Every finding on record at Healthy Choice Homecare LLC

A relicensure/recertification survey entrance conference was conducted with the Administrator, Alternate Administrator/Director of Nurses and Alternate Director of Nurses on 09/11/2024 at 11:10 AM. Census: LCHHS: 43 LHHS: 0 PAS: 150 The agency was found in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A relicensure/recertification survey entrance conference was conducted with the Administrator, Alternate Administrator/Director of Nurses and Alternate Director of Nurses on 09/11/2024 at 11:10 AM. Census: LCHHS: 43 LHHS: 0 PAS: 150 An exit conference was conducted with the Administrator, Alternate Administrator/Director of Nurses and Alternate Director of Nurses on 09/17/2024 at 2:00 PM. The preliminary findings were discussed. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: HHA – home health agency LHHS – licensed home health services LCHHS – licensed and certified home health services PAS – personal assistance services

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 conduct and document performance improvement projects for three of three calendar years (2021, 2022 and 2023) and failed to have at least one performance improvement project in development or ongoing for calendar year 2024 that reflected the scope, complexity and past performance of the agency's services and operations and the measurable progress achieved on the projects. This failure could prevent the agency from identifying weaknesses and making improvements in patient care. Findings Include: Record review of the agency's quality assessment performance improvement binder did not include any reports, reviews or documentation that indicated the agency conducted performance improvement projects for calendar year 2021, 2022 and 2023 or had a performance improvement project in development or ongoing for calendar year 2024. In an interview with the Administrator on 09/11/2024 at 9:10 AM, the Administrator stated he was responsible for the HHA’s overall quality assessment performance improvement activities. Record review of the HHA’s quality assessment performance improvement binder did not include a performance improvement project for 2021, 2022, 2023 and 2024. In an interview with the Administrator on 09/17/2024 at 11:35 AM, the surveyor asked why the HHA did not have annual performance improvement projects for 2021, 2022 and 2023 or a project in development or an ongoing project for 2024. The Administrator reviewed the HHA’s quality assessment performance improvement binder and showed the surveyor a performance improvement project dated 02/01/2019 and stated that was the last project done by the HHA. The Administrator stated the HHA’s quality report numbers did not indicate a big decline in any area but there were always areas the HHA could improve so the HHA would start annual performance improvement projects. The Administrator stated HHA policy was not followed due to the reasons stated above. Agency policy titled, “Quality Assessment Performance Improvement… Project”, undated, read in part, “… POLICY [HHA] will develop, implement, maintain and document effective, ongoing agency-wide, data-driven quality assessment and performance improvement… program. The… activities will include Performance Improvement Projects… Performance Improvement Projects 1. Will be developed, implemented and evaluated by the agency and its Governing Board… 2… will be conducted at least annually… 3. Will be documented by the agency…”