Family Choice Home Care Oklahoma City

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) was reviewed and updated every two years for all patients and employees. Findings: A review of emergency preparedness records showed no review and update of a community-based risk assessment dated 12/04/22. On 02/19/26 at 9:20 a.m., Staff C stated the risk assessment was not updated after 12/04/22.”

“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 contact information for the agency for all patients and employees. Findings: A review of emergency preparedness program records included employee contact information who were no longer employed by the agency. On 02/19/26 at 9:20 a.m., Staff C stated the emergency preparedness communication plan was not updated.”

“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 record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted in calendar year 2024 for all patients and employees. Findings: A review of emergency preparedness records showed no disaster table-top exercises, drills, community drills or plan activation events for calendar year 2024. On 02/19/26 at 9:20 a.m., Staff C stated the agency had no disaster events or exercises in 2024.”

“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 patient case conferences were carried out as discharge planning activities for four (Patients #1, 2, 3 and #5) of 10 patients. Findings: Patient #1 A review of the clinical record showed a case conference date of 02/12/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:40 a.m., Staff C stated the conference was not conducted. Patient #2 A review of the clinical record showed a case conference date of 02/12/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:42 a.m., Staff C stated the conference was not conducted. Patient #3 A review of the clinical record showed a case conference date of 02/12/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:48 a.m., Staff C stated the conference was not conducted. Patient #5 A review of the clinical record showed a case conference date of 02/05/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:56 a.m., Staff C stated the conference was not conducted.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of patient quality indicator data in the QAPI program for all patients and employees. Findings: A review of quality assessment performance improvement records showed no measurements, analysis, tracking or evaluation of patient quality indicator data by the agency in calendar year 2024 and for 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated the QAPI meeting records did not report on the patient quality indicator data.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its QAPI program performance improvement projects for calendar year 2024 and for 01/01/25 to 06/30/25 for all patients and employees. Findings: A review of quality assessment performance improvement records showed no follow up or PIP status designation by the agency in calendar year 2024 and for 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated the QAPI records did not show performance improvement project designation or reporting.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its infection control program surveillance monitoring was included in QAPI program reporting for calendar years 2024 and 01/01/25 to 06/30/25 for all patients and employees. Findings: A review of quality assessment performance improvement records showed no infection control program surveillance data for calendar year 2024 and 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated the QAPI records did not show infection control program surveillance reporting.”

“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 record reviews and interviews, the agency failed to ensure informed consents were obtained and accessible for three (Patients #5, 8 and #10) of 10 patients. Findings: Patient #5 A review of a plan of care dated 12/27/25 to 02/24/26 showed no consent from the start of care date of 05/01/25. On 02/19/26 at 10:56 a.m., consent form from 05/01/25 was requested and yielded no results. At 12:00 p.m., Staff C stated the consent form was not found. Patient #8 A review of a plan of care dated 10/28/25 to 12/26/25 showed no consent from the start of care date of 10/28/25. On 02/19/26 at 11:15 a.m., consent form from 10/28/25 was requested and yielded no results. At 12:00 p.m., Staff C stated the consent form was not found. Patient #10 A review of a plan of care dated 12/14/25 to 02/11/26 showed no consent from the start of care date of 12/14/25. On 02/19/26 at 11:15 a.m., consent form from 12/14/25 was requested and yielded no results. At 12:00 p.m., Staff C stated the consent form was not found.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure an initial assessment was conducted within 48 hours of referral for two (Patients #5 and #9) of 10 patients. Findings: Patient #5 A review of the clinical record showed the agency received referral information on 03/25/25 and the initial assessment occurred on 05/01/25. The documentation showed no patient refusal of initial assessment, no physician notification of a delay in assessment and no change in orders. On 02/19/26 at 10:56 a.m., Staff C stated the initial assessment was not conducted within 48 hours of referral. Patient #9 A review of the clinical record showed the agency received referral information on 07/25/25 and the initial assessment occurred on 07/28/25. The documentation showed no patient refusal of initial assessment, no physician notification of a delay in assessment and no change in orders. On 02/19/26 at 10:56 a.m., Staff C stated the initial assessment was not conducted within 48 hours of referral.”

“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 reviews and interviews, the agency failed to ensure individualized patient POC included: Identified wound care site for one (Patient #1) of 10 patients. Physical therapy interventions for one (Patient #4) of 10 patients. Weight reporting parameters for one (Patient #6) of 10 patients. Goals for pain management interventions for one (Patient #7) of 10 patients. Skilled nursing interventions for one (Patient #8) of 10 patients. Pain reporting parameters for one (Patient #9) of 10 patients. Findings: Patient #1 A review of the POC dated 12/31/25 to 02/28/26 showed orders for SN to conduct wound site care and assessment every visit. The wound care orders did not identify the location of the wound site. SN visits for wound site care and assessment were conducted on 01/02/26, 01/05/26, 01/09/26, 01/12/26, 01/16/26, 01/19/26, 01/25/26, 01/28/26, 01/30/26, 02/02/26, 02/06/26 and 02/09/26. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 10:40 a.m., Staff C stated the wound care orders did not identify the location of the wound site. Patient #4 A review of the POC dated 01/20/26 to 03/20/26 showed orders for physical therapy to evaluate and establish a treatment plan with a frequency of one time a week for one week, two times a week for three weeks, then one time a week for one week. The POC orders showed no physical therapy interventions. PT visits were conducted on 01/22/26, 01/28/26, 01/31/26, 02/04/26 and 02/09/26. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 10:51 a.m., Staff C stated the PT orders did not include physical therapy interventions. Patient #6 A review of the POC dated 01/06/26 to 03/06/26 showed a primary diagnosis of heart failure and orders for SN to assess, instruct and weigh the patient every visit. The POC showed no weight reporting parameters for physician notification. SN visits to assess, instruct and weigh were conducted on 01/08/26, 01/15/26 and on 01/22/26. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 10:58 a.m., Staff C stated the care plan did not include weight reporting parameters. Patient #7 A review of the POC dated 08/21/25 to 10/19/25 showed orders for SN to assess and instruct on management of pain every visit. The POC showed no pain management goals. A SN visits to assess and instruct on management of pain was conducted on 09/05/25. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 11:01 a.m., Staff C stated the care plan did not include pain goals for the patient. Patient #8 A review of the POC dated 10/28/26 to 12/26/26 showed orders for SN frequency of one time a week for nine weeks. The POC orders showed no nursing interventions. SN visits were conducted on 10/28/26 with a transfer to in-patient services on 11/03/25. The clinical record showed no physician notifications and no change in orders prior to the in-patient transfer. On 02/19/26 at 11:15 a.m., Staff C stated the POC orders did not include nursing interventions. Patient #9 A review of the POC dated 11/25/25 to 01/23/26 showed orders for SN to assess and instruct patient pain level every visit. The POC showed no pain level reporting parameters for physician notification. SN visits were conducted on 12/12/25 with a transfer to in-patient services on 12/21/25. The clinical record showed no physician notifications and no change in orders prior to the in-patient transfer. On 02/19/26 at 11:20 a.m., Staff C stated the care plan did not include pain level reporting parameters.”

“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: SN conducted weight assessments for two (Patient #1 and #6) of 10 patients. SN conducted edema assessments of one (Patient #3) of 10 patients. PT conducted visits as ordered for one (Patient #4) of 10 patients. SN conducted pain assessments of one (Patient #7) of 10 patients. SN notified physician for diastolic blood pressure less than reporting parameter for one (Patient #10) of 10 patients. Findings: Patient #1 A review of the POC dated 12/31/25 to 02/28/26 showed orders for SN to conduct assessment of the patient’s weight every visit. SN visits were conducted on 01/02/26, 01/05/26, 01/09/26, 01/12/26, 01/16/26, 01/19/26, 01/25/26, 01/28/26, 01/30/26, 02/02/26, 02/06/26 and 02/09/26 showed no assessment of the patient’s weight was conducted, no patient refusal to weigh, no physician notifications and no change in orders. On 02/19/26 at 10:40 a.m., Staff C stated the nurse should have weighed the patient every visit. Patient #3 A review of the POC dated 12/30/25 to 02/27/26 showed orders for SN to conduct assessment of the patient’s edema every visit. SN visits were conducted on 01/07/26, 01/14/26, 01/21/26, 01/26/26, 02/06/26 and 02/12/26 showed no assessment of the patient’s edema, no physician notifications and no change in orders. On 02/19/26 at 10:48 a.m., Staff C stated the nurse should have assessed the patient’s edema every visit. Patient #4 A review of the POC dated 01/20/26 to 03/20/26 showed orders for physical therapy frequency of one time a week for one week, two times a week for three weeks, then one time a week for one week. A review of the clinical record showed during the week of 02/01/26 to 02/07/26 a PT visit was conducted on 02/04/26 (two visits ordered, one visit conducted). A review of the clinical record showed during the week of 02/08/26 to 02/14/26 a PT visit was conducted on 02/09/26 (two visits ordered, one visit conducted). The clinical record showed no missed visits, patient refusal of visits, physician notifications and no change in orders. On 02/19/26 at 10:51 a.m., Staff C stated the PT did not conduct the visits as ordered. Patient #6 A review of the POC dated 01/06/26 to 03/06/26 showed orders for SN to conduct assessment of the patient’s weight every visit. SN visits were conducted on 01/08/26, 01/15/26, 01/22/26, 02/06/26 and 02/10/26 showed no assessment of the patient’s weight conducted, no patient refusal to weigh, no physician notifications and no change in orders. On 02/19/26 at 10:58 a.m., Staff C stated the nurse should have weighed the patient every visit. Patient #7 A review of the POC dated 08/21/25 to 10/19/25 showed orders for SN to assess, instruct on pain management every visit. SN visits were conducted on 09/05/25 showed no assessment of the patient’s pain was conducted, no patient refusal to assess pain, no physician notifications and no change in orders. On 02/19/26 at 11:01 a.m., Staff C stated the nurse should have assessed the patient’s pain. Patient #10 A review of the POC dated 12/14/25 to 02/11/26 showed orders for SN to report patient’s diastolic blood pressure less than 60. A review of a SN visit note dated 12/16/25 showed a diastolic blood pressure of 58 and showed no re-assessment of the patient’s blood pressure, no physician notifications and no change in orders. On 02/19/26 at 11:25 a.m., Staff C stated the nurse should have re-assessed the blood pressure and then notified the physician as ordered.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure visit note documentation was completed for two (Patients #1 and #2) of 10 patients. Findings: Patient #1 A review of the POC dated 12/31/25 to 02/28/26 showed orders for SN to conduct wound site care and assessment every visit. A review of SN visit notes conducted on 01/02/26, 01/05/26, 01/09/26, 01/12/26, 01/16/26, 01/19/26, 01/25/26, 01/28/26, 01/30/26, 02/02/26, 02/06/26 and 02/09/26 showed no wound site assessment or care that was conducted during the visits and documented “wound care per order” on each SN visit note. On 02/19/26 at 10:40 a.m., Staff C stated the nurses should have documented the wound assessment and care that was performed on the patient in every visit note. Patient #2 A review of the POC dated 12/30/25 to 02/27/26 showed orders for PT with a frequency of one time a week for one week, two times a week for four weeks, then one time a week for four weeks. A review of a PT visit note dated 02/11/26 showed the visit was “not started” and showed no patient refusal of visit, PT missed visit, physician notification and no communication notes. On 02/19/26 at 10:42 a.m., Staff C stated the PT should have completed the visit note.”

“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 for 01/01/25 to 06/30/25 for all patients and employees. Findings: A review of quality assessment performance improvement records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar year 2024 and for 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated they did not have PT or OT participate in the QAPI program.”

“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 transfer/discharge summary was provided to a receiving service provider for three (Patients #8, 9 and #10) of 10 patients. Findings: Patient #8 A review of the clinical record showed transfer to in-patient services on 11/03/25 and showed no transfer summary was provided to the in-patient provider. A review of the clinical record showed the physician was provided with a transfer summary of care on 11/19/25 (16 days) after the transfer of care. On 02/19/26 at 11:15 a.m., Staff C stated the transfer summary was not sent to the in-patient facility and the physician was sent a copy 16 days later. Patient #9 A review of the clinical record showed transfer to in-patient services on 11/21/25 and showed no transfer summary was provided to the in-patient provider. A review of the clinical record showed the physician was provided with a transfer summary of care on 11/26/25 (5 days) after the transfer of care. On 02/19/26 at 11:20 a.m., Staff C stated the transfer summary was not sent to the in-patient facility and the physician was sent a copy 5 days later. Patient #10 A review of the clinical record showed transfer to in-patient services on 01/26/26 and showed no transfer summary was provided to the in-patient provider. A review of the clinical record showed the physician was provided with a transfer summary of care on 02/11/26 (16 days) after the transfer of care. On 02/19/26 at 11:25 a.m., Staff C stated the transfer summary was not sent to the in-patient facility and the physician was sent a copy 16 days later.”