Family Choice Home Care

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure administrative review of the Emergency Preparedness Plan at least every other year for all patients and employees. Findings: A review of emergency preparedness plan records showed an administrative review of the Emergency Preparedness Plan dated 10/02/20. On 04/08/26 at 12:25 p.m., Staff B stated the agency did not review the Emergency Plan since 2020.”

“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 record review and interview, the agency failed to ensure an emergency preparedness communication plan included current employee and physician contact information for the agency for all patients and employees. Findings: A review of emergency preparedness program records did not include contact information for all its current employees and showed a patient roster which did not include physician contact information dated 09/25/25. On 04/08/26 at 12:25 p.m., Staff B stated the communication plan was not updated to include all current employees and physicians who worked with the agency.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation, and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of emergency preparedness records showed no administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials. On 04/08/26 at 12:25 p.m., Staff B stated the plan did not include processes and resource contact information.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure discharge planning included patient case conference activities for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. Findings: Patient #1 A review of the clinical record showed no case conference communications since the start of care date of 03/14/24 and showed no coordination of care or communication notes of why the case conferences were not conducted. Patient #2 A review of the clinical record showed no case conference communications since the start of care date of 06/28/24 and showed no coordination of care or communication notes of why the case conferences were not conducted. Patient #3 A review of the clinical record showed no case conference communications since the start of care date of 11/12/25 and showed no coordination of care or communication notes of why the case conferences were not conducted. Patient #5 A review of the clinical record showed no case conference communications since the start of care date of 03/13/23 and showed no coordination of care or communication notes of why the case conferences were not conducted. Patient #6 A review of the clinical record showed no case conference communications since the start of care date of 01/18/25 and showed no coordination of care or communication notes of why the case conferences were not conducted. Patient #7 A review of the clinical record showed no case conference communications since the start of care date of 12/30/25 and showed no coordination of care or communication notes of why the case conferences were not conducted. On 04/08/26 at 1:15 p.m., Staff B stated the case conferences for patients #1, 2, 3, 5, 6 and #7 were: 1.Not conducted every month. 2.Not documented in a binder.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a care plan for home health aide services was completed prior to the first aide visit assignment for one (Patient #7) of seven patients. Findings: Patient #7 A review of the clinical record showed the patient had a comprehensive start of care assessment on 12/30/25 for an episode period of 12/30/25 to 02/27/26. The clinical record showed a home health aide visit was conducted on 01/06/26 and showed the care plan and assignment of staff for home health aide services was completed on 01/08/26 (two days after the first aide visit). On 04/08/26 at 1:05 p.m., Staff B stated the care plan for home health aide services was not completed before the first aide visit.”

“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 record review and interview, the agency failed to ensure an individualized patient POC included a last conducted or an intervention due date for an indwelling foley catheter change for one (Patient #6) of seven patients. Findings: Patient #6 A review of the POC dated 11/14/25 to 01/12/26 showed orders for SN to conduct indwelling foley catheter change with a 16 French/10 cubic centimeter catheter and site care every three weeks. The foley management intervention orders did not identify the date the last catheter change was conducted or the date the next intervention was due. SN visits for foley catheter care and change intervention were conducted on 12/05/25 and on 12/23/25. The clinical record showed no physician notifications and no change in orders. On 04/08/26 at 12:55 p.m., Staff B stated the catheter orders did not identify when the intervention was conducted or when it was due.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an order for SN to perform indwelling foley catheter irrigation with an identified solution was obtained from the physician for one (Patient #6) of seven patients. Patient #6 A review of the POC dated 11/14/25 to 01/12/26 showed no orders for SN to perform indwelling foley catheter irrigation. A SN visit conducted on 12/16/25 showed the nurse irrigated the foley catheter for observable increased sediment and showed no identification of what solution was used. The clinical record showed no physician notifications and no request to irrigate the catheter. On 04/08/26 at 12:55 p.m., Staff B stated there were no doctor orders for the nurse to irrigate the foley catheter.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for one (Patient #5) of seven patients. Findings: Patient #5 A review of a plan of care dated 02/25/26 to 04/25/26 showed a primary diagnosis of Stage 5 chronic kidney disease, end stage renal disease. A review of a communication note dated 03/23/26 showed the patient was experiencing a productive cough with thick phlegm, a variable oxygen saturation rate of 88-93% with a blood pressure of 146/80 and a heart rate of 91. The communication note showed no date the physician was notified and showed no follow up communications to the physician. A review of a communication note dated 03/27/26 showed the patient was experiencing a dry cough, a variable oxygen saturation rate of 88-90% with a blood pressure of 174/74 with a weight of 115 pounds (increase of 3 pounds in four days). The communication note showed no date the physician was notified and showed no follow up communications with the physician. A review of a communication note dated 03/30/26 showed the patient had a weight of 118 pounds (an additional increase of 3 pounds in three days). The communication note showed no date of notification to the physician and showed no follow up communications to the physician. A review of a communication note dated 04/03/26 showed the type of communication note was emergency room visit but was blank. The communication note showed no date of notification to the physician and showed no follow up communications to the physician. On 04/08/26 at 12:45 p.m., Staff B stated: 1.The 03/23/26 note was sent by fax on 03/23/26 to the physician but had no follow-up communication with the physician. 2.The 03/27/26 note was sent by fax on 03/27/26 to the physician but had no follow-up communication with the physician. 3.The 03/30/26 note was not sent to the physician and had no follow-up communication with the physician. 4.The 04/03/26 note was entered as a file name to attach any documentation we receive from the emergency room. The physician was not notified the patient had gone to the emergency room and there was not any follow-up communication with the physician.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the SN performed an indwelling foley catheter change intervention using a size of catheter different than what was ordered by the physician for one (Patient #6) of seven patients Findings: Patient #6 A review of the POC dated 11/14/25 to 01/12/26 showed orders for SN to conduct indwelling foley catheter change with a 16 French/10 cubic centimeter every three weeks. A review of a SN visit note dated 11/18/25 showed the indwelling foley catheter change was performed using an 18 French/10 cubic centimeter catheter and showed no change in the physician orders. On 04/08/26 at 12:55 p.m., Staff B stated the SN did not use the catheter size that was ordered by the physician.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff participated in its QAPI program for calendar year 2024 and 2025 for all patients and employees. Findings: A review of quality assessment performance improvement records showed no PT, OT or ST skilled professional staff participation in QAPI activities for calendar years 2024 and 2025. On 04/08/26 at 1:15 p.m., Staff B stated: 1.We did not have PT or OT participate in the QAPI program. 2.We contract therapy services for PT and OT when needed.”

“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 record review and interview, the agency failed to ensure clinical records were complete for four (Patients #2, 3, 4 and #5) of seven patients. Findings: Patient #2 A review of the clinical record showed a SN visit note dated 04/01/26 was blank and unsigned. Patient #3 A review of the clinical record showed a SN visit note dated 03/31/26 was blank and unsigned. Patient #4 A review of the clinical record showed SN and Aide visit notes dated 03/31/26 and 04/01/26 were suspended as not started, were blank and unsigned. Patient #5 A review of the clinical record showed SN and Aide visit notes dated 03/30/26 and 04/03/26 were suspended as not started, were blank and unsigned. On 04/08/26 at 12:45 p.m., Staff B stated: 1.The SN and Aide visit notes for patients #2, 3, 4 and #5 were not completed by staff. 2.Visit notes are due within 48 hours of the visits.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit notes documented medication dose and injection administration site for one (Patient #3) of seven patients. Findings: Patient #3 A review of the POC dated 03/12/26 to 05/10/26 showed orders for SN to administer Rocephin one-gram intramuscular injection daily for three days beginning 03/13/26 for urinary tract infection. A review of SN visit notes conducted on 03/14/26 and 03/15/26 showed no medication administration intra-muscular site or gram dosage of the ordered medication. On 04/08/26 at 12:34 p.m., Staff B stated the nurse did not document where the medication was given or the dose of the medicine that was administered.”

“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 record reviews and interviews, the agency failed to ensure a discharge summary was provided to hospice physician for one (Patient #6) of seven patients. Findings: Patient #6 A review of the clinical record showed discharge to care of self for referral to hospice services on 01/05/26 and showed no discharge summary was provided to the hospice physician. On 04/08/26 at 12:55pa.m., Staff B stated the discharge summary was not sent to the hospice physician.”