Every finding on record at Ico Care Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/22/26. 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 05/22/26. Standard level deficienies cited. Abbreviations: Pt/Pts. = Patient/Patients SOC = Start of Care

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical reviews and staff interviews, in 1 of 2 discharged clinical records (Pt. #7), the Agency failed to ensure that an updated comprehensive assessment was completed upon discharge. Findings include: 1. Pt.# 7 was admitted to home health services on 10/06/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 05/19/26. A physician order included documentation that Pt. 7 was discharged on 12/04/25. The record lacked a comprehensive assessment at the time of discharge. 2. During interviews with the Administrator and QA Nurse on 05/20/26 at 2:00 PM, the above finding was confirmed.

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 observation and interviews during a home visit, clinical record review and staff interview, for 1 of 7 (Pt. #1) clinical records reviewed, the Agency failed to ensure the information contained in the clinical records were complete and accurate. Findings include: 1. Pt. #1 was admitted to home health services on 12/31/24 with the diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris. A home visit was conducted with the Physical Therapist on 05/19/26 at 11:00 AM and during the home visit, the medications were reviewed with Pt. #1’s family member. The clinical record was reviewed on 05/19/26. The record included the document “Medication Profile” which was signed by the RN and dated 12/22/25. The medication profile listed the following medications Pt. #1’s family confirmed that Pt. #1 was no longer taking: Potassium Chloride, Isosorbide, Famotidine, Gabapentin, Amlodipine, Tamsulosin and Zolpidem. The medication profile also lacked documentation of the medication “(Empagliflozin), (dose): 10 mg 1 tablet once a day” – bottle dated 01/19/26. The medication profile was inaccurate. 2. During an interview with the Administrator and QA Nurse on 05/20/26, the above finding was confirmed.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 5/25/23. The Agency was not in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

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 review of Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has potential to affect all patients receiving services. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 05/24/23. The plan lacked the names and contact information of Agency staff, contracted staff and Patient’s physicians providing care. 2. During an interview with the Administrator and Quality Nurse on 5/24/23 at 1:00 PM, the Administrator confirmed the Agency failed to ensure the Agency’s Emergency Preparedness communication plan was complete.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to ensure testing of the Emergency Preparedness Plan was conducted. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 5/24/23. The plan lacked documentation to indicate that testing of the Emergency Preparedness Plan was conducted after 2020. 2. During an interview with the Administrator and Quality Nurse on 05/24/23 at 1:00 PM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirement on 5/25/23. Abbreviations: POC= Plan of Care Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Afternoon/ Evening SN = Skilled Nurse RN= Registered Nurse # = Number PT = Physical Therapy OT = Occupational Therapy

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the Agency's Patient admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to provide Patients complete information regarding the State Hotline. This was found in 3 of 3 (Patients # 1, 2 and 3) clinical records reviewed with home visits. Findings include: 1. The Agency's admission folder was reviewed on 5/22/23 at 10:30 AM. The folder lacked the address for which a Patient (Pt.) or patient's representative may file a complaint in writing to the State Hotline. 2. The clinical records of the following Patients (Pts.) were reviewed from 5/22/23 to 5/24/23 and home visits were conducted on 5/23/23 at 10:30 AM and 1:00 PM. Pt. #1. SOC 02/24/23. Pt. #2. SOC 04/04/23. Pt. #3 SOC 03/17/23. The records lacked the address to which a Pt./patient's representative may submit a complaint. 3. During an interview with the Administrator and the Quality Nurse on 5/24/23 at 11:00 AM to 1:00 PM, they both confirmed, the Agency failed to provide complete information regarding the State Hotline.

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 review of clinical records and staff interviews, it was determined the Agency failed to ensure the Agency assessed the need for Pneumococcal Pneumonia and/or Influenza vaccines. This was found in 6 of 7 (Patients # 1, 2, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 5/22/23 to 5/24/23. Pt. #1. Start of Care (SOC) 02/24/23. Lacked an Influenza and Pneumococcal Pneumonia dates. Pt. #2. SOC 04/04/23. Lacked an Influenza and Pneumococcal Pneumonia dates. Pt. #4. SOC 02/03/23. Lacked an Influenza and Pneumococcal Pneumonia dates. Pt. #5. SOC 04/10/23. Lacked an Influenza and Pneumococcal Pneumonia inquiry. Pt. #6. SOC 03/03/21. Lacked an Influenza and Pneumococcal Pneumonia dates. Pt. #7. SOC 02/19/21. Lacked an Influenza and Pneumococcal Pneumonia inquiry. 2. During an interview with the Administrator and Quality Nurse on 5/24/23 from 11:00 AM to 12:00 PM, the Agency Administrator stated, the Registered (RN) is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information is documented in the SOC comprehensive assessment. During the same interview, the Quality Nurse confirmed the SOC comprehensive assessment/clinical record lacked an inquiry for the Pneumococcal Pneumonia and Influenza vaccines.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Patient admission folder, observation and interviews during home visits, clinical record review and staff interview, it was determined the Agency failed to provide information regarding the Clinical Director (Director of Clinical Services) and her contact information. This was found in 3 of 3 (Patients # 1, 2 and 3) clinical records reviewed with home visits. Findings include: 1. The Agency's admission folder was reviewed on 5/22/23 at 10:30 AM and lacked documentation identifying the Clinical Director’s name and contact information. 2. The clinical records of the following Patients (Pts.) were reviewed from 5/22/23 to 5/24/23 and home visits were conducted on 5/23/23 between 10:30 AM and 1:00 PM: Pt. #1. SOC 02/24/23. Pt. #2. SOC 04/04/23. Pt. #3. SOC 03/17/23. 3. Review of Pts. #1, 2, and 3 admission folders lacked the Clinical Director’s name and contact information. During the home visits of Pts. #1, #2 and #3 the Pt. admission folders were observed and lacked the Clinical Director’s name and contact information. An interview was conducted with the Pt/patient's representative for Pts. #1, 2 and #3 who stated they were not aware of the Clinical Director’s name and contact information. 4. During an interview with the Administrator and Quality Nurse on 5/24/23 from 11:00 AM to 1:00 PM, they both confirmed, the Agency failed to provide to Pts. and/or their patient's representative the Clinical Director’s name and contact information.

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 reviews and staff interview, it was determined that the Agency failed to ensure that staff provide services and treatments as ordered by the Physician in the Plans of Care. This was found in 5 of 7 clinical records (Patients # 1, 3, 4, 5 and 6). Findings include: 1. Pt. #1. SOC (Start of Care) 2/24/23. Diagnosis: Polyosteoarthritis. The clinical record was reviewed on 5/23/23. The signed Plan of Care (POC) for certification period of 2/24/23 to 4/24/23, required Skilled Nursing (SN) visit 1 week 9. The clinical record lacked SN visit for the week of 4/16/22 to 4/22/23. No modification orders were found in the clinical record. 2. Pt. #3. SOC 3/17/23. Diagnosis: Polyosteoarthritis. The clinical record was reviewed on 5/23/23. The signed POC for certification period of 3/17/23 to 5/15/23, required SN visit 1 week 9. The clinical record lacked SN visit for the week of 5/7/23 to 5/13/23. The signed POC for certification period of 3/17/23 to 5/15/23 and certification period of 5/16/23 to 7/14/23, required Physical Therapy (PT) 1 week 1, 2 week 2. PT services not started until 4/20/23 (5 weeks after SOC) and 5/22/23 (1 week after recertification). No modification orders were found in the clnical record. 3. Pt. #4. SOC 2/3/23. Diagnosis: Hypertensive Heart disease with heart failure. The clinical record was reviewed on 5/24/23. The signed POC for certification period of 4/4/23 to 6/2/23, required PT 1 week 1 week, 2 week 2. PT services were not started until 4/20/23 (16 days after recertification). The signed POC for certification period 4/4/23 to 6/2/23, required Occupational Therapy (OT) 1 week 2. The clinical record did not contain any documentation that OT services were provided. No modification orders were found in the clnical record. 4. Pt. #5. SOC 4/10/23. Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 5/23/23. The POC for the certification period of 4/10/23 to 6/8/23 required PT 1 week 1, 2 week 2. PT services not started until 5/5/23. No modification orders were found in the clinical record. 5. Pt. #6. SOC 3/3/21. Diagnosis: Gastro-esophageal Reflux Disease Without Esophagitis. The clinical record was reviewed on 5/24/23. The POC for the certification period of 6/26/22 to 8/24/22 required SN 1 week 7. The clinical record lacked SN visits for 8/13/22 and 8/20/22. No modification orders were found in the clinical record. 6. During interviews with the Administrator and Quality Nurse on 5/24/23 from 11:00 to 1:00 PM, they both confirmed the above findings.