Every finding on record at Care Choice Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 07/31/25. The Agency was in compliance with the Condition, 42 CFR 484.102 Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 07/31/25. Standard level deficiencies cited. Abbreviations: PT = Physical Therapy SN = Skilled Nurse OT = Occupational Therapy MSW = Master of Social Work Pt./ Pts. = Patient/Patients SOC = Start of Care

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 review of the Agency’s Pt. admission folder, observations and interviews during home visits, clinical record reviews, and staff interviews, the Agency failed to ensure the Pt./representative was informed in writing of the services to be provided and the frequency of visits in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 07/28/25 at 3:00 PM. The folder included the “Request for Admission & Consent for Treatment” which lacked the disciplines that will furnish care, and the frequency of visits proposed to furnish. 2. The following clinical records were reviewed on 07/28/25 to 07/29/25: Pt #1. SOC 07/07/25. Pt. received SN, PT and OT services. Pt. #2. SOC 04/12/25. Pt. received SN, PT and HHA services. Pt. #3. SOC 06/24/25. Pt. received SN, PT, OT and MSW services. Pt. #4 SOC 02/26/25. Pt. received SN services. Pt. #5 SOC 05/28/25. Pt. received SN, PT, and OT services. Pt. #6 SOC 05/25/24. Pt. received SN and PT services. Pt. #7 SOC 06/13/24. Pt. received SN and PT services. The clinical records included the “Request for Admission & Consent for Treatment” form signed by the Pt./representative. The consent forms lacked documentation of the service(s) to be provided and visit frequencies. 3. Home visits were conducted on the following Pts. on 07/28/25 and 07/29/25: Pt #1. SOC 07/07/25. Pt. #2. SOC 04/12/25. Pt. #3. SOC 06/24/25. During the home visits of Pts. #1, 2, and 3, the Pt. admission folders were observed and lacked documentation indicating the Pt./representative was notified of the discipline(s) to provide service, and frequency of visits in writing. 4. During staff interviews with the Administrator and Agency Supervisor, on 07/30/25 at 10:30 AM, and 11:30 AM, the administrative team confirmed the above findings.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical records review, Agency policy review and staff interview, the Agency failed to ensure Pts. were assessed for the status of Pneumonia vaccination for 3 of 7 (Pts. # 1, 6 and 7) clinical records reviewed. 1. The following clinical records were reviewed on 07/28/25, 7/29/25, and 07/30/25: Pt. # 1. SOC 07/07/25. Pt. # 6. SOC 05/25/24 Pt. # 7. SOC 06/13/24. The clinical records lack documentation indicating that Pts. were assessed for pneumonia vaccination status. 2. The Agency Policy titled "Pneumonia Vaccination" was reviewed on 07/30/25 and required: "Instructions...3... The home health agency shall document in each client's / patient's medical record that a vaccination against pneumococcal pneumonia was offered and was administered, arranged, refused, or medically contraindicated or that the client / patient is not a member of a vaccination priority population." 3. During interviews with the Administrator and Director of Nursing on 07/30/25 between 10:30 AM and 11:30 AM, this finding was confirmed.