1st Choice Home Health Agency, Inc.

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Binder and staff interview, the Agency failed to include names and contact information for staff, contracted staff, patients’ physicians, and volunteers in the emergency preparedness communication plan. This has a potential to affect all staff and patients receiving services. Findings include: . 1.The Emergency Preparedness binder was reviewed on 03/17/26. The binder lacked documentation of contact information for staff, contracted staff, patients’ physicians and volunteers. 2. During an interview with the Administrator Designee and Director of Nursing on 03/18/26 at 10:15 AM the above findings were confirmed.”

“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 the Agency’s Emergency Preparedness binder review and staff interview, the Agency failed to provide training and maintain documentation of training for the Emergency Preparedness Plan since 2022. This has the potential to affect all staff and patients of the Agency. Findings include: . 1. The Emergency Preparedness binder was reviewed on 03/17/26. The binder lacked documentation of employee training on the Emergency Preparedness plan for the years 2023, 2024, 2025 and 2026. 2. During an interview with the DON and Adiminstrator Designee on 03/18/26 at 10:15 AM the above findings were confirmed. The DON stated the Agency educated on the Emergency Preparedness Plan upon hire, as needed and annually, however there is no documentation of the education.”

“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 review of the Emergency Preparedness Binder and staff interview the Agency failed to complete the analysis of the activation of the emergency plan in February of 2025. The Agency also failed to implement an additional test of the Plan by February 2026. Findings include: . 1.The Emergency Preparedness binder was reviewed on 03/17/26. The binder included documentation that the Emergency Plan was activated 02/19/25. The documentation of the event lacked an after action plan or analysis of the activation. The binder lacked an additional full scale exercise, mock drill or table top exercise the following year. 2. During an interview with the DON and Administrator Designee on 03/18/26 at 10:15 AM the above findings were confirmed.”

“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 the review of the Error Summary report and staff interview, the Agency failed to submit the OASIS assessments within 30 days after the assessment was completed. Findings include: . 1.The Error Summary report was reviewed on 03/16/26 at 10:00 AM. The report included 114 of 134 as late submissions. 79.72% of the OASIS reports submitted were more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and Administrator Designee confirmed the above finding.”

“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 records review and staff interviews, in 5 of 7 (Pts. #1,3, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure the PsOC were followed. Findings include: 1. Pt. #1 was admitted to Home Health Services on 02/03/26 with the diagnosis of Hemiplegia following Cerebral Infarction affecting Left Nondominant side. The clinical record was reviewed on 03/17/26. The clinical record included a POC effective 02/03/26 to 04/03/26, that required “….Dietitian ….1”. The same POC required, HHA frequency of 1/week x 1 week 2/week x 8 weeks. The clinical records lacked Home Health Aide visits for the week of 02/03/26 (week 1) and week of 02/08/26 (week 2). As of 03/18/26, there was no modification order or communication as to why the services were not provided as ordered. X. Pt. #7 was admitted to Home Health Services on 11/15/25, with the diagnosis of Parkinson’s disease. The clinical record was reviewed on 03/16/26. The clinical record included the POC effective 11/25/25 to 01/13/26, that required “….Dietitian 1….” As of 03/18/26, there was no modification order or communication as to why the service was not provided as ordered. X. During interviews with the DON and Administrator Designee on 03/18/26 between 10:15 AM to 12:30 PM, the DON confirmed the above findings. _. Pt. #3 was admitted to Home Health Services on 02/27/26 with diagnosis of fracture to right lower leg. The clinical record was reviewed on 03/17/26 and included a POC dated 02/27/26 to 04/27/26. The POC included an order for OT to Evaluate and Treat and an order for SN to asses O2 on room air every visit. During an interview with the DON on 03/18/26 at 10:15 AM she stated if the doctor orders therapy services for the patient, the therapy is to go out and evaluate the patient within 48 hours of SOC. As of 03/18/26, the clinical record lacked an OT Evaluation. The SN visit note dated 03/11/26 lacked an O2 assessment as ordered in the POC. _. Pt. #5 was admitted to Home Health Services on 11/03/25 with a diagnosis of malignant neoplasm of right ovary. The record included a POC dated 01/02/26. The POC included an order for a Dietician. As of 03/18/26, the clinical record lacked a visit from a Dietician. The clinical record also included an order dated 02/11/26 for PT. As of 03/18/26, the clinical record lacked a PT evaluation for the time frame after 2/11/26. _.Pt. #6 was admitted to Home Health Services on 10/17/25 with the diagnosis of Trauma subderal hematoma without loss of consciousness. The clinical record was reviewed on 03/16/26. The clinical record included a POC dated 10/17/25. The POC included an order for SN visits one time a week for 9 weeks. The clinical recorded documented missed visits for the weeks of 10/19, 10/26, 11/02 and 11/09. The record lacked MD notification of the missed visits and lacked any modification orders for the SN frequency. The POC frequency for SN was not followed.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on clinical record review and staff interview, for 1 of 2 discharged records reviewed (Pt. #7), the Agency failed to ensure that a comprehensive assessment was updated at discharge. Findings include: 1. Pt. #7 was admitted to Home Health Services on 11/15/25, with the diagnosis of Parkinson’s disease. The clinical record was reviewed on 03/16/26. The clinical record included the SN last visit dated 02/09/26. The clinical record include a Physician order dated 02/11/26, indicating: “.... Pt. discharged from skilled Nursing services. Physical therapy to continue per plan of care....” The PT (Physical Therapy) discharge note dated 03/05/26, indicating reason for discontinued service due to no further authorization. The clinical record lacked documentation that a comprehensive assessment was updated at discharge. 2. During an interview with the DON and Administrator Designee on 03/18/26 at 11:40 AM, the DON confirmed the above findings.”

“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 clinical records reviewed and staff interview for 4 of 7 clinical records reviewed (Pts. # 5, 1, 7 and 2), the Agency failed to include an individualized and complete plan of care. Findings include: Pt. #2 was admitted to Home Health Services on 10/05/26 with a diagnosis of Type 2 Diabetes Mellitus with foot ulcer. The clinical record was reviewed on 03/17/26. The record included a POC for a certification period of 02/02/26 to 04/02/26. The POC lacked updated wound care interventions from the physician order dated 02/20/26. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and Administrator Designee confirmed the above finding.Findings include: X. Pt. #1 was admitted to Home Health Services on 02/03/26 with the diagnosis of, but not limited to Hemiplegia following Cerebral Infarction affecting Right Nondominant side, Muscle Wasting and Atrophy, Right shoulder, Muscle Wasting and Atrophy, Essential (primary) Hypertension, Depression, Moderate Protein-calorie Malnutrition, Other Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Dysphagia, Other Symbolic Dysfunctions, Unspecified Visual Loss, Aortic Aneurysm of Unspecified Site, without Rupture. The clinical record was reviewed on 03/17/26. The clinical record included a POC effective 02/03/26 to 04/03/26, that required: “Notify physician of:….Fasting blood sugar greater than (>) 200 or less than () 250 or less than () lbs or less than (<) lbs.” These PsOC, lacked the Pt. specific weight parameters to notify Physician. The same PsOC, included the following medications: “….Eliquis…Visine….Carbidopa-Levodopa, Vitamin D3…Senna-Plus…Pravastatin…Pramipexole Dihydrochloride….Metformin….Fish Oil….Fenofibrate….Carbidopa-Levodopa….Flomax…Aspirin…Propanolol….” and required “….SN to assess blood sugar via finger stick every visit prior to insulin administration….”, Pt. #7 did not have insulin medication orders. The POC effective 11/15/25 to 01/13/26,included “…. HHA: 1/wk x 9 wk….Home Health Aide (freq) [text field] 3 wk x 8 for assistance….” The POC was inaccurate to include 2 different HHA frequency orders. _. Pt. #5 was admitted to Home Health Services on 11/03/25 with a diagnosis of Malignant Neoplasm of Right Ovary. The clinical record was reviewed on 03/17/26 and inlcuded a POC dated 01/02/26. The POC documented Displacement of Nephrostomy Catheter as the primary diagnois for the certification period of 01/02/26 to 03/02/26. The POC lacked interventions for the Nephrostomy Catheter, care and patient specific interventions on input and output for this patient. The clinical record lacked a POC for the certification period beginning 03/03/26. During an interview with the Administrator designee on 03/17/26 a request was made for the current POC. An undated document was provided as the POC. The POC lacked patient information, clinical data inlcuding diagnoses, and patient specific interventions.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical records reviewed and staff interview for 2 of 7 (Pts. #5 and 7) the Agency failed to coordinate care to meet the patients’ needs. Pt. #7 was admitted to Home Health Services on 11/03/25 with a diagnosis of malignant neoplasm of right ovary. The clinical record included a POC dated 01/02/26 that included SN services. The SN visit notes dated 02/12/26 and 2/19/26 documented a declince in patient status. The SN notes documented the DON was notified. The clinical record lacked coordination with the patient’s primary care provider in regards to the decline in status. The POC also included HHA services. The HHA visit note dated 03/03/26 documented, “...noted blisteres filled with fluid around the anus. Nurse was notified.” The HHA visit noted dated 03/04/26 documented, “...Patient has open sores around the anus, and the surrounding area is hard and sensitive to touch...pictures were taken and sent to DON... per request...” The HHa visit noted dated 03/06/26 documented, “...open sores to anal area..” The clinical record lacked documentation of coordination with the primary care provider in regards to change in patient status. The POC also included an order for MSW services. The MSW visited the patient on 02/06/26. Referrals were made for catholic charities homemaker, and meals on wheels. The clinical record lacked further documentation with the MSW for follow up on coordination of services. X. Pt. #7 was admitted to Home Health Services on 11/15/25, with the diagnosis of Parkinson’s disease. The clinical record was reviewed on 03/16/26. The clinical record included a Physician order dated 01/06/26 for MSW (Medical Social Worker) to evaluate for community resources. The clinical record included an MSW evaluation dated 01/07/26, and 2 MSW visit notes dated 01/16/26 and 01/26/26, that documented Social worker attempted to contact Pt. and wife, leaving a voicemail and requesting a return call. The last SN visit note dated 02/05/26, indicated Pt. requested to see a social worker. The clinical record lacked further documentation that the Social worker or Nurse contacted the Agency to ensure Pt.’s request for Social worker services were provided. X. During interviews with the DON and Administrator Designee on 03/18/26 between 10:15 AM to 12:30 PM, the DON 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 patient clinical records review, Agency’s Admission Folder review and staff interview, in 7 of 7 (Pts. # 1-7) clinical records reviewed, the Agency failed to provide the name of the current Director of Nursing to Pts. and / or their representative on Admission. Findings include: . 1.The Agency’s Admission Folder was reviewed on 03/16/26. The Admission Folder failed to include the name of the current Director of Nursing. 2. The following patient clinical records were reviewed between 03/16/26 and 03/18/26. The clinical records lacked documentation that the patient or representative were provided the name of the current Director of Nursing. Pt. # 1 SOC 02/03/26 Pt. # 2 SOC 10/05/25 Pt. # 3 SOC 02/27/26 Pt. # 4 SOC 03/11/26 Pt. # 5 SOC 11/03/25 Pt. # 6 SOC 10/17/25 Pt. # 7 SOC 11/15/25 3. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and the Administrator Designee confirmed the above findings.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on clinical record review and staff interview the Agency failed to ensure the Administrator was responsible for all day to day operations including ensuring the Agency’s address is documented correctly on all Agency documents. Findings include: 1.During entrance interview on 03/16/26 at 9:45 AM, the Agency’s Administrator Designee confirmed the Agency’s address as “18400 Maple Creek Drive, Suite 600...” 2. The Home Health Agency Renewal Licensure Application signed by the administrator on 09/30/25 and the Admission Folder were reviewed on 03/16/26, the licensure application and the folder included the Agency’s address as “18400 Maple Creek Drive, Ste 600...” 3. Clinical records were reviewed 03/16/26 through 03/18/26, 7 of 7 clinical records, listed below (Pts. # 1-7) included PsOC, that documented the Agency’s address as “18400 Maple Creek Court, Ste 900...” Pt. #1 SOC 02/03/26 Pt. #2 SOC 10/05/25 Pt. #3 SOC 02/27/24 Pt. #4 SOC 03/11/26 Pt. #5 SOC 11/03/25 Pt. #6 SOC 10/17/25 Pt. #7 SOC 11/15/25 4. The Emergency Preparedness binder was reviewed 03/17/26, the binder included a document titled “Agency Information” that documented the Agency’s address as “18400 Maple Creek Dr, Ste 900...” 5. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and the Administrator Designee confirmed the above findings. The Administrator Designee confirmed the address documentation on the PsOC and Emergency Preparedness document was inaccurate and the correct address as 18400 Maple Creek Dr. Suite 900.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on clinical records review and staff interview for 1 of 7 (Pt. #5) clinical records reviewed the Agency failed to incorporate accurate clinical notes into the clinical record. Findings include: . 1.Pt. #5 was admitted to home health services on 11/03/25 with the diagnosis of malignant neoplasm to the right ovary. The clinical record included a POC dated 01/02/26 that inlcuded SN visit frequency two times a week for three weeks, and then one time a week for five weeks. The SN visited the patient per order throughout the certification ending 03/02/26. The SN visit notes from 1/11/26 through 02/25/25 (12 visits) included documentation in the section titled, “Respiratory” that documented, “...cough: nonproductive...comments: no cough...” The SN visit notes dated 01/13/26, 01/17/26 and 1/20/26 include documentation in the section titled, “Digestive Nutrition” that documented, “...Abd Girth: 38 inches...Comments:...Patient’s adominal girth has decreased from 39 inches to 37 inches since her nephrostomy tubes were replaced...” The SN visit notes dated, 1/26/26, 01/29/26, 02/03/26, 02/05/26, 02/10/26, 02/12/26 and 02/17/26 include documentation in the section titled, “Digestive Nutrition” that documented “...Abd Girth: 39 inches...Comments:...Patient’s adominal girth has decreased from 39 inches to 37 inches since her nephrostomy tubes were replaced...” The SN visit notes dated, 02/19/26, 02/25/26 and 03/05/26 include documentation in the section titled, “Digestive Nutrition” that documented “...Abd Girth: 40 inches...Comments:...Patient’s adominal girth has decreased from 39 inches to 37 inches since her nephrostomy tubes were replaced...” The clinical notes included conflicting documentation. During an interview with the DON on 03/18/26 at 10:30 AM, she confirmed the documentation in the SN notes above regarding abdonminal girth and cough were conflicting and therefore inaccurate. 2. During an interview with the DON and Administrator Designee on 03/18/26 at 10:45 AM, the above findings were cofirmed.”

“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 records review and staff interview, for 1 of 2 (Pt. #6) discharged records reviewed the Agency failed to complete and send a discharge summary to the patient’s primary care provider within 5 days of discharge. Findings include: . 1.Pt. #6 was admitted to Home Health Services on 10/17/26 with the diagnosis of Trauma subdural hematoma without loss of consciousness. The clinical record included a discharge OASIS dated 11/21/25 that included “discharged from all services” completed by the SN. The record lacked an SN discharge summary that was sent to the patient’s physician with in 5 days from discharge. 2. During an interview with the DON and Administrator designee on 03/18/26 at 10:15 AM the above findings were confirmed.”