Choice Home Health Services, Inc.

“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 a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness Plan every two years. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness Plan was reviewed on 2/11/25. The Agency last reviewed and updated the plan on 4/2/2021. 2. During an interview with the Administrator, Agency Supervisor, and Clinical Manager on 2/13/25 at 9:30 AM, it was confirmed by the administrative team that the Agency failed to review and update its Emergency Preparedness Plan every two years.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to establish policies and procedures based on the risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The “Hazard Vulnerability Assessment Tool” (risk assessment) of the Emergency Preparedness Plan was last updated with the date of “December 2024” and was reviewed on 2/11/25. The Assessment contained the following possible events; “Heat Emergency, Cold Emergency, Thunderstorm, Tornado, Hurricane, Flooding, Ice/Snow, Blizzard, Earthquake, Fire, Epidemic/Pandemic, Flu, Epidemic/Pandemic Disease, Nuclear Incident, Air Pollution/Air Quality, Civil Disturbance, Bomb Threat, Mass Casualty, Workplace Violence, Active Shooter, Electrical Power Failure, Communication failure, Water Failure, Transportation, and Informational System Failure”. As of 2/11/25, the Emergency Preparedness Plan lacked the policies and procedures for the vulnerability risk assessments indicated above. 2. During an interview with the Administrator, Agency Supervisor, and Office Manager on 2/13/25 at 9:30 AM, the administrative team confirmed the Agency failed to establish policies and procedures based on the risk assessment.”

“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 the Agency’s employee in-service binder, employee files, and interviews, it was determined in 6 of 6 of Employees reviewed (Employees #1, 2, 3, 4, 5, and 6), the Agency failed to ensure Employees received training pertaining to the Agency’s Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The employee in-service binder and employee files were reviewed on 2/11/25, and they lacked documentation that the following Employees received education on the Agency’s Emergency Preparedness Plan: Employee #1PT/date of hire 3/11/22. Employee #2 CNA/ date of hire 8/4/20. Employee #3 RN/date of hire 8/4/20. Employee #4 RN/date of hire 8/6/20. Employee #5 CNA/date of hire 3/1/24. Employee #6 RN/date of hire 8/4/20. 2. During an interview with the Administrator, Agency Supervisor, and Office Manager on 2/13/25 at 9:30 AM, the administrative team confirmed the above findings.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan dated 4/2/21 was reviewed on 2/11/25. The Plan lacked documentation that the Agency conducted or participated in any table-top drill, full-scale exercise, facility-based exercise, or activated the Agency’s Emergency Preparedness in 2022, 2023, 2024, and 2025 (as of 2/13/25). 2. During an interview with the Administrator, Agency Supervisor, and Office Manager on 2/13/25 at 9:30 AM, the administrative team 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 4 of 822 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. 1. The Error Summary report for 01/28/24 to 1/28/25 (12 months), was reviewed on 2/11/25. The report included a warning for Error # -3330. The Error included 4 (0.49 %) of 822 assessments that were submitted late. 2. During staff interviews with the Administrator, Agency Supervisor, and Office Manager on 2/13/25 at 10:30 AM, the administrative team confirmed the above findings.”

“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 clinical record review and staff interview, it was determined that in 1 of 7 (Pts. 3) clinical record reviewed, the Agency failed to ensure POC was followed. Findings include: 1. Pt. # 3 was admitted to home health services on 10/18/24 with the diagnoses of Unspecified Open Wound, right lower leg, Subsequent encounter, Pressure ulcer of sacral region, stage 2, Hypertensive Heart disease with heart failure. The clinical record was reviewed on 2/11/25. The POC effective 12/17/24 to 2/14/25, required “….Orders for Discipline and Treatments….SN to assess/monitor BP….Goals….Patient’s vital signs will be maintained WNL or variances will be reported to MD. Vital sign parameters: Diastolic BP …Greater Than 60…” The SN notes were reviewed and indicated: 12/17/24 BP of 114/57 1/7/25 BP of 102/52 1/28/25 BP of 108/59 The following SN notes indicated a Diastolic BP reading outside the vital sign parameters range. There was no MD communication or notification as ordered in the POC. The same clinical record included orders for “….SN to do wound care and measure LXWXD then document every visit….” The SN wound notes dated 1/14/25, 1/18/25 and 1/25/25, indicated SN completed wound care but lacked wound measurements as ordered in the POC. 2. During an interview with the Administrator, Agency Supervisor and Office Manager on 2/13/25 at 10:30 AM, the Agency Supervisor confimred the above findings.”

“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 home visit observation, Agency procedure review and staff interview, it was determined that in 1 of 3 (Pt. #3) home visits, the Agency failed to ensure infection control measures were observed to prevent the potential for cross-contamination, as required by the Agency. Findings include: 1. Pt. #3 was admitted to home health services on 10/18/24 with the diagnoses of Unspecified Open Wound, right lower leg, Subsequent encounter, Pressure ulcer of sacral region, stage 2 and Hypertensive Heart disease with heart failure. During a home visit for Pt. # 3, conducted with Employee #7 (Physical Therapist/ Date of Hire 7/23/20) on 2/11/25 at 1:20 PM, Employee # 7 was observed to put down nursing bag on top of chair without a barrier, then proceeded to remove BP apparatus and thermometer from the bag and placed the equipment directly on the kitchen island without a barrier. 2. A policy on Bag technique was requested on 2/11/25. The document containing a“Bag technique procedure….”, was presented and reviewed on 2/11/25 and indicates: “3. Once in the patient’s home, select a clean, flat, hard surface to place a bag and set up work area. ….(Note : Use a barrier under bag to help prevent transmission of infections….) 5. Remove needed items from bag and place on clean barrier….” 3. During an interview with the Administrator, Agency Supervisor and Office Manager on 2/13/25 at 10:30 AM, the Agency Supervisor 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 6 of 7 (Pts. #1, 2, 3, 4 ,5 and 7) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. Findings include: 1. The following clinical records were reviewed on 2/11/25: Pt. #1. SOC 12/31/24. Pt. #2. SOC 12/3/24. Pt. #3. SOC 10/18/24. Pt. #4. SOC 12/9/24. Pt. #5. SOC 1/27/25. Pt. #7. SOC 8/23/24. The “Consent/Payment agreement/release & Acknowledgement of Receipt of Information” required for the clinician to mark the following sections on “Consent for Services….Authorization to Release….Receipt of Information…. Notification of Agency….Medicare Advantage, HMO or PPO Enrollment….Assignment of Medicare/Medicaid…Medicare – Medical Supplies & Outpatient Therapy….Assignment Agreement”. The sections above were left blank. 2. During interviews with the Administrator, Agency Supervisor and Office Manager on 2/13/25 from 9:30 AM to 11:30 AM, the Administrative team confirmed the above findings.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observations during home visits, and staff interviews, it was determined the Agency failed to provide the Pt./Pt.’s representative information regarding the Administrator. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 2/10/25 and lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 2/10/25 and 2/11/25: Patient #1. SOC 12/31/24. Patient #2. SOC 12/3/24. Patient #3. SOC 10/18/24. During the home visits of Pts. #1, #2, and #3, the patient’s admission folder was observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed on 2/11/25: Pt. #1. SOC 12/31/24. Pt. #2. SOC 12/3/24. Pt. #3. SOC 10/18/24. Pt. #4. SOC 12/9/24. Pt. #5. SOC 1/27/25. Pt. #6. SOC 4/8/24. Pt. #7. SOC 8/23/24. The clinical records lacked documentation that the Pt./Pt.’s representative was provided the name and contact information of the Administrator to file a complaint or grievance. 4. During staff interviews with the Administrator, Agency Supervisor, and Office Manager on 2/13/25 at 10:30 AM, the administrative team confirmed the above findings.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, clinical record reviews, observations, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 2/10/25 and lacked documentation of the Agency’s transfer and discharge policies. 2. The following home visits were conducted on 2/10/25 and 2/11/25: Patient #1. SOC 12/31/24. Patient #2. SOC 12/3/24. Patient #3. SOC 10/18/24. During the home visits of Pts. #1, #2, and #3, the patient’s admission folder was observed, and lacked documentation the Agency had provided Pts./patient’s representative information regarding the Agency’s transfer and discharge policies. 3. The following clinical records were reviewed on 2/11/25: Pt. #1. SOC 12/31/24. Pt. #2. SOC 12/3/24. Pt. #3. SOC 10/18/24. Pt. #4. SOC 12/9/24. Pt. #5. SOC 1/27/25. Pt. #6. SOC 4/8/24. Pt. #7. SOC 8/23/24. The records lacked documentation the Agency provided Pts./patient’s representative information regarding the Agency’s transfer and discharge policies. 4. During staff interviews with the Administrator, Agency Supervisor, and Office Manager on 2/13/25 at 10:30 AM, the administrative team 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 the Agency’s Pt. admission folder, observation and interview 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 2/10/25. The folder included the “Consent/Payment Agreement/Release & Acknowledgement of Receipt of Information” and “Initial Discharge Planning” form that included a section titled “Home Health Care Services Needed and Frequency”, requiring the SN to complete during the SOC visit and document the services to be provided and visit frequencies. 2. The following clinical records were reviewed on 2/11/25: Pt. #1. SOC 12/31/24. Pt. received SN and PT services. Pt. #2. SOC 12/3/24. Pt. received SN services. Pt. #3. SOC 10/18/24. Pt. received SN, PT and OT services. Pt. #4. SOC 12/9/24. Pt. received SN services. Pt. #5. SOC 1/27/25. Pt. received SN, PT, OT, and ST services. Pt. #6. SOC 4/8/24. Pt. received SN, PT, and OT services. Pt. #7. SOC 8/23/24. Pt. received SN services. The clinical records included the “Consent/Payment Agreement/Release & Acknowledgement of Receipt of Information” form signed by the Pt./representative. The “Initial Discharge Planning” forms lacked documentation of the service(s) to be provided and visit frequencies. 3. The following home visits were conducted on 2/10/25 and 2/11/25: Patient #1. SOC 12/31/24. Patient #2. SOC 12/3/24. Patient #3. SOC 10/18/24. During the home visits of Pts. #1, 2, and 3, the Pt. admission folders were observed and lacked documentation indicating the Pt./representative was notified of the discipline(s) to provide service, and frequency of visits in writing. 4. During staff interviews with the Administrator, Agency Supervisor, and Office Manager on 2/13/25 at 10:30 AM, the administrative team confirmed 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 clinical record review, Agency policy review and staff interview, it was determined that in 5 of 7 (Pts. #1, 2, 3, 4 and 7), the Agency failed to ensure Pts. were assessed for the Influenza and / or Pneumonia vaccination status per Agency policy. Findings include: 1. The following clinical records were reviewed on 2/11/25 and contained an “Influenza / Pneumonia Vaccination” form that lacked completed entries to sections on Influenza and /or Pneumonia vaccination assessment, as the form required: Pt. #1 SOC 12/31/24 Pt. #2 SOC 12/3/24 Pt. #3 SOC 10/18/24 Pt. #4 SOC 12/9/24 Pt. #7 SOC 8/23/24 2. The Agency’s policy titled: “Administration of Influenza Vaccine to Adults” was reviewed on 2/13/25 and required: “….Procedure: 1. Identify adult in need of influenza vaccination….2. Screen all patients for contraindication and precautions to influenza vaccine….6. Document each patient’s vaccine administration information and follow- up in the: Medical record – record the date vaccine was administered….If vaccine was not given, record the reason(s) For non-receipt of the vaccine (….medical contraindications, patient refusal.) The Agency’s policy titled: “Home Health Guideline for Standing order for Pneumococcal Vaccination (PPV) of Patients” was reviewed on 2/13/25 and required: “….A. Each patient’s pneumococcal immunization status will be determined upon admission or soon afterwards, and will be documented in the patient’s medical record. Current patients will have their immunization status determined by reviewing available past and present medical records…..D. Patients may refuse vaccination. Vaccination refusal and reasons why...should be documented by the agency. 3. During interviews with the Administrator, Agency Supervisor and Office Manager on 2/13/25 from 9:30 AM to 11:30 AM, the Agency Supervisor confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical record review and staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) discharged clinical record reviews, the Agency failed to ensure the Physician was sent a copy of the Discharge summary. Findings include: 1. Pt. #6 was admitted to home health services on 04/08/24 with the diagnosis of Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 2/11/25. The discharge assessment indicated that Pt. #6 was discharged from the Agency on 6/13/24. The record contained a discharge summary that lacked documentation that it was sent to the Physician. 2. Pt. #7 was admitted to home health services on 8/23/24 with the diagnosis of Pressure Ulcer of Sacral region, stage 4. The clinical record was reviewed on 2/11/25. The discharge assessment indicated that Pt. #7 was discharged from the Agency on 12/18/24. The record contained a discharge summary that lacked documentation that it was sent to the Physician. 3. During an interview with the Administrator, Agency Supervisor and Office Manager on 2/13/25 at 10:30 AM, the Agency Supervisor confirmed the above findings.”