Every finding on record at Advocate Home Health Care Serv

Substantial Allegation Survey conducted for complaint # 2121423 /IL #61448. Standard level deficiency cited. Abbreviations: x = times wk = week # = number AM = morning HHA = Home Health Aide POC = Plan of care SOC = Start of care PsOC = Plans of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients

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: A. Based on review of clinical record, Agency policy and staff interviews, it was determined that the Agency failed to ensure services and treatments were provided as ordered by the Physician in the Plans of Care. This was found in 2 of 3 (Pt. #1 and 2) clinical records reviewed. Findings include: 1. Pt. #1 SOC 11/11/21 Diagnosis: Multiple Sclerosis Pt. #1’s clinical record was reviewed on 1/18/22 at 12:30 PM. #1’s Plan of care for certification period 11/11/21 to 1/09/22 and signed by Attending Physician included: Home Health Aide (HHA) Frequency 11/15/2021 to 1/8/2022, 1 visit every week for 8 weeks. The record lacked documentation of any visit for week of 11/14/21 to 11/20/21 and a missed visit note dated 11/22/21, comments: “mom cancelled visit and hung up on me…”. There were no further attempts to contact or reschedule visits.The record lacked documentation of communication to Pt. #1’s nurse or physician of the missed visit. 2. Pt. #2 SOC 12/27/21. Diagnosis: Hypertensive Heart and Chronic Kidney Disease. Pt. #2’s clinical record was reviewed on 1/18/22 at 3:00 PM. Pt. #2’s Plan of Care for certification period 12/27/21 to 2/24/22 and signed by Attending Physician included: HHA Frequency 12/27/21 to 1/15/2022, 2 visits every week for 3 weeks. The record included no visit documentation for week of 12/27/21 to 1/1/22 and missed visit notes dated 1/6/22, 1/11/22 and 1/14/22 comments: patient not answering phone or calling back. There were no further attempts to contact or reschedule visits.The record lacked documentation of communication to Pt. #2’s nurse or physician of these missed visits. 3. The Agency’s policy titled “HHS Physician and Home Health Responsibilities in Managing the Medical Care of Patients” effective date 09/21/2020 was reviewed at 4:15 PM. The policy documents: “Advocate at Home Responsibilities to Physicians:…4. Communication with the physician should occur when:…f. Visits are missed for any reason…” 4. Interview was conducted with Employee #6 (Clinical Manager) on 1/18/22 at 4:15 PM and confirmed that there were no documentation of physician notification for HHA missed visits for Pts. #1 and 2. An interview was conducted with Employee #1(Director of Clinical Services) on 1/18/22 at 4:30 PM and it was stated that for missed visits, physician would be informed. During same interview, Employee #1 confirmed the above findings.

Substantial Allegation Survey conducted for complaint # 212286 /IL 00132213. Standard level deficiencies cited. Abbreviations: AM = Morning PM = Afternoon SN = Skilled Nurse SOC = Start of Care Pt./Pts. = Patient/Patients POC/PsOC = Plan of Care/Plans of Care OASIS = Outcome and Assessment Information Set

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: A. Based on record review, complaint log review, agency policy review, and staff interview, the Agency failed to ensure documentation of an existence and resolution of a complaint was completed. This was found in 1 of 3 ( Pt. #1 ), clinical records reviewed . Findings Include: 1. Pt. #1's clinical record was reviewed on 4/8/21 at 1:00. Pt. #1 was admitted for skilled home health services by the Agency on 3/13/21, with a diagnosis of Secondary Malignant Neoplasm of Brain. The clinical record lacked documentation of a complaint made by the family on 3/25/21, of requesting another SN for Pt. #1. 2. Review of Agency's 2021 grievance/complaint log , was done on 4/8/21 at 11:35 AM. The grievance/complaint log lacked a complaint made by the family on 3/25/21, of requesting another SN for Pt. #1. 3. Review of Agency's complaint/grievance policy, was done on 4/8/21 at 12:00 PM. The policy states impart that complaints once received are to be investigated immediately and the investigation and outcome are to be documented. 4. An interview was conducted with the Clinical Manager on 4/8/21 at 2:10 PM. The Clinical Manager stated , "I received a call on 3/25/21 from Pt. #1's family requesting a new SN due to a scheduling conflict. The resolution was to assign another SN. I did not document the complaint, nor the resolution. It was an oversight on my part."

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provided services as ordered by the Physician as required in the PsOC. This was found in 2 of 3 (Pt. #1, and #2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 3/9/21. Principal Diagnosis: Secondary Malignant Neoplasm of Brain. The clinical record was reviewed on 4/8/21 at 2:00 PM. The record included the POC for the certification period of 3/9/21 to 5/7/21 requiring, "SN Frequency: 3/9/21 to 3/13/21: 2 visits every week for 1 week, 3/14/21 to 5/1/21: 2 visits every week for 7 weeks." The record lacked documentation of a second SN visit for the week of 3/21/21 to 3/27/21. The record also included notes for missed SN visits dated 3/11/21, 3/16/21, 3/19/21, 3/23/21 but lacked documentation Pt. #1's Physician was notified of these missed visits. 2. Pt. #2. SOC 11/6/20. Principal Diagnosis: Pressure Ulcer of the Right Heel, Unstageable. The clinical record was reviewed on 4/8/21 at 1:00 PM. The record included a POC for the certification period of 1/5/21 to 3/6/21 requiring, , "SN Frequency: 1/10/21 to 3/6/21: 2 visits every week for 8 weeks, 3/7/21 to 5/5/21: 2 visits every week for 9 weeks." The record lacked documentation of a second SN visit for the weeks of 1/31/21 to 2/6/21, 2/28/21 to 3/6/21, 3/7/21 to 3/13/21. The record also lacked documentation of any SN visits for the weeks of 2/7/21 to 2/13/21 and 3/28/21 to 4/1/21. The record lacked documentation as to why the skilled visits were missed and Physician notification of these missed visits. 3. During an interview with E#1 (Director of Clinical Services South Region) on 4/8/21 at 11:10 AM, E#1 stated, there is no policy for missed visits but a procedure is followed and that is, if the clinician is unable to reach the patient, the physician is called and notified. E#1 also stated that if there is a missed visit, it is documented as a missed visit note in the electronic clinical records of the patient. 4. During an interview with E#1, E#2 (Clinical Manager), E#3 (Clinical Manager), E#4 (Clinical Manager), E#5 (Clinical Manager), E#6 (Clinical Manager) on 4/8/21 between 1:00 PM to 3:30 PM, the above findings were confirmed.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: . A. Based on clinical record and staff interviews, it was determined the Agency failed to ensure that the wound treatment provided was ordered by the Physician. This was found in 1 of 3 (Pt # 1) clinical record reviews. Findings include: 1. Pt. #1. SOC 3/9/21. Principal Diagnosis: Secondary Malignant Neoplasm of Brain. The clinical record was reviewed on 4/8/21 at 2:00 PM. The clinical record contained "SN Routine Visit" notes dated 3/30/21 and 3/31/21 which includes the section, "Encounter Wound Assessment ...Active Wound." These SN notes include documentation of the following: "Wound Groin Right Pressure Injury: Date first Assessed - 3/30/21 ...Dressing Activity - Changed ...Cleansing Agent - Normal Saline ....Topical Agent - Hydrogel ...Wound Dressing - Foam with borders ..." The record lacked documentation of a Physician order for treatment of the pressure ulcer located on Pt.#1's right groin. 2. During an interview with E#1 (Director of Clinical Services, South Region), E#2 (Clinical Manager), E#3 (Clinical Manager), E#4 (Clinical Manager), E#5 (Clinical Manager), E#6 (Clinical Manager) on 4/8/21 between 1:00 PM to 3:30 PM, the above findings were confirmed. The team confirmed that clinician should obtain physician orders prior to wound treatment.

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: . A. Based on clinical record review and staff interviews, the Agency failed to ensure that the physician was notified regarding changes in condition. This was found in 2 of 3 (Pt. #1 and #2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 3/9/21. Principal Diagnosis: Secondary Malignant Neoplasm of Brain. The clinical record was reviewed on 4/8/21 at 2:00 PM. The clinical record included "SN -OASIS Start of Care" dated 3/9/21 which included an assessment item, "M1311 - Current number of Unhealed Pressure Ulcers/Injuries at Each Stage: A1 = 2, B1 = 0, C1= 0, D1 = 0, E1 = 0, F1 = 0" and, a section of wound assessments which describes Pt. #1's active wounds- "Wound Coccyx, Right Pressure Injury...Wound Coccyx, Left Pressure Injury..." The clinical record also contained "SN Routine Visit" notes dated 3/30/21 and 3/31/21 which include the section, "Active Wounds: Wound Coccyx Right Pressure Injury - date first assessed 3/9/21, Wound Coccyx Left Pressure Injury - date first assessed 3/9/21, Wound Groin Right Pressure Injury - date first assessed 3/30/21." As of 4/8/21, the record lacked documentation the Physician was notified of the new onset of pressure injury on the right groin identified on 3/30/21. The same record also contained a POC for the certification period of 3/9/21 to 5/7/21 requiring, "SN Frequency: 3/9/21 to 3/13/21: 2 visits every week for 1 week, 3/14/21 to 5/1/21: 2 visits every week for 7 weeks." The record lacked documentation of a second SN visit for the week of 3/21/21 to 3/27/21. The record also included notes for missed SN visits dated 3/11/21, 3/16/21, 3/19/21, 3/23/21 but lacked documentation Pt. #1's Physician was notified of these missed visits. 2. Pt. #2. SOC 11/6/20. Principal Diagnosis: Pressure Ulcer of the Right Heel, Unstageable. The clinical record was reviewed on 4/8/21 at 1:00 PM. The record included a POC for the certification period of 1/5/21 to 3/6/21 requiring, , "SN Frequency: 1/10/21 to 3/6/21: 2 visits every week for 8 weeks, 3/7/21 to 5/5/21: 2 visits every week for 9 weeks." The record lacked documentation of a second SN visit for the weeks of 1/31/21 to 2/6/21, 2/28/21 to 3/6/21, 3/7/21 to 3/13/21. The record also lacked documentation of any SN visits for the weeks of 2/7/21 to 2/13/21 and 3/28/21 to 4/1/21. The record lacked documentation as to why the skilled visits were missed and Physician notification of these missed visits. 3. During an interview with E#1 (Director of Clinical Services, South Region), E#2 (Clinical Manager), E#3 (Clinical Manager), E#4 (Clinical Manager), E#5 (Clinical Manager), E#6 (Clinical Manager) on 4/8/21 between 1:00 PM to 3:30 PM, the above findings were confirmed. E#1 stated the Physician should be notified of the missed visits and change in patient condition.