Evangel Home Care Services

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides completed at least 12 hours of in-service education hours every 12 months for 1 out of 1 HHA clinical record for 2025. This failure had the potential to cause physical harm to agency patients due to HHA who might not have had the competency, knowledge, or skills needed to safely provide effective care, including infection control, patient handling and emergency response. Review of the personnel files revealed that the home health aide did not have the required 12 hours of Inservice education for 2025. During an interview with the Administrator on 03/13/2026 at 12:00 PM, he stated that he was unaware that the HHA had not submitted her in-service certificates. The Administrator confirmed that, the Administrator is responsible for ensuring that each HHA completes at least 12 hours of in-service training within each 12-month period. The HHA was interviewed on 03/13/2026 at 12:12 PM and stated that she was not aware that she needed to complete 12 in-service hours annually. At the time of the survey, the HHA had not completed the required 12 hours for the year 2025. The Administrator, who started this position at the end of February 2026 and is the only office staff present while the supervising nurse is not available, immediately contacted the HHA at 12:08 PM to clarify the in-service requirements. The Administrator acknowledged the gap in communication and oversight. Failure to complete the required in-service training could potentially impact patient care by limiting the HHA’s knowledge of updated agency policies, procedures, and clinical best practices, which are critical for ensuring safe and effective patient care. The agency has initiated steps to ensure the HHA completes her required training promptly and that future in-service compliance is monitored regularly. Record review of the agency’s policy and procedures confirmed that all home health aides are required to meet certain criteria, including the completion of Inservice education as required by state and federal law, which mandates 12 hours annually for certified home health agencies. Record review of policy titled-Home Care Aide-Criteria for Employment and Competency Policy, unknown date 2008, read in part: Inservice education will be provided as required by state and federal law (12 hours annually for certified home health).”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s plans of care were reviewed by the patients physician no less than every 60 days, beginning with the start of care date, for 5 of 7 patients (Patients #1,#3,#4,#5 and #7) whose records were reviewed in that: the plans of care for Patients #1,#3,#4,#5 and #7 were not signed by the physician within the required timeframe. This failure had the potential to cause physical harm to agency patients in that care may be provided without documented physician authorization, and the physician may not be aware of the patient’s need for additional care or services. Findings Included: Review of the clinical record for Patient #1 revealed a start of care date of 11/04/2025, 75 years old, with the following diagnosis long-term loss of kidney function, constant high blood sugar without complications, urine bladder infection, and high blood pressure. With skilled nursing services. Review of the record revealed the POC for the time-period of 01/03/2026 to 03/03/2026 was not signed by the physician within 60 days. Further review of the POC revealed the POC was not signed at all by the approved physician. Review of the clinical record for Patient #3 revealed a start of care date of 10/01/2025, 75 years old, with the following diagnosis heart is unstable and not getting enough blood and oxygen, fluid buildup in stomach, easily irritated airways that makes it hard to breath, urine bladder infection and enlarged prostate. With skilled nursing, physical and occupational therapy services. Review of the record revealed the POC for the time-period of 11/30/2025 to 01/28/2026 was not signed by the physician within 60 days. Further review of the POC revealed the POC was not signed at all by the approved physician. Review of the clinical record for Patient #4 revealed a start of care date of 06/25/2025, 88 years old, with the following diagnosis urine bladder infection site not specified, inflamed stiff joints, weakness and personal history of urine bladder infections. With skilled nursing and physical therapy services. Review of the record revealed the POC for the time-period of 12/22/2025 to 02/19/2026 was not signed by the physician within 60 days. Further review of the POC revealed the POC was not signed at all by the approved physician. Review of the clinical record for Patient #5 revealed a start of care date of 08/05/2025, 83 years old, with the following diagnosis long term pain, muscle weakness, with wore down joints to both knees, and weakness. With skilled nursing, home health aide, physical and occupational therapy services. Review of the record revealed the POC for the time-period of 12/04/2025 to 02/01/2026 was not signed by the physician within 60 days. Further review of the POC revealed the POC was not signed at all by the approved physician. Review of the clinical record for Patient #7 revealed a start of care date of 06/13/2025, 91 years old, with the following diagnosis high blood pressure, difficulty in walking, and weakness. With skilled nursing, physical and occupational services. Review of the record revealed the POC for the time-period of 10/11/2025 to 12/05/2025 was not signed by the physician within 60 days. Further review of the POC revealed the POC was not signed by the approved physician and or submitted for signature. Record review of the Agency’s QAPI plan and meeting minutes for 2023, 2024, and 2025 did not contain documentation of an identified issue or improvement plan related to unsigned physician orders. During an interview conducted with the Administrator on 03/12/2026 at 1:30PM, this Nurse Surveyor inquired regarding Patients #1, #3, #4, #5, and #7 whose POCs had not been signed by the physician within the required 60-day timeframe. The Administrator stated that the agency did not have the signed POCs at that time. The Administrator explained that intake staff had sent the POCs to the physician via fax or email, and if the signed documents were not returned within two weeks, staff followed up with a phone call and the fax was resent. The Administrator reported that, despite these efforts, the POCs had not been returned signed by the physicians at the time of the interview. When asked about the agency’s policy and procedure regarding physician signatures on POCs, the Administrator stated that the orders are emailed, faxed and or mailed. “If not received within 2 weeks, we call the physician’s office and resend the fax. Agency policy requires physician review and signature of the POC within 2 weeks of initiation or recertification”. When asked what actions were taken to obtain the physician’s signature for Patients #1, #3, #4, #5, and #7, the Administrator stated that the agency had made multiple attempts to obtain the signature, including sending the POCs to the physician’s office and follow-up communication. However, the physicians had not returned the signed document. Record review of policy, titled-Plan of Care Skilled Care Policy, unknown date 2008, read in part: The plan of care will be signed by a practitioner. Record review of policy, titled-Processing Practitioner Orders Policy, unknown date 2008, read in part: If the signed orders are not returned within two (2) weeks of date mailed or delivered, a call shall be made to the practitioner’s office.”