Every finding on record at Alert Home Health Care, Inc

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure the plan was established based on an updated risk assessment utilizing an all-hazards approach. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 10/25/2022 at 2:00 PM. The Plan lacked a community specific updated risk assessment utilizing an all-hazard approach for the years 2019, 2020 and 2021. 2. During an interview with the Director of Nursing and the Office Manager on 10/26/2022 at 11:15 AM, the above findings were confirmed.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: SOC - Start of Care Pt./ Pts. - Patient/Patients AM - Morning PM - Afternoon, Evening PT - Physical Therapy OT - Occupational Therapy HHA - Home Health Aide ABN - Advance Beneficiary Notice of Non-Coverage

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. were informed and/or participated in the frequency of visits provided by each discipline. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed on 10/24/22 at 11:55 AM to 10/26/22 at 9:20 AM: Pt. #1. SOC: 09/19/22. Pt. received SN and PT services. Pt. #2. SOC: 05/12/22. Pt. received SN and Home Health Aide services. Pt. #3. SOC: 08/01/22. Pt. received SN, PT and Home Health Aide services. Pt. #4. SOC: 08/12/22. Pt. received SN services. Pt. #5. SOC: 09/05/22. Pt. received SN, PT and OT services. Pt. #6. SOC: 02/28/22. Pt. received SN services. Pt. #7. SOC: 03/01/22. Pt. received SN, PT and Home Health Aide services. The records lacked documentation that at the SOC, the Pt./patient's representative participated or was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. During an interview with the Director of Nursing and the Office Manager on 10/26/2022 at 11:15 AM, the Director of Nursing confirmed the Agency failed to ensure Pts. were informed, and/or participated in the frequency of visits provided by each discipline.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: A. Based on review of the Agency’s Pt. admission folder, clinical record review, observations made during 3 home visits, and staff interview, it was determined the Agency failed to ensure Pts. were provided with the telephone number and address to file a concern or complaint with the Illinois Department of Public Health. This was found in 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6, and 7). Findings include: 1. The Agency’s Pt. admission folder was reviewed on 10/24/22 at 11:00 AM. The folder lacked the telephone number and address to file a concern or complaint with the Illinois Department of Public Health. 2. The following clinical records were reviewed beginning 10/24/22 at 11:55 AM to 10/26/22 at 9:20 AM: Pt. #1 SOC: 9/19/22. Pt. #2 SOC: 5/12/22. Pt. #3 SOC: 8/1/22. Pt. #4 SOC: 8/12//22. Pt. #5 SOC: 9/5/22. Pt. #6 SOC: 2/28/22. Pt. #7 SOC: 3/1/22. All of the above records lacked documentation the Pt. was provided with the phone number and address to file a concern or complaint with the Illinois Department of Public Health. 3. Home visits were conducted with Pt. #1, 2, and 3, beginning 10/24/22 at 1:30 PM to 10/25/22 at 11:00 AM. During these home visits, the Agency's Pt. admission folder was observed. All of these admission folders lacked the phone number and address to file a concern or complaint with the Illinois Department of Public Health. 4. During an interview with the Director of Nursing and the Office Manager on 10/26/22 beginning at 11:15 AM, it was confirmed the above Pts. were not provided with the Illinois Department of Public Health's complaint telephone number or address.

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: A. Based on review of clinical records, observation during 2 home visits, and staff interview, the Agency failed to ensure forms were complete and accurate. This was found in 4 of 7 (Pts. #2, 1, 6, and 7) clinical records reviewed. 2. Pt. #1. SOC 9/19/22. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 10/24/22 at 2:10 PM. The record included a document titled “Advance Beneficiary Notice of Non-coverage (ABN),” which was signed by the Pt.; however, the Pt. specific items/services Medicare doesn’t pay for, and the date were all left blank. 3. Pt. #6. SOC 2/28/22. Primary Diagnosis: Pressure Ulcer of Right Buttock, Stage 2. The clinical record was reviewed on 10/25/22 at 10:40 AM. The record included a document titled “Advance Beneficiary Notice of Non-coverage (ABN),” which was signed by the Pt.; however, the Pt. specific items/services Medicare doesn’t pay for, the Patient’s Medicare Number, and the effective date the coverage of the Patient’s home health services would end were all left blank. 4. Pt. #7. SOC 3/1/22. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 10/26/22 at 9:20 AM. The record included a document titled “Advance Beneficiary Notice of Non-coverage (ABN),” which was signed by the Pt.; however, the Pt. specific items/services Medicare doesn’t pay for, the Patient’s Medicare Number, and the effective date the coverage of the Patient’s home health services would end were all left blank. 5. During an interview with the Director of Nursing and the Office Manager on 10/26/22 beginning at 11:15 AM, the above findings were confirmed. Findings include: 1. Pt. #2. SOC 5/12/22. Principal Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 10/25/22 at 9:30 AM. The record included the form titled "Advance Beneficiary Notice of Non-coverage (ABN)" signed by the Pt. without a date. Option #3. was checked and it read “I don’t want home health services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay;" however, there were no specific home health services listed.