Every finding on record at Ann's Choice Inc

Based on the findings of an unannounced on-site Medicare recertification survey conducted April 21, 2025, through April 22, 2025, Ann's Choice Visiting Nurse Services was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced on-site Medicare recertification survey conducted April 21, 2025, through April 22, 2025, Ann's Choice Visiting Nurse Services was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based upon review of agency policy, clinical records (CR) and interview with the agency Administrator and the Clinical Manager, the agency failed to ensure that physician orders were signed by the professional receiving the order, in accordance with agency policy, for five (5) of seven (7) CR reviewed (CR #1, 3, 4, 5, and 6), and by the attending physician for one (1) of seven (7) CR reviewed. (CR #5) Findings include: Review of agency policy titled "SOP (Standard Operating Procedure)-RAP (Request for Anticipated Payment)/Final Timelines" on April 22, 2025, at approximately 3:15 P.M. states, " Procedure: RAP – Start of Care/BP1 (BP1 abbreviation not clarified), Day Six: CM Updates/Completes/Prints 485... Day Seven: OC (Office Coordinator) mails 485 to physician and marks "sent" in Doc (document) tracker." Review of agency policy titled "Physician Orders" on April 22, 2025, at approximately 3:15 P.M. states, " Procedure: 4. Orders will be documented on a form provided by the Home Health Agency, dated, timed, and signed by the professional receiving the order... 8. Signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation." Review of CR on April 21, 2025, from approximately 1:30 P.M. to 3:30 P.M. and April 22, 2025, from approximately 9:00 A.M. to 11:30 A.M. and 1:30 P.M. to 3:30 P.M. revealed the following: CR #1, start of care April 1, 2025, contained a Home Care Certification and Plan of Care for the certification period April 1, 2025, through May 30, 2025, was not signed by the professional receiving the order. CR #3, start of care April 15, 2025, contained a Home Care Certification and Plan of Care for the certification period April 15, 2025, through June 13, 2025, was not signed by the professional receiving the order. CR #4, start of care April 11, 2025, contained a Home Care Certification and Plan of Care for the certification period April 11, 2025, through June 9, 2025, was not signed by the professional receiving the order. CR #5, start of care March 23, 2025, contained a Home Care Certification and Plan of Care for the certification period March 23, 2025, through May 21, 2025, was not signed by the professional receiving the order, and was not signed by the physician as of the exit date of the survey, April 22, 2025, which was day 30 when the Home Care Certification and Plan of Care was due back signed by the physician. CR #6, start of care December 3, 2024, contained a Home Care Certification and Plan of Care for the certification period December 3, 2024, through January 27, 2025, was signed by the professional receiving the order on December 23, 2025, twenty-one (21) days after the start of care. The Home Care Certification and Plan of Care was not signed prior to the seventh day after start of care when it was required to be sent to the physician for signature. An interview with the agency Administrator and the Clinical Manager on April 22, 2025, at approximately 4:15 P.M. confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policies, clinical home visit observations (OBS), and an interview with the agency Administrator and the Clinical Manager, the agency failed to follow its policy pertaining to infection control for one (1) of three (3) home visits observations. (OBS#1) Findings include: The "Hand Hygiene- Standard Operating Procedure" policy reviewed on April 22, 2025, at approximately 3:55 pm states in part, "Purpose and scope: To prevent the spread of potentially infectious organisms to residents/patients, staff and visitors. This SOP is applicable to all departments within Erickson Senior Living, LLC. Procedure: 1. When to perform some form of hand hygiene (at minimum): ...Immediately before, between, and after physical contact with a resident/patient..." OBS#1 An on-site observation home visit was conducted on April 22, 2025, at approximately 11:00 AM at the home of CR#1. The Speech Therapist (ST) was observed attempting to perform vital signs on the patient by placing the pulse oximeter on CR #1's finger without performing hand hygiene, before contact with the patient. The ST touched the laptop to record the results, touching the keypad. The ST then picked up the blood pressure cuff from the barrier and went over to place the cuff on CR #1. The ST removed the device and placed it back on the barrier without performing hand hygiene during this entire process. An interview with the agency Administrator and the Clinical Manager conducted on April 22, 2025, at approximately 4:15 pm, confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey conducted April 11, 2022 through April 13, 2022, Ann's Choice Visiting Nurse Services was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of personnel file documents, educational materials, and an interview with the home health administrator, the agency failed to document emergency preparedness training at least every two years for one (1) of eight (8) PF's: PF#7. Findings include: An interview was conducted with the Home Health Administrator on April 13, 2022 at approximately 1:00 pm to review the educational record of PF#7 and specifically, that the record showed that the Emergency Preparedness Course had not been started. The Home Health Administrator confirmed that the course titled, "Emergency Procedures for Home Care" shown on the educational record was the equivalent of and contained education regarding Emergency Preparedness Training. A review of personnel documents gathered by the home health administrator from various sources was conducted on April 13, 2022 starting at 09:00 AM. The date of hire (DOH) is indicated below. PF#7 DOH 05/13/2019 contained documentation of initial emergency preparedness training in 2019, but there was no documentation that emergency preparedness training was completed in 2021. A document presented to the surveyor for PF#7 showed that the "Emergency Procedures for Home Care" electronic course had not yet been started by the employee. An interview conducted with the home care administrator and clinical manager on April 13, 2022 starting at 4:00 PM confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey conducted April 11, 2022 through April 13, 2022, Ann's Choice Visiting Nurse Services was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of clinical records (CR), agency policies, and an interview with the home health administrator, the agency failed to assure 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. Four (4) of seven (7) clinical records did not meet the requirement: CF#2, CF#3, CF#5, and CF#7. Findings include: In an interview with the Home Health Administrator on April 13, 2022 at approximately 10:00 AM, she confirmed that a Registered Nurse is required to review all medication profiles and in the case of rehabilitation therapy only cases, document a note in the electronic medical record (EMR) that the medications were reviewed by a Registered Nurse. On April 13, 2022 at approximately 10:30 AM, a review of the following agency policy took place: "Medication Monitoring" which states the following,...."Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen and reconcile medications; In States that limit therapy assessment of medications, the medication profile should be completed and submitted to the Clinical Manager or designee for review. A note will be made to state that the medications were reviewed by a Registered Nurse; Any discrepancy between what the patient was previously taking, what they are taking, and what has been ordered by the physician must be reconciled and clarified with the physician; All medications ordered by the patient's physician will be recorded in the patient record on the medication profile and updated as changes occur. The medication profile will include: ....the route of the medications, the frequency of the medication." On April 13, 2022 at approximately 10:30 AM, a review of the following policy took place: "Initial and Comprehensive Assessment" which states the following, "Review of medication history, as applicable to care and service and current medication use, including prescription, over-the-counter medications and herbal medications, and identifying drug interactions, duplicate drug therapy, potential adverse effects and drug reactions, ineffective drug therapy, significant side effects and noncompliance with therapy; A review of all medications the patient is currently using in order to identify and potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy." A review of CR was conducted on April 11, 2022 starting at approximately 10:00 AM and again on April 12, 2022 starting at approximately 09:10 AM. The start of care (SOC) and Certification Period (CP) for the Home Health Certification and Plan of Care is indicated below. CR#2 SOC 02/01/2022, CP 02/01/2022 to 04/01/2022 contained a Medication Profile that was reconciled with the orders on CMS-485 Home Health Certification and Plan of Care at the start of care. An order for Trazodone (antidepressant) 50 mg (milligrams), 1/2 Tablet, Oral, PRN (as needed) for pain did not contain a frequency. CR#3 SOC 03/10/2022, CP 03/10/2022 to 05/08/2022 contained a Medication Profile that was reconciled with the orders on CMS-485 Home Health Certification and Plan of Care at the start of care. An order for Ponaris nasal solution (nasal dryness), 1, intranasal (apply in each nostril), PRN (as needed) did not contain a frequency. An order for Polyethylene Glycol 3350 (laxative) 17 gram/dose oral powder, 0.5, oral, dissolve one-half dose in eight (8) ounces of liquid, PRN (as needed) for constipation did not contain a frequency. An order for Diclofenac (non-steroidal anti-inflammatory drug) 1% (percent) topical (on skin) gel, two times daily, apply to "painful area" did not specify the body site of the painful area to which the medication should be applied. The medications were reconciled by a Physical Therapist since physical therapy was the only service being provided to the patient. There was no documentation that the medications were reviewed by a Registered Nurse in a rehabilitation-therapy only case. CR#5 SOC 03/06/2022, CP 03/06/2022 to 05/04/2022 contained a Medication Profile that was reconciled with the orders on CMS-485 Home Health Certification and Plan of Care at the start of care. An order for Tramadol (opioid for pain) 50 mg, 1 tablet, four times daily did not contain further specific information regarding the interval frequency with which the opioid should be taken. CR#7 SOC 10/15/2021, CP 02/12/2022 to 04/12/2022 contained a Medication Profile that was reconciled with the orders on CMS-485 Home Health Certification and Plan of Care at the start of the recertification period. An order for Aspercreme (pain, numbness) 4% (percent) topical (applied to skin), 1 application, three times daily did not state the body site to which the medication should be applied. An order for Spironolactone (high blood pressure and heart failure), 25 mg (1/2 tablet), oral, three times weekly did not state which days of the week the medication should be taken. An interview with the home health administrator and the clinical manager conducted on April 13, 2022 starting at 4 PM confirmed the above findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records (CR), an interview with the home health administrator, and a review of the Agency's policies, the agency failed to notify the physician of missed visits for four (4) of seven (7) CR: CR#1, CR#3, CR#4, and CR#6. Findings include: On April 11, 2022 at approximately 3:00 PM, the following policy "Missed Visits" was reviewed which states the following: "Policy: Missed visits will be communicated to the clinical manager and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Procedure: If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled, the clinician will notify the physician of the missed visit if there is a potential for clinical impact upon the patient. The physician will decide if the visit may be skipped or additional intervention si required by the organization. Notify the clinical manager of the missed visit and reason for the missed visit. Document in the patient's clinical record the following information: ....Physician notification including date, time, physician name, method of notification and the staff reporting the information....Other persons who were notified of the missed visit." A review of clinical records (CR) was conducted on April 11, 2022 starting at approximately 10:00 AM and again on April 12, 2022 starting at approximately 09:10 AM. The start of care (SOC) and Certification Period (CP) for the Home Health Certification and Plan of Care (CMS 485) is indicated below. CR#1 SOC 01/06/2022, CP 01/06/2022 to 03/06/2022. Per the Home Health Certification and Plan of Care, the patient had orders for skilled nursing (SN) two times weekly for the week of 01/09/2022 to 01/15/2022. The patient was scheduled for a visit on 01/11/2022. The registered nurse documented that the patient requested the 01/11/2022 visit be rescheduled. The RN rescheduled the visit to 01/13/2022. The patient again requested that the 01/13/2022 visit be rescheduled. The patient had a visit on 01/14/20222, but a second skilled nursing visit was missed during the week of 01/09/2022 to 01/15/2022. There was no documentation that the physician was notified of the missed visit. For the week of 01/16/2022 to 01/22/2022, the patient had orders for one skilled nursing visit. There was a missed visit on 01/21/2022. There was no documentation that the physician was notified of the missed visit. CR#3 SOC 03/10/2022, CP 03/10/2022 to 05/08/2022. Per the Home Health Certification and Plan of Care, the patient had orders for physical therapy two times per week for two weeks, encompassing 03/13/2022 to 03/19/2022 and 03/20/2022 to 03/26/2022. There was a missed physical therapy visit on 03/21/2022. A missed visit note by the physical therapist noted that the visit was unable to be rescheduled due to other conflicts. There was no documentation that the physician was notified of the missed visit. CR#4 SOC 03/19/2022, CP 03/19/2022 to 05/17/2022. Per the Home Health Certification and Plan of Care, the patient had orders for skilled nursing two times per week for the weeks encompassing 03/20/2022 to 03/26/2022, and 03/27/2022 to 04/02/2022. There was a missed visit on 03/31/2022. There was no documentation that the physician was notified of the missed visit. CR#6 SOC 03/14/2022, CP 03/14/2022 to 05/12/2022. Per the Home Health Certification and Plan of Care, the patient had orders for physician therapy two times per week for two weeks, encompassing 03/20/2022 to 03/26/2022 and 03/27/2022 to 04/02/2022. There was a missed visit on 03/24/2022. There was no documentation that the physician was notified of the missed visit. An interview with the home health administrator and clinical manager conducted on April 13, 2022 starting at 4:00 PM confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of agency policies, personnel file documents (PF), and an interview with the Home Health Administrator, the agency failed to demonstrate the presence of initial or annual competency evaluations/skills assessments for three (3) of eight (8) personnel files: PF#3, PF#6. and PF#7. Findings include: A review of the policy/procedure titled, "Competency Assessment" took place on April 13, 2022 at 11:00 AM. The document states the following, "Orientation and Probation Period - Using a Competency Skills Performance Checklist and the Orientation Checklist, the preceptor/clinical manager will observe the new personnel performing the required skills and activities. Ongoing Assessments - Competency assessments will be completed at least one (1) time per year. Using a Competency Skills Performance Checklist developed specifically for each clinical job category, the clinical manager will evaluate the competency in performing and rendering care according to organization policies and standards of practice." A review of personnel documents gathered by the home health administrator from various sources was conducted on April 13, 2022 starting at 09:00 AM. The date of hire (DOH) is indicated below. PF#3 DOH 08/11/2020 did not contain evidence of a completed competency skills performance checklist upon hire. PF#6 DOH 11/09/2016 to the organization with a transition to the home health division and home health registered nurse position around 02/26/2019 did not contain evidence of an annual, completed competency skills performance checklist in 2020 or 2021. PF#7 DOH 05/13/2019 did not contain evidence of a annual, completed competency skills performance checklist in 2020 or 2021. An interview with the home health administrator and clinical manager on April 13, 2020 starting at 4:00 PM confirmed the above findings.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on a review of Governing Board documents/resolutions, and an interview with the home health administrator, the agency failed to document, in writing, a qualified, pre-designated person who is authorized by the administrator and governing body to assume the same responsibilities and obligations as the home health administrator, in the absence of the administrator. Findings include: In an interview conducted with the Home Health Administrator (HHA) on April 11, 2022 at approximately 2:30 pm, the HHA stated that the Assistant Home Care Administrator would serve as the alternate administrator for the home health agency. A review of the home health agency's Organizational Chart on April 11, 2022 at approximately 2:00 PM did not specify an alternate home health administrator, and depicts that the Assistant Home Care Administrator (hired 09/21/2021) is responsible for home care (non-medical) services . On April 13, 2022 at approximately 3:00 PM, a review of Governing Board documents/resolutions took place. There was no documentation that the Governing Board authorized, in writing, that the the Assistant Home Care Administrator would serve as the Alternate Home Health Administrator, nor was there evidence that the Governing Body sanctioned the qualifications of the Assistant Home Care Administrator to serve in the role of Alternate Administrator for Home Health Services. An interview conducted with the Home Health Administrator and Clinical Manager on April 13, 2022 starting at 4:00 PM confirmed the above findings.