included a warning for Error # -3330. The Error included 345 (40.68 %) of 848 assessments that were submitted late. 2. During staff interviews with the Administrator and Director of Clinical Services, on 06/12/25 at 11:00 AM, the administrative team confirmed the above findings.”

“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 a review of clinical records, Agency policy, and staff interviews, it was determined that in 2 of 7 (Pts. #2 and 4) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. Findings include: 1. Pt. #2 was admitted for Home Health Services on 02/05/25 with the diagnosis of Atherosclerotic Heart Disease of Native Coronary artery without Angina Pectoris. The clinical record was reviewed on 06/10/25 and 06/11/25. The clinical record included the form titled: “Beneficiary Elected Transfer” form, that required the SN to enter the date of transfer and name of the previous Agency. These sections were left blank. 2. Pt. #4 was admitted for Home Health Services on 02/24/24 with the diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 06/10/25 and 06/11/25. The clinical record included the form titled: “Documentation of Authorization and Acknowledgment”, included a section on Advance Directives. The section required the SN to place a check mark, indicating if Pt. had an Advance Directive (Living will.... Durable Power of Attorney for Health Care…. Executed Surrogate Act), and if a copy will be provided to the Agency. These sections were left blank. 3. During an interview with the Administrator and Director of Clinical Services on 06/12/25 at 11:00 AM, the Administrative staff confirmed the above findings.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on review of Agency’s Pt. Admission folder, observation during home visits, clinical record review and staff interviews, it was determined that in 7 of 7 (Pts. # 1,2 ,3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure the Pt. / representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 06/10/25. The folder included: “Documentation of Authorization and Acknowledgment” form, the form did not include the frequency of visits and disciplines who will provide care. 2. The following clinical records were reviewed from 06/10/25 to 06/11/25: Pt. #1. SOC 05/22/25. Pt. received SN and PT services. Pt. #2. SOC 02/05/25. Pt. received SN, PT and HHA services. Pt. #3. SOC 05/29/25. Pt. received SN services. Pt. #4. SOC 02/24/24. Pt. received SN, PT and HHA services. Pt. #5. SOC 04/14/25. Pt. received SN and MSW services. Pt. #6. SOC 09/24/24. Pt. received SN and PT services. Pt. #7. SOC 12/12/24. Pt. received SN and PT services. The clinical records included the “Documentation of Authorization and Acknowledgment” form, signed by the Pt. / representative. The forms lacked documentation of the service(s) to be provided and visit frequencies. 3. The following home visits were conducted on 06/10/25 and 06/11/25: Pt. #1. SOC 05/22/25. Pt. #2. SOC 02/05/25. Pt. #3. SOC 05/29/25. During the home visits, the Pt. admission folders were observed, and lacked documentation indicating the Pt. / representative was notified of the discipline (s) to provide service, and the frequency of visits in writing. 4. During interviews with the Administrator and Director of Clinical Services on 06/12/25 between 9:15 AM to 11:00 AM, the Administrative staff confimred the above findings.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on record review and staff interview, it was determined that in 7 of 7 (Pts. # 1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were assessed for the status of Influenza and Pneumonia vaccination. Findings include: 1. The following clinical records were reviewed from 06/10/25 to 06/11/25: Pt. #1 SOC 05/22/25. Lacked inquiry for Influenza and Pneumonia vaccines. Pt. #2 SOC 02/05/25. Lacked inquiry for Influenza and Pneumonia vaccines. Pt. #3. SOC 05/29/25. Lacked inquiry for Influenza and Pneumonia vaccines. Pt. #4 SOC 02/24/24. Lacked inquiry for Influenza and Pneumonia vaccines. Pt. #5. SOC 04/14/25. Lacked an inquiry for Influenza and Pneumonia vaccines. Pt. #6. SOC 09/24/24. Lacked inquiry for Pneumonia vaccine. Pt. #7. SOC 12/12/24. Lacked inquiry for Pneumonia vaccine. 2. During the entrance interview with the Administrator on 06/10/25 at 9:00 AM, the Administrator stated the Influenza and Pneumonia assessments are done at the Start of care and documented in the clinical record. During staff interviews with the Administrator and Director of Clinical Services on 9:15 AM to 11:00 AM, the Director of Clinical Services confirmed the above findings.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Clinical Manager. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 06/10/25. The folder lacked the Clinical Manager’s name, address, and phone number. 2. The following clinical records were reviewed from 06/10/25 to 06/11/25: Pt. #1. SOC 05/22/25. Pt. #2. SOC 02/05/25. Pt. #3. SOC 05/29/25. Pt. #4. SOC 02/24/24. Pt. #5. SOC 04/14/25. Pt. #6. SOC 09/24/24. Pt. #7. SOC 12/12/24. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Clinical Manager. 3. The following home visits were conducted on 06/10/25 and 06/11/25: Pt. #1. SOC 05/22/25. Pt. #2. SOC 02/05/25. Pt. #3. SOC 05/29/25. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Clinical Manager. Interviews were conducted with the Pt./patient’s representative, they were not aware of the name and contact information of the Clinical Manager. 4. During interviews with the Administrator and Director of Clinical Services on 06/12/25 between 9:15 AM to 11:00 AM, the Administrative staff confirmed the Agency failed to provide the Pt./patient’s representative with the Clinical Manager’s name and contact information.”