Every finding on record at Abundant Home Health Care, Inc

Recertification Survey conducted on 05/02/24. Standard level deficiencies cited. Abbreviations: Pt / Pts = Patient / Patients

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 Pt. admission folder and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 04/29/24. The folder lacked information identifying the Clinical Manager's name and contact information. 2. The clinical records of the following Pts. were reviewed from 4/29/24 to 5/01/24. Pt. #1. SOC 09/25/23. Pt. #2. SOC 04/06/24. Pt. #3. SOC 04/09/24. Pt. #4. SOC 11/16/23. Pt. #5. SOC 11/20/23. Pt. #6. SOC 05/23/23. Pt. #7. SOC 11/02/22. The clinical records reviewed lacked information identifying the Clinical Manager's name and contact information. 3. During staff interviews with the Administrator and Clinical Supervisor on 05/01/24 at 12:00 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and staff interviews, it was determined that the Agency failed to ensure the Administrator, or a pre-designated person is available during all operating hours. Findings include: 1. On 04/29/24 arrived at Agency at 9:00 AM to conduct a recertification survey. The Agency was closed. A sign on the door of the Agency included the Home Health Agency (HHA) name, office hours 9:00 AM to 5:00 PM, and the same telephone number listed in the Illinois Department of Public Health (IDPH) telephone directory. The phone number listed on the door of the Agency was called, no one answered, and the phone number was not set up to leave a voicemail. The Administrator did not arrive until 10:00 AM to open the office. 2. During the entrance interview on 4/29/24 at 10:30am, the Administrator confirmed that the Agency phone was not answered or set up to receive messages. The above finding was confirmed, the Agency lacked an available person during all operating hours.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 5/6/21. The Facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon/Evening SOC = Start of Care POC = Plan of Care RN = Registered Nurse SN/Sn = Skilled Nurse LPN = Licensed Practical Nurse SNV = Skilled Nursing Visits PT = Physical Therapy/Physical Therapist MG/mg = milligrams PO = by mouth w = week ADL's = Activities of Daily Living. COVID-19 = Coronavirus 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, Agency policy, 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 4 of 7 (Pts. #3, 6, 7, and 2) clinical records reviewed. Findings include: 1. Pt. #3. SOC 3/19/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 5/3/21 at 4:00 PM. The record included a Physician referral for home health services dated 2/26/21. The record also contained the initial SOC assessment, dated 3/19/21, 21 days after the Physician referral. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. 2. Pt. #6. SOC 12/10/20. Primary Diagnosis: Chronic Venous Hypertension without Complications of Bilateral Lower Extremities. The clinical record was reviewed on 5/3/21 at 1:45 PM. The record included a Physician referral for home health services dated 11/24/20. The record also contained the initial SOC assessment, dated 12/10/20, 16 days after the Physician referral. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. 3. Pt. #7. SOC 7/30/20. Primary Diagnosis: Hypertensive Heart Disease Without Heart Failure. The clinical record was reviewed on 5/4/21 at 12:15 PM. The record included a Physician referral for home health services dated 6/29/20. The record also contained the initial SOC assessment, dated 7/30/20, 31 days after the Physician referral. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. 4. Pt. #2. SOC 12/28/20. Primary Diagnosis: Moderate, Recurrent Major Depressive Disorder. The clinical record was reviewed on 5/4/21 at 3:30 PM. The record contained the "Patient Profile" form which included the referral date of "12/21/2020". The SOC comprehensive assessment form was completed on 12/28/20 (7 days after the referral date). The record lacked documentation of an inpatient facility stay or physician ordered SOC date. The Agency failed to initiate service within 48 days after receipt of the referral. 5. The Agency policy titled "Admission Policy" was reviewed on 5/5/21 at 2:45 PM. The policy required: "Patients are accepted for treatment in the home on the basis of reasonable criteria and under the expectation that the Patient's medical, nursing, and social needs can be met adequately by the Agency in the Patient's place of residence within 48 hours of accepting the referral..." 6. During an interview with the Administrator and the Director of Nursing on 5/5/21 at from 9:45 AM to 11:45 AM. The Administrator confirmed the Agency failed to ensure services were initiated within 48 hours of the referral date.

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: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide services as ordered in the POC. This was found in 1 of 1 (Pt. #3) clinical records reviewed, wherein PT services were ordered by the Physician. Findings include: 1. Pt. #3. SOC 3/19/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 5/3/21 at 4:00 PM. The record included the POC effective 3/19/21, which contained the Physician's order: "PT Frequency: 1w1, evaluation." The record also included the SOC comprehensive assessment dated 3/19/21. This assessment contained: "...referral from Physician for SNV/PT...acute on chronic and intermittent pain, pain in limbs...history of repeated falls with injuries...Patient needs Physical Therapy services to assess and treat functional deficit, for therapeutic pain management to be able to move around/function Patient's ADL's safely and independently..." The record lacked a PT evaluation, or a Physician's order to cancel the PT evaluation. 2. The Agency policy titled "Physical Therapist" was reviewed on 5/4/21 at 2:00 PM. The policy required: "Essential Functions/Areas of Accountability: Performs Physical Therapy assessments...under a medically-approved plan of care...Completes initial assessments within forty-eight (48) hours of referral, unless other arrangements are made..." 3. During an interview with the Administrator and the Director of Nursing on 5/5/21 at 10:45 AM, the Director of Nursing confirmed the above findings, and stated PT evaluations should be performed within 48 hours of the Physician's order.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the RN provided supervision of the LPN. This was found in 1 of 1 (Pt. #4) clinical records reviewed, wherein care was provided by a LPN. Findings include: 1. Pt. #4. SOC 2/19/21. Primary Diagnosis: Multiple Sites Rheumatoid Arthritis without Rheumatoid Factor. The clinical record was reviewed on 5/3/21 at 3:40 PM. The record contained weekly LPN visit notes from 3/3/21 to 3/22/21 and 3/31/21. The record also contained the Inpatient Transfer form dated 3/23/21 and Resumption of Care comprehensive assessment form dated 3/26/21, both forms were completed by the RN and lacked documentation the RN supervised the LPN. As of 5/3/21, the record lacked documentation the RN supervised the LPN in March 2021, as required by the Agency. 2. The Agency policy titled "Licensed Practical Nurse Supervision" was reviewed on 5/4/21 at 1:00 PM. The policy required "...shall provide Licensed Practical Nurse services under the direction and supervision of a Registered Professional Nurse...3. Supervisory visits are to be documented in the patient's chart..." 3. During an interview with the Administrator and the Director of Nursing on 5/5/21 at 9:45 AM, the Administrator stated the RN is required to supervise the LPN "once a month". During the same interview, the Administrator confirmed the RN failed to supervise the LPN as required by the Agency.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: . A. Based on review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the information contained in the clinical assessments are accurate. This was found in 1 of 1 (Pt. #4) clinical record reviewed, wherein the Pt. had wounds. Findings include: 1. Pt. #4. SOC 2/19/21. Primary Diagnosis: Multiple Sites Rheumatoid Arthritis without Rheumatoid Factor. The clinical record was reviewed on 5/3/21 at 3:40 PM. The record contained the LPN visit note dated 3/17/21 which included: "...Patient... having surgery on the 23rd to remove mass from ovary..." The Transfer to an Inpatient Facility form completed by the RN and dated 3/23/21 contained "...reason(s) did the patient require hospitalization? Scheduled treatment or procedure." The Resumption of Care comprehensive assessment form completed by the RN and dated 3/26/21 lacked the name of the inpatientreatment/procedure, and documentation of any wounds. The next SN visit was conducted by the LPN on 3/31/21 and included: "Sn-Patient had right ovarian mass removed robotically and the incisions were glued together open to air to heal..." The LPN visit note dated 3/31/20 also contained documentation that the Pt. had 4 abdominal incision wounds (1-right upper, 2-left upper and 1-belly button) each wound measured 2 centimeters in length and left open to air. The next SN visit was conducted by the RN (Recertification comprehensive assessment) on 4/15/21, the assessment lacked any documentation of the patient's surgery and status of the 4 abdominal wounds. The assessment forms (3/26/21 and 4/15/21) lacked the type of surgery Pt. #4 had on 3/23/21, and a description of the abdominal wounds. 2. The Agency policy titled, "Wound Management" was reviewed on 5/5/21 at 2:35 PM. The policy included: "... Documentation Guidelines 1. Document in the clinical record... c. Location, size...d. Color and appearance..." 3. During an interview with the Administrator on 5/5/21 at 2:00 PM, the Administrator stated the SN is required to document a description of each wound at least weekly. 4. During an interview with the Administrator and the Director of Nursing on 5/5/21 at 9:45 AM, and the Administrator on 5/5/21 at 2:00 PM, the Administrator confirmed the assessments forms indicated above were inaccurate.

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: . A. Based on a review of clinical records, observation and interview during a home visit, Agency policy review and staff interview, it was determined the Agency failed to ensure medications contained in the clinical record were accurate. This was found in 2 of 7 (Pts. #2 and 3) clinical records reviewed. Findings include: 1. Pt. #2. SOC 12/28/20. Primary Diagnosis: Moderate, Recurrent Major Depressive Disorder. The clinical record was reviewed on 5/4/21 at 3:30 PM. The record contained the "Physician Order" dated 3/24/21 which included, "...New Medication: Methylprednisolone 4 MG Oral Tablet 4 mg tablet/day, day 1 - 6 tablets, day 2 - 5 tablets, day 3 - 4 tablets, day 4 - 3 tablets, day 5 - 2 tablets, day 6 - 1 tablet By mouth (PO)". The "Medication Profile" form completed by the RN for the certification period effective 4/27/21 lacked the Methylprednisolone. 2. Pt. #3. SOC 3/19/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 5/3/21 at 4:00 PM. The clinical record contained a Medication Profile. effective 3/19/21. The clinical record lacked any additional Physician's orders for changes in medications. A home visit was conducted on 5/4/21 at 10:45 AM, along with E #5. During this home visit, an observation was made of Pt. #3's medications, which was compared with Pt. #3's Medication Profile. The Medication Profile included Gabapentin 600 mg 1 tablet three times a day. Pt. #3 presented a bottle of Gabapentin; the label on this bottle read to take 1 tablet four times a day. Pt. #3 confirmed the bottle listed the correct dosage. The Medication Profile also included Hydrocodone-Acetaminophen 5 mg-325 mg one tablet daily as needed for pain. Pt. #3 presented a bottle of Hydrocodone-Acetaminophen; the label on this bottle read to take 1 tablet every 6 hours as needed for pain. Pt. #3 confirmed the bottle listed the correct dosage. The Medication Profile was inaccurate. 3. The Agency policy titled "Medication Profile" was reviewed on 5/5/21 at 9:45 AM. The policy required: "...The Medication Profile shall document: Date medication ordered or care initiated. Medication name. Medication dosage. Route and frequency of administration...If the Physician changes the medication orders, the Nurse must add newly ordered drugs or medication changes to the Medication Profile...The Medication Profile shall be reviewed by a Registered Nurse...and updated whenever there is a change or discontinuation in medication..." 4. During interviews with the Administrator and the Director of Nursing at 9:45 AM to 11:45 AM, the above findings were confirmed. The Director of Nursing stated the SN should review and reconcile a Patient's medications at each SN visit. If the Pt. reports any new/changes in medications, the Physician should be notified for orders, and the Medication Profile should then be updated with the new medication orders.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: . Based on a review of clinical records, observation during a home visit, Agency policy, and staff interview, the Agency failed to ensure forms were complete and accurate. This was found in 3 of 7 (Pts. #3, 6, and 7) clinical record reviewed. Findings include: 1. Pt. #3. SOC 3/19/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 5/3/21 at 4:00 PM. A home visit was conducted on 5/4/21 at 10:45 AM, along with E #5. During this home visit, Pt. #3 presented the Agency's admission folder given to the Pt. This folder contained a "Notice of Medicare Non-Coverage" document, which was signed by the Pt. on 3/19/21, the date of admission. This document included sections for the description of the current services provided and the date these services would end, which were both left blank. The record lacked a copy of this document. The "Notice of Medicare Non-Coverage" document seen on the home visit was both incomplete and inaccurate. 2. Pt. #6. SOC 12/10/20. Primary Diagnosis: Chronic Venous Hypertension without Complications of Bilateral Lower Extremities. The clinical record was reviewed on 5/3/21 at 1:45 PM. The record contained a "Notice of Medicare Non-Coverage" document, which was signed by the Pt. on 12/10/20, the date of admission. This document indicated the Agency's services would end 2/3/21, which was the date of Pt. #6's discharge from the Agency, not the date Pt. #6's Medicare coverage would end. The "Notice of Medicare Non-Coverage" document was inaccurate. 3. Pt. #7. SOC 7/30/20. Primary Diagnosis: Hypertensive Heart Disease Without Heart Failure. The clinical record was reviewed on 5/4/21 at 12:15 PM. The record contained a "Notice of Medicare Non-Coverage" document, which was signed by the Pt. on 7/30/20, the date of admission. This document indicated the Agency's services would end 1/21/21, which was the date of Pt. #6's discharge from the Agency, not the date Pt. #7's Medicare coverage would end. The "Notice of Medicare Non-Coverage" document was inaccurate. 4. The Agency policy titled "Notice of Medicare Non-Coverage" was reviewed on 5/5/21 at 10:00 AM. The policy required: "A Physician order Notice of Medicare Non-Coverage will be given to the Patient no later than two (2) days before the termination of covered services. The provider will insert the following information into the notice: The beneficiary's name and Medicare number. The date the Medicare coverage of services ends...The effective date will be the last day of covered service...If the Patient is not able to comprehend the contents of the notice, it must be delivered to, and signed by, an authorized representative.. 5. During an interview with the Administrator and the Director of Nursing on 5/5/21 at 10:45 AM, the above findings were confirmed. The Director of Nursing stated Pts. should be given the "Notice of Medicare Non-Coverage" at the appropriate time, only if applicable.