Every finding on record at Adoration Home Health of Illinois, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 3/21/2024. The Agency was not in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey. Abbreviations: EP - Emergency Preparedness EPP - Emergency Preparedness Program

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 document review and interview, it was determined the Agency failed to establish a bi-annual testing plan for its Emergency Preparedness Program (EPP), inclusive of participation in a full-scale community-based exercise every 2 years. Findings include: 1. On 3/20/2024 at approximately 9:00 AM, the agency’s Emergency Preparedness (EP) binder was reviewed. The EP binder lacked documentation of a full-scale community-based exercise. 2. On 3/20/2024 at approximately 10:30 AM, an interview was conducted with the Director of Operations (E #1). E #1 reviewed the binder and agreed a full-scale community-based exercise was not done.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 03/21/24. The Home Health Agency was not in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies, for this survey. Abbreviations: E - Employee Pt – Patient SOC- Start of Care HHA- Home Health Agency mg- milligrams

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, document review and interview, it was determined for 1 of 1 (Pt #4) patient, where home visits were conducted, the Home Health Agency (HHA) failed to visualize all medications and compare them to the current medication profile to ensure the patient was taking the correct medication(s). Findings include: 1. On 3/19/2024 at 12:00 PM, a home visit was conducted at Pt #4’s residence. Pt #4 began home health services on 2/18/2024, due to an infection following a procedure, superficial incisional surgical site. During the home visit E #4 requested to do the drug regimen review. Pt #4 refused to allow nurse to have access to his medication bottles so she could perform the drug regimen review. Family member presented with patient’s medication bottles and a medication review was completed. The following discrepancies were noted: 1. Over the counter Aspirin 81 mg was not on medication list (Pt #4 reports he has been taking this medication for 2-3 years). 2. Jardiance 10 mg was on medication list and Pt #4 reports he does not take this medication as it was discontinued in mid-February 2024. 2. On 3/19/2024 at approximately 3:30 PM, the policy “Drug Regimen Review” (revised 12/1/13), was reviewed. Under “Procedure: 3.” it stated, “The clinician will question the patient and/or caregiver periodically regarding changes in medications…The visualized medications are compared to the current medication profile to ensure accuracy of the medication profile.” 3. On 3/19/2024 at approximately 3:45 PM, an interview was conducted with Director of Operations (E #1). E #1 reviewed Pt #4’s medication record and agreed with the above findings. E #1 stated, “Our standard is to physically observe patient’s medication bottles and compare to medication list every visit.”

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined for 1 of 17 patients (Pt #6), the nurse failed to follow the physician orders as received at the time of referral for services. Findings include:1. Pt#6 Start of Care (SOC): 2/13/2024 Diagnosis: Chronic Obstructive Pulmonary Disease. Pt #6’s record was reviewed on 3/19/2024 at approximately 2:00 PM. The Plan of Care for the certification period 2/13/2024 to 4/12/2024 included a physician order to observe patient ability to monitor and record daily weights…record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of greater than 2 pounds in 1 day or greater than 5 pounds in 1 week or 5 pounds or more over target weight. May measure abdominal girth if unable to weigh. Pt #6’s record lacked documentation of daily weight and lacked documentation of abdominal girth. 2. An interview was conducted with the Director of Operations (E #1) on 3/19/2024 at approximately 3:00 PM. Pt #1 reviewed the record of Pt #6 and agreed the daily weights and the abdominal girth was not measure as required by the physician order.

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey, on03/18/2021.The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP), for this survey.

A recertification survey was conducted in conjunction with a Focused Infection Control (FIC) survey on 03/18/2021. The Agency was not in compliance with standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: # - number E - employee HHA - home health agency Pt - patient

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, document review and interview, it was determined for 1 of 1 (Pt #15) patient, where home visits were conducted, the Home Health Agency (HHA) failed to visualize all medications and compare them to the current medication profile to ensure the patient was taking the correct medication(s). This has the potential to affect all patients receiving care from an Agency with a current census of 149 patients. Findings include: 1. On 03/17/2021 at 9:30 AM, a home visit was conducted at Pt #15's residence. Pt #15's resided in an assisted living facility and began home health services on 01/27/2021, due to a fractured right femur and unspecified dementia. During the visit the certified occupational therapist assistant (E #9) was observed reviewing the patients medications via an electronic tablet and comparing it with a paper medication listing that was in the patient's home. It was also observed, on the patient's bedroom wall, a medication lock box. Pt #15 explained that the lock box was used to securely store medications and is opened by the nurse employed by the assisted living facility. It is then locked after the medication is given. At no time was E #9 observed opening, or getting access to the patient's medication lock box to ensure the medication bottles in the box matched the current medication profile, ensuring proper medication administration and accurate medication profile. 2. On 03/17/2021 at 2:00 PM, the policy "Drug Regimen Review" (revised by facility, 01/2020), was reviewed. Under "Procedure: 2." it reads "The clinician will question the patient and/or caregiver periodically regarding changes in medications....... . The visualized medications are compared to the current medication profile to ensure accuracy of the medication profile." 3. On 03/17/2021 at approximately 9:45 AM, an interview with the certified occupational therapist (E #9), who performed the home visit at Pt #15's residence was conducted. E #3 confirmed there was a bottle labeled "Tramadol HCL" on Pt #1's kitchen table. E #3 was not aware of the bottle during past home health visits and was not sure how the bottle ended up on the patient's table. "I've provided care for the patient in the past and have never seen that bottle before." 4. On 03/17/2021 at approximately 10:30 AM, an interview with the Director of Operations (E #1) was conducted. E #1 stated "I just went over medication reconciliation with all my staff and they've been trained on how to ensure the patient's medications are accurate."

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on observation, document review and staff interview, it was determined for 1 of 17 patients (Pt #9), the nurse failed to follow the physician orders as received at the time of referral for services. This failure has the potential to affect all patients receiving services, currently a census of 149 patients. Findings include: 1. A home visit was performed with Registered Nurse (E#10) for Pt #9 on 3/16/20 at 2:30 PM. During the visit E#10 provided wound care including cleaning with normal saline and packing the primary open area, a surgical incision related to the diagnosis of urogenital candidiasis of groin/scrotum. It was noted there was a second open incision below the primary site. E#10 cleansed the open incision and left it open. Pt #9's wife asked, "Aren't you going to pack that wound?" and E#10 replied, "I think it is to only be cleaned but left open to air." E#10 reviewed the care plan but found no orders for the smaller open area. E#10 was also the nurse who conducted the initial assessment at start of care. 2. A review of Pt #9's medical record was completed on 3/17/21. The record indicates Pt #9 was admitted to the home health for services on 3/9/21 with diagnosis of urogenital candidiasis of groin/scrotum, diabetes mellitus and coronary artery disease/CABG x6. Documentation on the "Hand-Off to Home Care" referral, dated 3/8/21 includes under "Dressing change procedure(specifics)... wet to dry dressing change every 24 hours; groin right side; two packing sites." A review of the plan of care dated 3/9/21 includes the following order for wound care: skilled nurse to perform/teach incision care to groin incision area; irrigate /cleanse with wound cleanser or soap and water, apply wet gauze and packing... Cover with dry gauze. Secure with tape as needed..." 3. An interview was conducted with the Director of Operations (E#1) on 3/17/21 at 3:45 PM. E#1 reviewed the medical record of Pt #9 and agreed the orders received on the physician referral were not included in the plan and care, so the nurse did not follow the physician orders for the incision care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, document review and staff interview, it was determined for 1 of 17 patient (Pt #9), the nurse failed to notify the physician the patient had not been taking medications as prescribed, potentially causing complications. This has the potential to affect all patients taking medications, currently a census of 149. Findings include: 1. A home visit was conducted with Registered Nurse (E#10) for Pt #9 on 3/16/21 at 2:30 PM. During the visit E#10 asked to view Pt #9's medication bottles and proceeded to match the medication list with Pt #9's bottles. E#10 asked if there was a missing bottle for the prescribed Aspirin 81 mg. Pt #9's wife/caregiver stated, "He has not taken that for several months. He has been on it for a long time, I just haven't gotten it." 2. A review of Pt #9's medical record was completed on 3/17/21. The record indicates Pt #9 was admitted to the home health for services on 3/9/21 with diagnosis of urogenital candidiasis of groin/scrotum, diabetes mellitus and coronary artery disease/CABG x 6. A review of the discharge medication list provided at the time of referral shows the first medication as: "Aspirin 81 mg by mouth daily". The Plan of Care dated 3/9/21 on page 4 also indicates the first medication as "Aspirin low dose 81 mg tablet, delayed release, daily". Nurses notes indicate the medication reconciliation was completed on each nursing visit. There was no documentation of Pt #9's physician being notified Pt #9 was not taking the Aspirin as prescribed. 3. An interview was conducted with Director of Operations (E#1) on 3/17/21 at 10:00 am. E#1 agreed the Aspirin was prescribed and identified on Pt #9's medication record to be taken daily, 81 mg. E#1 agreed the nurse should have known from Pt #9's wife's report Pt #9 was not taking the Aspirin and should have notified the physician at the start of care.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on documentation review and staff interview, it was determined for 3 of 3 (Pt #5, Pt #6, Pt #8) patients who expired at home, the Agency failed to ensure the deaths were included as an adverse event, tracked, analyzed and preventive actions implemented. This has the potential to affect all patients receiving care from an Agency with a current census of 149 patients. Findings include: 1. The clinical record of Pt #5 was reviewed on 3/15/2021 at 1:00 PM. Pt #5 admitted on 03/03/2020 with diagnoses of heart disease. Documentation indicated Pt #5 died at home 03/20/2020. 2. The clinical record of Pt #6 was reviewed on 03/16/2021 at 11:00 AM. Pt #6 admitted on 05/09/2020 with diagnoses of chronic obstructive pulmonary disease with acute respiratory infection. Documentation indicated Pt #6 died at home on 05/13/2020. 3. The clinical record of Pt #8 was reviewed on 03/115/2021 at 11:00 AM. Pt #8 admitted on 07/09/2020 with diagnoses of pressure ulcer of tight buttocks, stage 2. Documentation indicated Pt #8 died at home on 07/14/2020 4. The Agency policy "Incident/Occurrence Reporting System" (revised by the facility, 05/2019), was reviewed on 03/16/2021 at 11:35 AM. Under "6. Serious occurrences/adverse events include" it reads "Unexpected death not resulting from the patient's medical condition." 5. On 03/16/2021 at 11:10 AM, the "Incident/Occurrence Event Report" for the period of 03/04/2020 thru 01/06/2021 was reviewed. Pt #5, Pt #6 and Pt #8's names were not included on the report. All three patients' died at home and should have been included on the report. 6. On 03/16/2021 at approximately 10:45 AM, an interview with the Director of Operations (E #1) was conducted. E#2 confirmed that Pt #5, Pt #6 and Pt #8 died at home and their deaths were not reported on the Incident/Occurrence Event Report, per Agency policy, and stated "I didn't know deaths at home had to be included on the report."