Carechoices Home Health Services, LLC

The agency failed to ensure the emergency preparedness plan included the process for collaboration with the regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

The agency failed to ensure the emergency preparedness P&P included the procedures wherein the HHA must inform State and local officials of any on-duty staff that they are unable to contact, creating the risk of unable to request for assistance during the emergency events.

The agency failed to ensure the communication plan included the contact information for the Federal, State, regional, and local emergency preparedness staff.

The agency failed to ensure the emergency communication plan included a primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies.

The agency failed to ensure the emergency preparedness training was provided to their personnel at least once every two years.

The agency failed to ensure documentation of all drills and full-scale exercises were maintained.

The agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets.

The agency failed to ensure the care was provided as per the POC and P&P for three of 18 sampled patients (Patients 5, 7, and 11).

The agency failed to analyze and track the quality indicators to assess the processes of care as part of the QAPI program.

The agency failed to perform the PIPs for 2023 and 2024. This created the risk of not identifying the opportunity for improvement for care and services provided to the patients. #.Review of the hospice's QAPI program for 2024 was conducted on 3/25/25. On 3/25/25 at 1545 hours, an interview and…

The agency failed to ensure the standard precautions to prevent the transmission of infections and communicable diseases were implemented for two of sampled 18 patients (Patients 2 and 4).

The agency failed to implement and maintain the infection control program which included prevention, action plan and control of infections.

The agency failed to provide the annual infection control training to their personnel.

The agency failed to ensure the written patient care instructions for the CHHA were developed by the RN for one of eight sampled patients (Patient 14).

The agency failed to ensure the clinical records were complete and authenticated for two of 18 sampled patients (Patients 1 and 16).

The facility failed to ensure the written notice of the patient’s rights and responsibilities was provided to one of 18 sampled patients (Patient 16) or her authorized representative within four business days of the initial evaluation visit.

The agency failed to ensure the initial comprehensive assessments were completed no later than five calendar days after the SOC, consistent with the patients' immediate needs for three of 17 sampled patients (Patients 7, 15, and 16).

The agency failed to ensure the review of the medications included all of the patient's current medications to identify any potential adverse effects and drug reactions for seven of 18 sampled patients (Patients 2, 3, 4, 5, 6, 7, and 8).

The agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for five of 18 sampled patients (Patients 2, 6, 9, 16, and 17).

The agency failed to ensure the discharge assessment was completed for two of 18 sampled patients (Patients 16 and 17).

The agency failed to ensure the POCs included the specific information related to visit frequency, medications, and diagnosis for five of 18 sampled patients (Patients 11, 12, 13, 14, and 17).

The agency failed to ensure the verbal orders were recorded and included in the POCs for three of 18 sampled patients (Patients 2, 7, and 18).

The agency failed to ensure wound treatment and G-tube care were provided only with a physician's order for two of 18 sampled patients (Patients 5 and13).

The agency failed to revise and update the POC for one of 18 sampled patients (Patient 13).

The agency failed to ensure the physician was notified promptly related to the changes of conditions for two of 18 sampled patients (Patients 12 and 16).

The agency failed to ensure the MSW and OT services were integrated in the POC for three of 18 sampled patients (Patients 5, 12, and 18).

The agency failed to provide the written instructions outlining the disciplines (SN, PT, OT, and CHHA) visit schedules for one of 18 sampled patients (Patient 8).

The agency failed to ensure the patients received care and services as per the written plans of care for nine of 18 sampled patients (Patients 1, 2, 4, 5, 7, 10, 13, 14, and 17 ).

The agency failed to ensure the patient and or caregiver was provided education related to fluid restrictions as per the plan of care for two of 18 sampled patients (Patients 13 and 17).

The agency failed to ensure the agency's skilled professionals had accurately prepared the clinical notes for 11 of 18 sampled patients (Patients 1, 2, 4, 5, 6, 10, 12, 13, 14, 17, and 18).

The agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of 18 sampled patients (Patient 14).

The agency failed to ensure the CHHA services were provided in accordance with the care plans for two of 18 sampled patients (Patient 9 and 14).

The agency failed to ensure the agency's RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for two of 18 sampled patients (Patients 9 and 14).

The agency failed to ensure the agency's P&Ps were implemented as evidenced by: The annual performance evaluation and skilled competency were not completed for CHHAs 1 and 2. The TB screening was not updated for CHHA 2.The wound assessments were not performed for Patients 4, 5, 10, and 13.The…

The agency failed to ensure the agency's CHHA prepared the accurate visit notes to reflect the interventions provided as per the plan of care for one of 18 sampled patients (Patient 3).

The agency failed to ensure the completed discharge summaries were sent to the primary care practitioner within five business days of the discharge date for two of 18 sampled discharged patients (Patients 16 and 17 ).

The agency failed to ensure their comprehensive emergency preparedness program was based on the facility and community based risk assessment, utilizing an all hazards approach.

The agency failed to ensure the emergency preparedness plan included procedures to follow up with on-duty staff and patients to determine services needed and procedures to inform the state and local officials of any on-duty staff or patients they are unable to contact.

The agency failed to ensure the agency's emergency preparedness P&P addressed the use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

The agency failed to ensure the emergency preparedness communication plan included the updated name and contact information of the patients' physicians.

The agency failed to ensure the exercises to test the emergency plan was conducted at least annually.

The agency failed to revise and update the POC for one of 17 sampled patients (Patient 14).

The agency failed to ensure the QAPI program included analysis of the collected data, implementation of the preventive actions, and evaluation of the current practices to improve the overall care and services provided to the patients.

The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections.

The agency failed to provide at least 12 hours of in-service training during each 12-month period for one of two CHHAs (CHHA 1).

The agency failed to ensure the written assignment for CHHA was prepared by the RN for one of 17 sampled patients (Patient 9).

The agency failed to implement their P&P related to the grievances for three nonsampled patients (Patients A, B, and C), creating the risk of violating the patients' rights and not providing quality of care and services to these patients.

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs for nine of 17 sampled patients (Patients 2, 3, 4, 5, 7, 10, 11, 12, and 14).

The agency failed to ensure the medication profiles were updated for six of 17 sampled patients (Patients 1, 2, 4, 5, 6, and 7), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients.

The agency failed to perform assessment of the patient's PCG for ability to provide care related to IV medication administration for one of 17 sampled patients (Patient 15) creating the risk of not providing safe quality care and services to this patient.

The agency failed to ensure the POCs addressed specific interventions related to the patient’s care and treatment for six of 17 sampled patients (Patients 2, 3, 4, 9, 10, and 14).

The agency failed to ensure the verbal orders were signed by the physician in a timely manner for two of 17 sampled patients (Patients 3 and 16).

The agency failed to ensure the communication with the physician related to the patient's condition for three of seventeen sampled patients (Patients 5, 9, and 11).

The agency failed to coordinate the necessary care services for three of 17 sampled patients (Patients 1, 9 and 17).

The agency failed to provide the written instructions outlining the SN visit schedule for four of 17 sampled patients (Patients 2, 3, 4, and 6) creating the risk of not providing the necessary information to these patients 3. Review of Patient 2's clinical record was initiated on 5/10/22. The…

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for nine of 17 sampled patients (Patients 2, 3, 5, 9, 10, 11, 13, 14, and 17).

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for six of 17 sampled patients (Patients 2, 3, 6, 10, 12, and 14), creating the increased risk of substandard healthcare outcomes to these patients.

The CHHA failed to provide services as per the plan of care for one of 17 sampled patients (Patient 11), creating the risk of not providing the appropriate care and services to this patient.

The agency failed to ensure the CHHA reported the changes in the patient’s condition to the RN for two of 17 sampled patients (Patients 10 and 11).

The agency failed to ensure the RN provided supervision to the CHHA no less than every 14 days for one of 17 patients (Patient 9).

The agency's Administrator failed to ensure responsibility for the day-to-day operations of the agency as evidenced by: * The agency failed to ensure four of the eight employee files reviewed (CHHA 1, LVN 1, RNs 2, and 4) had the required TB screening and testing. * The agency failed to ensure the…

The agency failed to provide services in accordance with the clinical practice guidelines and accepted professional standards of practice for four of 17 sampled patients (Patients 3, 8, 10, and 16). * The agency failed to ensure the CHHA visit note was completed in a timely manner for Patient 10. *…

The agency failed to ensure the completed discharge summary included the patients’ medications and vital signs at the time of discharge for three of 17 sampled patients (Patients 14, 16 and 17).

The agency failed to ensure the emergency preparedness P&P addressed a system of medical documentation that protected confidentiality of the patient information, and secured and maintained availability of records.

The agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency failed to ensure the emergency preparedness communication plan included a method for sharing information and medical documentation for patients under the HHA's care, as necessary, with other health providers to maintain the continuity of care.

The agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.

The agency failed to ensure the initial training in the emergency preparedness program was provided to all staff, including the contracted individuals providing services under arrangement.

The agency failed to conduct the performance improvement projects annually, creating the risk of persistent of poor practices and substandard health outcomes to the patients receiving services from the agency.

The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections, creating the risk of spread of infections.

The agency failed to ensure the clinical records were accurate for five of 18 sampled patients (Patients 4, 10, 11, 12, and 15).

The agency failed to ensure the patient and PCG were advised of the availability of the toll-free state hotline established by the State, the hours of its operation, and that the purpose of the hotline was to receive complaints or questions about local HHAs for one of 18 sampled patients (Patient…

The agency failed to ensure the RN conducted the initial assessment visit within 48 hours after the referral for two of 18 sampled patients (Patients 2 and 9).

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for three of 18 sampled patients (Patients 4, 8, and 13), creating the risk of not identifying and…

The agency failed to ensure the review of the medications included all of the patient's current medications to identify any potential adverse effects and drug reactions for five of 18 sampled patients (Patients 1, 2, 3, 8, and 9).

The agency failed to ensure the comprehensive assessments were updated within the last 5 days of every 60 days for one of 18 sampled patients (Patient 1), creating the increased risk of not addressing the care needs for this patient.

The agency failed to ensure the comprehensive assessment was complete at discharge timely for one of 18 sampled patients (Patient 13), creating the risk of not updating the patient's status for this patient.

The agency failed to ensure the POCs included specific interventions related to wound care for two of 18 sampled patients (Patients 1 and 3), creating the risk of not addressing the care needs for these patients.

The agency failed to ensure the treatments were administered only as ordered by the physician for three of 18 sampled patients (Patients 3, 10, and 15), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the physician signed the orders within 30 working days as per the agency's P&P and the State regulations for one of 18 sampled patients (Patient 2).

The agency failed to coordinate care to meet the patients' care needs for six of 18 sampled patients (Patients 3, 7, 8, 10, 14, and 15), creating the risk for not providing the necessary care and services to these patients.

The agency failed to ensure the SN provided education to the patient/PCG related to wound care, blood sugar monitoring, and medications for four of 18 sampled patients (Patients 3, 8, 14, and 17), creating the risk of not providing the necessary care and services to these patients.

The agency failed to provide the written instructions outlining the SN visit schedule for one of 18 sampled patients (Patient 1), creating the risk of not providing the necessary information to this patient.

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for six of 18 sampled patients (Patients 1, 8, 11, 16, 17, and 18).

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for three of 18 sampled patients (Patients 1, 8, and 10), creating the increased risk of substandard healthcare outcomes to this patient.

The agency failed to ensure the RN provided supervision to the LVN to ensure quality of care and services provided as per the agency's P&P for one of 18 sampled patients (Patient 17), creating the risk for a substandard healthcare outcome to this patient.

The agency failed to ensure the CHHA provided care and services in accordance with the POC for two of 18 sampled patients (Patients 1 and 11), creating the risk of not providing necessary care and services to these patients.

The agency failed to ensure the agency's RNs provided supervision to CHHAs no less than every 14 days to ensure quality of care and services provided for three of 18 sampled patients (Patient 4, 11, and 12).

The agency's Administrator failed to be responsible for the day-to-day operations as the agency's P&P related to licensure verification, competency assessment, and written health examination and TB tests were not implemented for five employees (LVN 2, RNs 1, 2, ST 1, and CHHA 1), creating the risk…

The agency failed to ensure the SN provided nursing services related to PICC line and wound care in accordance with professional standards and principles for three of 18 sampled patients (Patient 1, 7, and 10).

The agency failed to ensure the completed transfer summaries were sent to the physician within two business days of becoming aware of an unplanned transfer for two of 18 sampled patients (Patients 8 and 9), creating the risk of the physician not knowing the patients' condition to anticipate the…