Every finding on record at Adventist Midwest Health

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 06/11/26. 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 the Emergency Preparedness requirements, on 06/12/26. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse RN = Registered Nurse POC = Plan of Care PsOC = Plans of Care Pt. / Pts. = Patient / Patients AM = morning PM = afternoon SOC = Start of Care OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report for the last 12 months and staff interviews, the Agency failed to submit 318 of 8631 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 05/01/25 to 05/28/26, was reviewed on 06/10/26. The report documented 318 of 8631 (3.68%) reports were submitted more than 30 days after the assessment was completed. 2. During staff interview with the Home Health Quality (RN) and Clinical Manager on 06/10/26 at 2:30 PM, the above findings were confirmed.

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, in 10 of 10 (Pts #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) the Agency failed to provide information regarding the Agency Supervisor/Clinical Manager, and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 06/09/26. The folder lacked information identifying the Agency Supervisor's name and contact information. 2. The clinical records of the following Pts. were reviewed from 05/5/26 to 05/06/26. Pt. #1. SOC 05/07/26 Pt. #2. SOC 04/05/26 Pt. #3. SOC 02/25/26 Pt. #4. SOC 05/13/26 Pt. #5. SOC 05/15/26 Pt. #6. SOC 04/10/26 Pt. #7. SOC 05/07/26 Pt. #8. SOC 06/06/25 Pt. #9. SOC 11/02/25 Pt. #10. SOC 04/04/25 The clinical records reviewed lacked information identifying the Agency Supervisor's name and contact information. 3. During staff interview with the Home Health Quality (RN) and Clinical Manager on 06/10/26 at 2:30 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.