Every finding on record at Seniors Choice Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 07/25/25. 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 07/25/25. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse POC/PsOC = Plan of care/Plans of Care Pt./ Pts. = Patient/Patients mg/dl = milligrams per deciliter mm/Hg = millimeters per mercury BP = Blood Pressure SOC = Start of Care

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, and Staff interviews, the Agency failed to ensure Staff provide service indicated in the PsOC for 2 of 7 (Pts. #3 and 4) clinical records reviewed. Findings include: 1. Pt. #3 was admitted to Home Health Services on 06/05/25 with the diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 07/22/25. The clinical record included the POC effective 06/05/25 to 08/03/35, that required SN “….Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar: greater than (>)150 mg/dl….” The SN assessment dated 06/05/25, documented a fasting blood glucose: 185 mg/dl. The clinical record lacked documentation the Physician was notified of blood sugar assessment that was out of range, as ordered in the POC. 2. Pt. #4 was admitted to Home Health Services on 04/07/25 with the diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Atrial Fibrillation. The clinical record was reviewed on 07/23/25. The clinical record included the PsOC effective 04/05/25 to 06/05/25 and 06/06/25 to 08/04/25, that required: “….Notify Physician of vital sign parameters out of range:….Diastolic Blood Pressure:….less than ( 3. During an interview with the Alternate Administrator and Director of Nursing on 07/23/25 at 2:15 PM, the Director of Nursing confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: # = Number AM = Morning SOC = Start of Care SN = Skilled Nurse RN = Registered Nurse HHA = Home Health Aide Pt./Pts. = Patient/Patients PM = Afternoon, Evening COVID-19 = Coronavirus Disease 2019

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services. This was found in 3 of 7 (Pts. #5, 3, and 6) clinical records reviewed. 2. Pt. #3. SOC 1/12/22. Principal Diagnosis: Unspecified Fracture of Shaft of Right Tibia (Subsequent Encounter for Close Fracture with Routine Healing). The clinical record was reviewed on 4/5/22 at 12:00 PM. The record contained the form titled, "Patient Profile" which included the referral date of 3/1/21. The Initial comprehensive assessment was conducted by the RN on 1/12/22. The record also contained a form titled " Encounter - Telemedicine Visit" which required SN visits. The "Encounter - Telemedicine Visit" form was faxed from the physician's office to the Agency on 1/28/22, which was 10 days after the initial comprehensive assessment was conducted. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 4/7/22, it cannot be determined whether the Initial assessment was initiated within 48 hours of the referral date. 3. Pt. #6. SOC 6/22/21. Principal Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 4/6/22 at 9:50 AM. The record contained the form titled, "Patient Profile" which included the referral date of 11/5/20. The record also contained the form titled, "Encounter Summary Progress Note” which included documentation of a physician visit dated 5/13/21 and required SN visits. This form was faxed from the Physician's office to the Agency on 5/14/21. The Initial comprehensive assessment was conducted by the RN on 6/22/21, which was 39 days after the physician encounter. The record lacked documentation of a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 4. During an interview with the Administrator and Director of Nursing on 4/6/22 between 2:40 PM – 3:30 PM, the above findings were confirmed. It was also stated that the initial assessment should be conducted within 48 hours of the referral date. Findings Include: 1. Pt. #5. SOC 3/10/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/5/22 at 3:00 PM. The record included the "Patient Profile" form which documents a referral date of "2/21/22”. The SOC comprehensive assessment documents the SN initiated service for Pt. #5. The referral/”Encounter Telemedicine” date of service 2/23/22 documents “Pt. requires SN services.” The referral was faxed from the Physician’s office to the Agency on 3/3/22. The record lacked a Physician ordered SOC date or documentation of discharge date from an inpatient facility. As of 4/7/22, it cannot be determined whether the SOC was initiated in a timely manner.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Pts. are screened for COVID-19, prior to providing Pt. care and services. This was found in 2 of 7 (Pts. #1 and 4) clinical records reviewed. 2. Pt #4. SOC 3/7/22. Principal Diagnosis: Unspecified Dementia without Behavioral Disturbance. The clinical record was reviewed on 4/5/22 at 1:50 PM. The record included documentation that Pt. #4 received HHA services on 3/9/22, 3/16/22, 3/23/22 and 3/30/22. The record lacked documentation the HHA screened the Pt. for COVID-19 symptoms, prior to the visits indicated above. 3. The Agency policy titled, “Infection Control Policy for COVID-19 Pandemic” was reviewed on 4/6/22 at 2:00 PM. The Policy required, “To measure success of implemented plans, the following indicators will be utilized: 2. Integration of screening protocols upon admission of patients and during succeeding visits..." 4. During an interview with the Administrator and Director of Nursing on 4/6/22 between 2:40 PM and 3:30 PM, the above findings were confirmed. During the same interview, both stated that Pt. screening is to be conducted by all staff prior to providing home visits. Findings Include: 1. Pt #1. SOC 3/11/21. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/5/22 at 9:30 AM. The record lacked documentation the HHA screened Pt. #1 for symptoms of COVID-19, prior to the visits on 2/10/22, 2/17/22, 2/25/22, 3/3/22, 3/11/22, 3/17/22, 3/17/22, 3/24/22, 4/1/22 and 4/5/22.