Best Choice Home Health Inc.

“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) that identified a date the assessment was developed and implemented and/or was review for all patients and employees. Findings: A review of administrative records showed a community-based risk assessment which identified the agency but showed no date the assessment was developed and implemented and/or was review for the agency, its patient population, or its employees. On 02/05/25 at 12:50 p.m., Staff A stated the AHRA did not identify a date the assessment was developed, implemented and/or was reviewed for the agency.”

“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 updated required information related to current employee contact information for the agency, for all patients and employees. Findings: Administrative records showed no updated Emergency Preparedness Communication Plan which included current employee contact information for the agency. On 02/05/24 at 12:50 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for current employees of the agency.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a transfer/discharge summary for five (Patients #3, 10, 11, 12 and #13) of 13 patients. Findings: Patient #3 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/22/25. Documentation showed no transfer summary was completed. Patient #10 A review of the clinical record showed the patient was transferred with discharge to in-patient hospice care on 10/01/25. Documentation showed no transfer/discharge summary was completed. Patient #11 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/05/25. Documentation showed no transfer summary was completed. Patient #12 A review of the clinical record showed the patient was transferred to in-patient hospital care on 10/15/24. Documentation showed no transfer summary was completed. Patient #13 A review of the clinical record showed the patient was discharged from the agency on 08/05/24. Documentation showed no discharge summary was completed. On 02/05/25 at 1:14 p.m. to 1:50 p.m., Staff A stated the agency did not complete provide: 1. Transfer summaries for patients #3, 11, 10 and 12 and; 2. No discharge summary for patient #13.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI quality indicator data from OASIS (patient assessment data) reporting to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative QAPI records for calendar years 2023 and 2024 showed no quality indicator data collection sources from OASIS (patient assessment data) reporting utilized in the analysis of data in the agency’s QAPI Program. On 02/05/25 at 1:00 p.m., Staff A stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no collection or analysis of quality indicator data from OASIS (patient assessment data) reporting for calendar years 2023 and 2024.”

“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 interviews, the agency failed to ensure the required performance improvement project documentation for the agency included measurable goals (threshold levels) to measure performance in calendar years 2023 and 2024.for all patients and employees. Findings: A review of QAPI Program documentation showed no required performance improvement project documentation for the agency included no measurable goals (threshold levels) to measure performance in calendar years 2023 and 2024. On 02/05/25 at 1:00 p.m., Staff A stated the agency had no QAPI PIP documentation which included measurable goals (threshold levels) to measure performance in calendar years 2023 and 2024.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile was updated for ordered medications for one (Patient #5) of 13 patients. Findings: Patient #5 A review of a POC dated 12/04/24 to 02/01/25 showed a SN visit note dated 01/20/25 that documented the patient was taking an antibiotic for infection. The SN visit note did not identify the antibiotic or note a dosing regimen of the medication. Documentation showed no follow up review or update to the medication profile by the SN. Documentation showed no physician notifications, and no change in orders. On 02/05/25 at 1:19 p.m., Staff A stated documentation showed no follow up review or update to the medication profile by the SN.”

“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 individualized patient POC included: 1. SN intervention durations for two (Patients #2 and #3) of 13 patients. 2. SN intervention for assessment, instruction and interventions for wound management showed no identified wound care site or goals for one (Patient #3) of 13 patients. 3. SN intervention for assessment, instruction and management of Mickey button (gastrostomy feeding tube) change every three months did not identify a button (gastrostomy feeding tube) location, size, last changed or due date of intervention for one (Patients #4) of 13 patients. 4. SN intervention for assessment and instruction for management of weight showed no weight reporting parameters to report to the physician for one (Patient #5) of 13 patients. 5. SN intervention for assessment, instruction and interventions for venipuncture and laboratory monitoring of a health condition for one (Patient #6) of 13 patients. Findings: Patient #2 A review of the POC dated 12/29/24 to 02/26/25 showed orders for SN to assess and instruct the patients’ health conditions every visit. Documentation showed no duration of SN services showed no physician notifications and no change in orders. On 02/05/25 at 1:12 p.m., Staff A stated the POC documentation identified no duration of SN services. Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed orders for SN to assess and instruct the patients’ health conditions and perform wound site care every visit. Documentation showed no duration of SN services and no identified wound care site or goals. Documentation showed no physician notifications and no change in orders. On 02/05/25 at 1:14 p.m., Staff A stated the POC documentation identified no duration of SN services and did not identify wound care site or goals. Patient #4 A review of the POC dated 01/04/25 to 03/30/25 showed orders for SN to assess and instruct the patients’ health conditions and perform Mickey button (gastrostomy feeding tube) management with intervention to change the Mickey button every 3 months. Documentation did not identify a button (gastrostomy feeding tube) location, size, last changed or due date of intervention and showed no physician notifications and no change in orders. On 02/05/25 at 1:17 p.m., Staff A stated the POC documentation identified no button (gastrostomy feeding tube) location, size, last changed or due date of intervention. Patient #5 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN to assess and instruct the patient weight every visit. Documentation showed no weight reporting parameters to report to the physician and showed no physician notifications and no change in orders. On 02/05/25 at 1:19 p.m., Staff A stated the POC documentation identified no weight reporting parameters to report to the physician. Patient #6 A review of the POC dated 12/13/24 to 02/10/25 showed orders for SN to perform venipuncture and laboratory monitoring of a complete blood count and clozapine (a medication) every month. Documentation showed no last completed or next due date of the intervention. On 02/05/25 at 1:19 p.m., Staff A stated the POC documentation identified no last completed or next due date for the intervention.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physician order for SN to perform wound site care and management was a part of the patient’s plan of care for one (Patient #3) of 13 patients. Findings: Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed a physician’s order dated 01/13/25 attached to the clinical record for SN to perform wound site care and management two times a week but documented no location of the wound site. Documentation showed no physician notification and no changes in orders. On 02/05/25 at 1:14 p.m., Staff A stated the SN order for patient #3 showed no wound site location, no physician notifications and no changes in orders.”

“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: 1. SN conducted visits as ordered for six (Patients #1, 3, 7, 10, 11 and #12) of 13 patients. 2. SN monitored the patients’ weight every visit as ordered for one (Patient #5) of 13 patients. 3. SN reported a patient’s reported pain level every visit as ordered for one (Patient #7) of 13 patients. Findings: Patient #1 A review of the POC dated 01/15/25 to 03/15/25 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week for nine weeks. Documentation showed during the week of 01/15/25 to 01/18/25 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:10 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed orders for SN to assess, instruct and monitor patients’ health conditions with a SN frequency of two times a week. Documentation showed during the week of 12/14/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:14 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #5 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN frequency of two times a week for one week, then one time a week for eight weeks for SN to assess, instruct and monitor patients’ weight every visit. Documentation of SN visit notes dated 12/06/24, 12/09/24, 12/11/24, 12/16/24, 12/23/24, 01/09/24 and on 01/20/25 showed no weight monitoring as ordered. Documentation showed no patient or caregiver refusal of weight monitoring, no physician notification and no changes in orders. On 02/05/25 at 1:19 p.m., Staff A stated weight monitoring of the patient should have been conducted as ordered by the physician. Patient #7 A review of the POC dated 01/06/25 to 03/06/25 showed orders for SN frequency of one time a week for SN to assess, instruct and monitor patients’ pain level every visit and report reported pain levels greater than 6 of 10 to the physician. Documentation of SN visit notes dated 01/06/25 reported a pain level of 7, 01/14/24 reported a pain level of 7 and on 01/27/25 reported a pain level of 7. Documentation showed no physician notifications and no changes in orders. On 02/05/25 at 1:30 p.m., Staff A stated the SN should have notified the physician of the patient’s reported pain levels greater than 6 of 10 as ordered by the physician. Patient #10 A review of the POC dated 08/29/25 to 10/27/25 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week for nine weeks. Documentation showed during the week of 09/01/24 to 09/07/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:35 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #11 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week. Documentation showed during the week of 12/04/24 to 12/07/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:40 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #12 A review of the POC dated 08/19/24 to 10/17/24 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week. Documentation showed no during the week of 08/25/24 to 08/31/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:45 p.m., Staff A stated a SN visit should have been conducted as 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 were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2023 and 2024. On 02/05/25 at 1:00 p.m., Staff A stated documentation showed no evidence of multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency.”

“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 clinical visit note documentation was completed for two (Patients #3 and #8) of 13 patients. Findings: Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed orders for SN to assess, instruct and monitor patients’ health conditions and perform wound site care each visit with a SN frequency of two times a week. SN visit notes dated 12/20/24 and 12/24/24 documented no wound site interventions performed during the visits and documented no patient response to the interventions. On 02/05/25 at 1:14 p.m., Staff A stated SN clinical visit notes for 12/20/24 and 12/24/24 documented no wound site interventions and no patient response to the interventions. Patient #8 A review of the POC dated 12/18/24 to 02/15/25 showed orders for SN to assess, instruct and monitor patients’ health conditions and perform wound site care each visit with a SN frequency of two times a week for nine weeks. SN visit notes dated 12/23/24, 12/26/24, 12/30/24, 01/06/25, 01/09/25, 01/20/25 and on 01/27/25 documented no wound site interventions performed during the visits and documented no patient response to the interventions. On 02/05/25 at 1:32 p.m., Staff A stated SN clinical visit notes for 12/23/24, 12/26/24, 12/30/24, 01/06/25, 01/09/25, 01/20/25 and on 01/27/25 documented no wound site interventions and no patient response to the interventions.”

“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 completed transfer/discharge summaries were provided to receiving service providers for five (Patients #3, 10, 11, 12 and #13) of 13 patients. Findings: Patient #3 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/22/25. Documentation showed no transfer summary, and no in-patient follow up communication was provided to the in-patient hospital service provider or physician. Patient #10 A review of the clinical record showed the patient was transferred with discharge to in-patient hospice care on 10/01/25. Documentation showed no transfer/discharge summary, and no in-patient follow up communications were provided to the in-patient hospice service provider, patient/caregiver or physician. Patient #11 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/05/25. Documentation showed no transfer summary, and no in-patient follow up communication was provided to the in-patient hospital service provider or physician. Patient #12 A review of the clinical record showed the patient was transferred to in-patient hospital care on 10/15/24. Documentation showed no transfer summary, and no in-patient follow up communication was provided to the in-patient hospital service provider or physician. Patient #13 A review of the clinical record showed the patient was discharged from the agency on 08/05/24. Documentation showed no discharge summary, and no summary of care was provided to the patient/caregiver or physician. On 02/05/25 at 1:14 p.m. to 1:50 p.m., Staff A stated the agency did not provide: 1. Transfer summaries for patients #3, 11, 10 and 12 to the receiving service providers and; 2. No discharge summary to the patient/caregiver or physician at the time of discharge from agency services for patient #13.”