Every finding on record at All About Healthcare, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 4/3/25. Standard level deficiencies cited.

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), §485.542(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: Based on review of the Agency's Emergency Preparedness Plan, Agency Policy and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Agency. . Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 3/31/25 at 2:30 PM. The plan lacked documentation of a Hazard Vulnerability Assessment for 2023 and 2024. 2. The policy (Revised February 2021), “Agency Facility Based and Community-Based Risk Assessment Policy” was reviewed on 4/1/25 and required, “Policy: The Agency will perform, a facility-based and community-based risk assessment utilizing an all-hazard approach in order to develop an emergency plan…Procedure: Hazard Vulnerability Analysis (HVA) will be conducted and evaluated biennially…” 3. During an interview with the Agency Supervisor on 4/1/25 at 3:30 PM, the above finding was confirmed.

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 a review of the Agency's Emergency Preparedness Program and Plan, Policy and staff interview, it was determined the Agency failed to ensure the Agency conducted the required individual and/or community exercises every 2 years to ensure the effectiveness of the Emergency Preparedness Plan. This has the potential to affect all patients receiving home health services. . Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 4/1/25. The Plan lacked documentation that full-scale community or individual exercises were conducted by the Agency for 2023 and 2024. 2. The Policy titled, "Testing Program for Emergency Operations Plan EOP)" which was revised February 2021, was reviewed on 4/1/25. The Policy requires, "The Agency will ensure that the Emergency Operations Plan (EOP) is functional through testing and evaluation. Two tests will occur every two years, which may either be one community-based full exercise, if available or an individual facility-based exercise every other year and in the opposite years. ..." 3. During an interview with the Agency Supervisor and Nurse on 4/1/25 at 3:10 PM, it was confirmed the Agency failed to meet the testing requirements of the Agency’s Emergency Plan.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 4/3/25. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients % = percent RN = Registered Nurse PT = Physical Therapy/Physical Therapist SN = Skilled Nurse AM = morning PM = afternoon POC = Plan of Care PsOC = Plans of Care SOC = Start of Care lb. = pound AV = Arteriovenous Fistula MSW = Medical Social Worker ADL = Activities of Daily Living QA = Quality Assurance > = greater than HHA = Home Health Aide DME = Durable Medical Equipment 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 the review of the Error Summary report and staff interview, it was determined in 591 of 1243 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. . Findings include: 1. The Error Summary report for 3/1/24 to 3/26/25, was reviewed on 3/31/25 at 9:30 AM. The report included error # -3330 for 591 of 1243 late submissions, 47.55 % of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Agency Supervisor and the QA RN on 4/2/25 at 11:00 AM, it was confirmed that the error occurred.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined in 3 of 7 (Pts. # 4, 5, and 6) clinical records reviewed, the Pt. care was not provided as ordered in the POC. 2. Pt. #5 was admitted to home health services on 2/4/25 with the diagnoses of but not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy and Acute in Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 3/31/25. The record included a POC effective 2/4/25 which required, “Orders and Treatments: SN 1 week 9.” The clinical record included documentation of 2 SN visits for the following weeks: 2/4/25 to 2/8/25, 2/9/25 to 2/15/25, 2/16/25 to 2/22/25 and 2/23/25 to 3/1/25. The SN failed to follow the visit frequency as required. The same POC also required, “Instruct caregiver to weigh patient daily and record, SN to report to doctor’s office for weight gain > 2 lb./day or > 5 lb./week…” The record lacked documentation of weight monitoring. 3. Pt. #6 was admitted to home health services on 3/20/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The POC for the certification period of 3/20/24 to 5/18/24 required, “Orders and Treatment: PT: Evaluation and Treatment.” The record lacked documentation of a PT evaluation or visit. 4. The Policy dated February 2021 titled, “Plan of Care – CMS #485 and Physician/Practitioners Orders” was reviewed on 4/1/25 and required, “Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources… Procedures: 20. Care and services provided will be provided according to physician/practitioner orders. Orders are current and updated…25. All clinical services are implemented only in accordance with a Plan of Care established by a physician/practitioner’s written order… 30. If the Agency misses a visit or treatment or services as required by the plan of care…then the Agency must notify the responsible physician/practitioner of such missed treatment or service…” 5. An interview was conducted with the Agency Supervisor and QA RN on 4/1/25 from 10:15 AM to 11:45 AM. During the interview, it was stated that the POC should be followed. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #4 was admitted to home health services on 12/5/24 with the diagnosis of Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 4/1/25 and 4/2/25. The clinical record included a POC dated 12/5/24, that required SN to assess the patient 1 time a week for 9 weeks and notify the physician if weight greater than 5 pounds per week or less than 2 pounds per day. The SN assessed the weight on 12/5/24 as 170 pounds and on 1/30/25 as 183 pounds. The SN failed to notify the physician of the weight assessment not being done weekly and SN missed visits on 2/6/25, 2/13/25 and 3/6/25, and PT missed visits on 2/6/25, 2/13/25 and 3/4/25.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined that 2 of 7 (Pts. #7 and 4) clinical records reviewed, the Agency failed to ensure that the PsOC include Pt. specific information. 2. Pt. #4 was admitted to home health services on 12/5/24 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 4/1/25 and 4/2/25. The clinical record included a POC dated 12/5/24, that required SN to assess the patient 1 time a week for 9 weeks. The POC lacked the orders for the AV Graft/Fistula site care management. 3. The above findings were confirmed, during the interview with the Agency Supervisor and QA RN, on 4/2/25 between 9:30 AM and 11:45 AM. Findings include: 1. Pt. #7 was admitted for home health services on 9/3/24 with the diagnoses of, but not limited to, Hemiplegia Following Cerebral Infarction Affecting The Left Non-Dominant Side and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms. The clinical record was reviewed on 4/1/25 at 10:00 AM. The clinical record included the comprehensive assessment dated 9/3/24. The POC included “(T)exas catheter” in the list of DME. The POC lacked Pt. specific instructions related to Texas catheter/condom catheter care: cleansing/hygiene, frequency of changing catheter, monitoring for skin breakdown, ensuring proper fit, and Pt./family education. The Pt. has a diagnosis of Benign Prostatic Hyperplasia and is on the following medications: Furosemide, Oxybutynin, Tamsulosin, and Finasteride. The POC dated 9/3/24 lacked: interventions related to the use of diuretics and genitourinary system medications, interventions related to urinary output/monitoring, and SN follow-up with the Physician regarding the lack of these interventions on the POC.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on Pt./family/staff interviews during home visit, observation, clinical record review, policy review, and staff interview, it was determined that 3 of 7 (Pts. #1, 7, and 5) clinical records reviewed, the Agency failed to ensure that concerns are communicated/coordinated within the healthcare team to ensure Pt. needs were identified and addressed. 3. Pt. #5 was admitted for home health services on 2/4/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 3/31/25. The MSW assessment note dated 2/10/25 included the documentation, “Interventions/Linkages/Recommendations: Pt. to be evaluated by IDOA (Illinois Department of Aging) within 2-4 weeks for Homemaker Services to address ADL needs, reduces risk of hospitalization…” The clinical record lacked documentation of coordination between the Pt., the Agency and IDOA related to the referral for Homemaker services made by the MSW. During an interview with the Agency Supervisor and Quality Assurance RN on 4/1/25 at 11:00 AM, the Agency Supervisor stated that the Agency had no documentation of the follow up and information related to the referral for homemaker services. 4. The Agency policy titled, “Coordination of Patient Care” was reviewed on 4/2/25, and required, “1. The Agency must: Coordinate care delivery to meet the patient's needs, involve the patient, representative (if any), caregiver, as appropriate, in the coordination of activities...2. The Director of Clinical Services provides oversight of all patient care services includes...coordinating patient care, coordinating referrals, ensuring that patient needs are continually assessed...6. Staff provides the physician/practitioner with patient information on an ongoing basis regarding current condition and changes in condition, outcomes of care and services… 8. Care will be coordinated with other involved external organizations… e.g. community agencies, staff will: share relevant information to facilitate appropriate continuity and care coordination…” 5. During an interview with the Agency Supervisor and Quality Assurance RN on 4/1/25 from 9:30 AM to 11:15 AM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted for home health services on 2/18/25 with the diagnoses of, but not limited to, Type 2 Diabetes Mellitus With Foot Ulcer and Long Term (Current) Use Of Insulin. During the home visit on 3/31/25, the Pt., the patient’s wife, and PT stated that he does not have a bedside commode and the Pt. is having bowel movements in a large bucket with his wife’s assistance. No bedside commode was visualized in the apartment. The clinical record was reviewed on 4/1/25. The comprehensive assessment dated 2/18/25 included bedside commode as DME. The clinical record lacked documentation of care coordination between the PT and Agency requesting for a bedside commode. SN documented constipation in each SN Visit note and the Pt. is ordered a daily osmotic laxative plus medications with the side effect of constipation. The clinical record lacked communication to the Physician to report chronic constipation despite daily laxative use and lacked Pt./family education regarding constipation prevention. 2. Pt. #7 was admitted for home health services on 9/3/24 with the diagnoses of, but not limited to, Hemiplegia Following Cerebral Infarction Affecting The Left Non-Dominant Side and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms. The clinical record was reviewed on 4/1/25. The clinical record included the certification period dates 9/3/24. SN documented constipation in the SN Visit notes from 1/3/25 to 2/7/25. The Pt. is ordered a twice daily stool softener, an as needed laxative suppository, and is on medications with the side effect of constipation. The clinical record lacked communication to the Physician to report chronic constipation despite stool softener and laxative use, and lacked Pt. education regarding constipation prevention.

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: Based on home visit, family interview, clinical record review, Agency policy review, and staff interview, it was determined that 5 of 7 (Pts. #1, 7, 3, 2, and 4) clinical records reviewed, the Agency failed to ensure that the clinical record was accurate. 4. Pt. #2 was admitted to home health services on 1/18/25 with the diagnosis of Other Hypertension. The clinical record was reviewed on 4/1/25. The clinical record included a POC dated 1/18/25. The record also included “Discharge Instructions” form completed by the RN at the SOC on 1/18/25 and signed by Pt. #4 at that time. The form was incomplete and lacked documentation of patient's status, treatments, and services. 5. Pt. #4 was admitted to home health services on 12/5/24 with the diagnosis of Hypertensive Chronic Kidney Disease With Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 4/1/25. The clinical record included a POC dated 12/5/24, that required SN to assess the patient 1 time a week for 9 weeks. The record included the following dates: 1/16/25, 1/23/25, 2/6/25, 2/13/25, 2/20/25, 2/27/25, 3/6/25, 3/11/25, that lacked documentation of the Skilled Nurse visit notes as of 4/1/25. =6. The Policy “Nurse Documentation Submission and Verification of Visit Forms” (Revised January 2024) was reviewed on 4/3/25 and documents under: Policy Statement: “All nursing documentation, including visit notes, assessments, and verification of visit forms, must be completed accurately, and submitted on time. Submission must occur within one week of visit, and failure to submit within this period will result in non-payment for services rendered.” 9. During an interview with the Agency Supervisor on 4/2/25 between 9:30 AM and 11:45 AM., the Agency Supervisor stated, "we know the nurse made the visits, but the notes have not been completed." During the same interview, it was confirmed Pt. assessments were incomplete, and not placed in the clinical record as required by the Agency. On 4/2/25 at 3:30 PM, The Agency Supervisor and QA RN stated, “Agency staff are completing all the forms upon admission at the SOC". 3. Pt. #3 was admitted to home health services on 2/15/25 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 unspecified Chronic Kidney Disease. The clinical record was reviewed on 4/1/25. The SN notes dated 3/15/25, 3/22/25 and 3/29/25 recorded Pt. #3's weight of 257 lbs. for all of the above-mentioned notes. A home visit was conducted with the Agency Supervisor on 4/1/25. During the home visit, Pt. #3 weight was recorded at 210 lbs. During the home visit, Pt. #3 was asked when the last time the nurse recorded his weight to which Pt. #3 replied, “it hasn’t been taken for more than a month…” The clinical record included documentation that Pt. #3 is alert and oriented to person, time, place and orientation. The Admission Booklet containing the RN's documentation of vital signs did not include a record of the patient's weight. The weight recorded on the clinical record is inaccurate. The clinical record also included the form “Discharge Instructions” which was completed by the RN and signed by Pt. #3 on 2/15/25 (SOC). The form was incomplete and lacked documentation of patient's current status, treatments and services. 7. The Agency policy, “Consent for Treatment and Services” was reviewed on 4/2/25 and required, “Consent for treatment and services will be completed upon admission.” 8. The Agency policy, "Discharge Criteria and Planning" was reviewed on 4/2/25 and required, "7. Patient will receive verbal or written discharge instructions two weeks prior to the end of the certification period..." Findings include: 1.Pt. #1 was admitted for home health services on 2/18/25 with the diagnoses of, but not limited to, Type 2 Diabetes Mellitus With Foot Ulcer and Long Term (Current) Use Of Insulin. During the home visit on 3/31/25, there was no bedside commode observed and wife stated that a bedside commode has not bee provided since the SOC. The clinical record was reviewed on 4/1/25. The comprehensive assessment dated 2/18/25 and the Aide Care Plan dated 2/21/25 included bedside commode as DME to be included in the patient's care. The clinical record is inaccurate. The POC lists three different high glucose perimeters for when to notify the physician: :Insulin Lispro...400 and above=6 Units and call MD," "Fasting blood sugar greater than...200," and "Random blood sugar greater than...250." The POC has conflicting documentation. The Pt. "Admission Consent" was not in the chart and was not located in the agency upon initial request. The clinical record included the form “Discharge Instructions” which was completed by the RN and signed by Pt. #1's wife on 2/18/25 (SOC). The form was incomplete and lacked documentation of patient's current status, treatments, and services. 2. Pt. #7 was admitted for home health services on 9/3/24 with the diagnoses of, but not limited to, Hemiplegia Following Cerebral Infarction Affecting The Left Non-Dominant Side and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms. The clinical record was reviewed on 4/1/25. The clinical record included the form “Discharge Instructions” which was completed by the RN and signed by Pt. #7 on 9/3/24 (SOC). The form was incomplete and lacked documentation of patient's current status, treatments, and services.

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: Based on observations and interviews during home visits, clinical record review, Agency policy review, and staff interviews, it was determined in 2 of 3 (Pts. #1 and 3) home visits conducted, the Agency failed to ensure the clinical record included accurate medication records. 2. Pt. #3 was admitted to home health services on 2/15/25 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 unspecified Chronic Kidney Disease. A home visit was conducted on 4/1/25 with the Agency Supervisor. During the home visit, Pt. #3 presented the medication, “Breo Ellipta inhaler” and stated that “these are current inhalers that was prescribed by the doctor…” The clinical record was reviewed on 4/1/25. The clinical record included “Medication Profile” for 2/15/25 to 4/15/25, but it did not list the above-mentioned medication. The medication profile was not updated. 3. The Agency policy "Medication Reconciliation" which was revised February 2021, was reviewed on 4/2/25. The policy required, "2. Medications ordered while the patient is receiving will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication." 3. During an interview with the Agency Supervisor on 4/2/25 from 9:30 AM to 11:15 AM, it was stated that the clinical records should contain all the patient’s medications. During the same interview, the above findings were confirmed. Findings include: 1.Pt. #1 was admitted for home health services on 2/18/25 with the diagnoses of, but not limited to, Type 2 Diabetes Mellitus With Foot Ulcer and Long Term (Current) Use Of Insulin. During the home visit, the Agency's Current Medication list dated 2/18/25 was compared to the medications the patient's wife is administering to the Pt. The patient's wife stated she administers the following medications differently than as stated on the Agency's Current Medication list: Seroquel, Metolazone (she does not know what this medication is and does not administer it), Insulin Lantus, Insulin Lispro (she does not know what sliding scale insulin dosing is and does not consistently check his blood glucose), Potassium Chloride, and Divalproex. Record review of the Agency's policy titled, "Medication Profile," revised March 2018, showed direction for the Agency staff to add all new or changed medications to the medication list every home visit and as new orders are received. The Agency failed to follow this policy.

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, Agency policy, and staff interview, it was determined that for 3 of 7 (Pts. #1, 2, and 3) clinical record reviewed, the Agency failed to ensure forms and records were complete and accurate. Findings include: 1. The following clinical records were reviewed on 3/31/25 to 4/2/25. The following records contained the form "Notice of Medicare Non-Coverage" and included the statement "The Effective Date of Your Current Home Health Services Will End": Pt. #1. SOC: 2/18/25 – “The Effective Date Coverage of Your Current Home Health Services Will End 4/18/25.” Pt. #2. SOC: 1/18/25 - “The Effective Date Coverage of Your Current Home Health Services Will End 3/18/25… 5/17/25.” Pt. #3. SOC: 2/15/25 – “The Effective Date Coverage of Your Current Home Health Services Will End 4/15/25.” The above-mentioned forms were signed by the Pt. or Pt. representative at the SOC. The forms were inaccurate. 2. The Agency policy titled, "Medial Record Entries and Authentication" was reviewed on 4/2/25 and required, "All entries in patient records will be legible, clear, complete and appropriately authenticated, dated and timed." 3. During an interview with the Agency Supervisor on 4/2/25 at 3:30 PM, it was stated that the form "Notice of Medicare Non-Coverage" is to be filled out once the Agency has determined the effective date Medicare will not pay for the services, and not to be automatically filled out by Agency staff at the SOC.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: POC/PsOC = Plan of care/ plans of care SN = Skilled Nurse RN = Registered Nurse PT = Physical Therapy/Therapist SOC = Start of Care AM = morning PM = afternoon/evening # = number x = times Mg/MG = milligrams cap = capsule tab = tablet Mg/dl = milligrams per deciliter = greater than FBS = Fasting Blood Sugar RBS = Random Blood Sugar vs = vital signs BP = Blood pressure Pt/Pts. = Patient/Patients % = percent ABN = Advance Beneficiary Notice of Non-Coverage HHCCN = Home Health Change of Care Notice HHA = Home Health Aide

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Pt. complaint log, Agency policy, interview during a home visit and staff interview, it was determined the Agency failed to ensure a patient’s caregiver complaint was investigated and resolved, as required by the Agency. This was found in 1 of 7 (Pt. #1) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/1/21. Diagnoses: Hypertensive Chronic Kidney Disease with Stage 1 to 4 / Unspecified Chronic Kidney Disease, Left Hip Unilateral Primary Osteoarthritis and Malignant Neoplasm of Unspecified Site of Right Female Breast. The clinical record was reviewed on 12/28/21 at 9:35 AM. The record contained the “Patient Communication” note completed by the Agency Supervisor/Director of Nursing and dated 10/12/21. The communication note included: “…called and complaining that patient was only getting once a week HHA to help with personal care and patient is incontinent and use diaper…Was asking for 4 days a week… referred to the department on aging on admission… HHA will be increased to 2x/week visits…” 2. The Agency’s Pt. complaint log was reviewed on 12/27/21 at 11:45 AM, the complaint log lacked documentation of the complaint mentioned above. 3. The Agency’s policy titled “Complain / Grievance Policy” was reviewed on 12/27/21 at 11:55 AM and contained: “The Agency will have the complaints in writing, should contain Name and address of the person filing it, and should briefly described the grievance / complaints. The agency receive, investigate and respond to complaints… 2. The administrator or RN supervisor will contact you and/or your representatives and will make every effort to resolve to your satisfaction…” 4. A home visit was conducted on 12/29/21 at 9:00 AM with Employee #1. During the home visit an interview was conducted with the patient’s caregiver. The patient’s caregiver stated the HHA was increased from once a week to 2x/week. No one from the Agency contacted the family to inquiry whether this complaint was resolved, they just accepted the HHA service 2x/week; also no one from the Department on Aging contacted them to evaluate for homemaker services. 5. An interview was conducted with the Administrator, Agency Supervisor/Director of Nursing and the Nursing Supervisor/Quality Assurance (administrative staff) on 12/29/21 at 1:06 PM. The Administrator presented an email sent to Aging@Cityof Chicago.org dated 10/12/21 that had an attachment and included, “Hi Sir/Madam: Please see referral for Home Maker...” The email attachment had the demographic information of Pt. #1. The Agency did not submit an application for homemaker services with the Department on Aging or obtain a Physician's order for Medical Social Worker service to assist family with applying for homemaker services. The Agency also failed to document, investigate and respond to the complainant/patient’s caregiver regarding to determine whether this issue was resolved. During the same interview, the administrative staff confirmed the above findings.

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 interview and observation during a home visit, Agency policy and staff interview, it was determined the Agency failed to inform the Pt./patient’s caregiver on actions that affect the patient’s care and/or services. This was found in 1 of 3 (Pt. #1) home visit conducted. Findings include: 1. Pt. #1. SOC 9/1/21. Diagnoses: Hypertensive Chronic Kidney Disease with Stage 1 to 4 / Unspecified Chronic Kidney Disease, Left Hip Unilateral Primary Osteoarthritis and Malignant Neoplasm of Unspecified Site of Right Female Breast. A home visit was conducted on 12/29/21 at 9:00 AM with Employee #1. During the home visit an interview was conducted with the patient’s caregiver and Employee #1. A request was made to review the Agency’s Pt. home booklet presented to the Pt./caregiver at the SOC. The patient’s caregiver responded, “Which one? The one they (Employee #4) brought by last night (7:30 pm) or the first one?(provided at SOC)” Both booklets were observed and included the same information. However, the first booklet presented at the SOC was blank, none of the sections were filled-out (Emergency Preparedness, vital sign log, staff names and visit frequencies, fall risk assessment and other required forms). The second booklet delivered on 12/28/21 had each section filled-in. The patient’s caregiver stated, “The nurse told me to sign something, I don’t know what it was I just signed it”. The booklet provided on 12/28/21 included a form titled, “Notice of Medicare Non-coverage form” with the patient’s caregiver’s signature and dated 12/28/21. The Agency failed to verbally inform the patient’s caregiver of written information provided on 12/28/21, including the form the patient’s caregiver signed on 12/28/21. 2. The Agency’s Pt. booklet contained the policy titled, “Patient Rights and Responsibilities” reviewed on 12/27/21 at 10:30 AM. The policy included: “As a home care provider, we have an obligation to protect and promote the exercise of your rights… " 3. During an interview with the Administrator, Agency Supervisor/Director of Nursing and the Nursing Supervisor/Quality Assurance on 12/29/21 at 1:06 PM. The administrative staff confirmed the above findings.

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 a review of clinical records, Agency policy and staff interview, it was determined that the Agency failed to ensure the SOC assessment was conducted within 48 hours of the referral date. This was found in 2 of 7 (Pts. #5 and 6) clinical records reviewed. 1. Pt. #5. SOC 9/17/21. Diagnoses: Hypertensive Heart Disease and Acute Embolism and Thrombosis of Unspecified Deep Veins of Proximal Lower extremity. The clinical record was reviewed on 12/29/21 at 10:00 AM. The record contained SOC assessment, completed by SN and dated 9/17/21 and documented; “Inpatient discharge date: 9/10/2021”. The record lacked referral date or a physician ordered start of care date. It cannot be determined that the SOC was conducted within the 48 hours of the referral date. 2. Pt. #6. SOC 7/23/21. Diagnoses: Essential (Primary) Hypertension and Unspecified Anemia. The clinical record was reviewed on 12/28/21 at 1:00 PM. The record contained a referral dated 7/15/21 faxed from the Physician’s office to start SN and PT services. The SOC comprehensive assessment completed by the SN was dated 7/23/21 (8 days after the referral date). The Agency failed to initiate services within 48 hours of receipt of the referral. 3. During an interview with the Administrator, Agency Supervisor/Director of Nursing and the Nursing Supervisor/Quality Assurance (administrative staff) on 12/29/21 at 1:06 PM. The administrative staff confirmed the Agency failed to initiate service with 48 hours of referral date.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observation and interview during home visits and staff interviews, it was determined the Agency failed to ensure the POC contained accurate medications and interventions. This was found in 3 of 7 (Pts. #1, 3 and 2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/1/21. Diagnoses: Hypertensive Chronic Kidney Disease with Stage 1 to 4 / Unspecified Chronic Kidney Disease, Left Hip Unilateral Primary Osteoarthritis and Malignant Neoplasm of Unspecified Site of Right Female Breast. The clinical record was reviewed on 12/28/21 at 9:35 AM. The record contained the POC for the certification period of 10/31/21 to 12/29/21 which included the medication “Lisinopril Oral 20 MG 1 Tab (s) Twice a day”. A home visit was conducted on 12/29/21 at 9:00 AM with Employee #1. During the home visit, an interview was conducted with the patient’s primary caregiver that stated, “The Lisinopril, it's not taken that twice a day anymore. The doctor changed it to once a day about 2 months ago.” The POC effective 10/31/21 was inaccurate and the record lacked any updates to the POC regarding this medication. 2. Pt. #3. SOC 10/1/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. A home visit was conducted on 12/29/21 at 10:00 AM with Employee #1. During the home visit, Employee #1 provided a treatment/skin care to both legs and feet which included: Cleaning with wound cleanser, rinse with 0.9 % normal saline, applied Vaseline petroleum jelly, wrap with gauze wrap, then coban wrap. During an interview, Employee #2 stated, “I’ve been doing this for more than a month. The clinical record was reviewed on 12/28/21 at 11:45 AM and contained the POC effective 11/30/21 which lacked the treatment indicated above. The records lacked any updates to the POC regarding this treatment. 3. Pt #2 SOC 11/13/21. Diagnoses: Encounter for Surgical Aftercare following surgery on digestive system and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/28/21 at 9:30 AM. The POC and medication profile for episode 11/13/21 to 1/11/22 and included Medications: “...Gabapentin oral 300 mg 1 cap(s) 3x a day (N)….Levemir Subcutaneous 100 unit/ml 10 units ml at bedtimes (N)…” A home visit was conducted on 12/28/21 at 10:30 AM with Employee #3. During the home visit, the Pt. stated that she has never heard of Levemir and has not taken it and stopped taking Gabapentin about a month ago from hearing about its side effects. The POC was inaccurate to include Levemir and Gabapentin. 4. During interview with Administrator, Agency Supervisor/Director of Nursing and Nursing Supervisor/Quality Assurance Nurse on 12/29/21 from 1:06 PM to 4:30 PM, the Quality Assurance Nurse stated that medications are reviewed on every visit. The Administrative staff confirmed that PsOC for Pts. # 1, 3 and 2 were inaccurate.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. 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 fully assess Pt. Influenza and/or Pneumococcal vaccine status at the SOC. This was found in 6 of 7 (Pts. #1, 3, 6, 7, 4 and 5) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/1/21. Diagnoses: Hypertensive Chronic Kidney Disease with Stage 1 to 4 / Unspecified Chronic Kidney Disease, Left Hip Unilateral Primary Osteoarthritis and Malignant Neoplasm of Unspecified Site of Right Female Breast. The clinical record was reviewed on 12/28/21 at 9:35 AM. The record contained the SOC comprehensive assessment form and dated 9/1/21, and an undated “Influenza / Pneumococcal…Vaccination” form, both forms competed by the SN. The forms included documentation the Pt. had received the vaccines. The form lacked the date the Pt. received the vaccines. 2. Pt. #3. SOC 10/1/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The record contained the SOC comprehensive assessment form and dated 10/1/21, and an undated “Influenza / Pneumococcal…Vaccination” form, both forms competed by the SN. The forms included documentation the Pt. had received the Influenza and Pneumococcal Pneumonia vaccines. The forms lacked the date the Pt. received the vaccines. 3. Pt. #6. SOC 7/23/21. Diagnoses: Essential (Primary) Hypertension and Unspecified Anemia. The clinical record was reviewed on 12/28/21 at 1:00 PM. The record contained the SOC comprehensive assessment form dated 7/23/21 competed by the SN which included documentation the Pt. had received the Influenza and Pneumococcal Pneumonia vaccines. The forms lacked the dates the Pt. received the vaccines. 4. Pt. #7. SOC 5/8/21. Primary Diagnosis: Essential Hypertension. The clinical record was reviewed on 12/28/21 at 2:00 PM. The record contained the SOC comprehensive assessment and the “Influenza / Pneumococcal…Vaccination” forms, both forms dated 5/8/21 and competed by the SN. The forms included documentation the Pt. had received the Influenza and Pneumococcal Pneumonia vaccines, the forms lacked the date the Pt. received the vaccines. 5. Pt #4. SOC 12/04/21. Diagnoses: Rheumatoid Arthritis and Hypertensive Kidney Disease. The clinical record was reviewed on 12/28/21 at 2:00 PM. The record contained the SOC comprehensive assessment completed by the SN, dated 12/04/21 and an undated "Influenza/Pnuemococcal....Vaccination form. The forms included documentation the Pt. had received the vaccines. The form lacked the date the Pt. received the vaccines. 6. Pt. #5. SOC 09/17/21. Diagnoses: Hypertensive Heart Disease and Acute Embolism and Thrombosis of Unspecified Deep Veins of Proximal Lower extremity. The clinical record was reviewed on 12/29/21 at 10:00 AM. The clinical record included SOC assessment completed by SN, dated 9/17/21. The form included documentation the Pt. had received the vaccines. The form lacked the date the Pt. received the vaccines. 7. The Agency Policy titled: “Influenza/Pneumococcal Vaccination Program” was reviewed on 12/29/21 at 4:00 PM and documented: “…agency shall document in the client’s/patient’s medical record that an annual vaccination against influenza was administered, arranged, refused or medically contraindicated….The following shall be considered to be documentation….A)Individual client/patient record entries identifying assessment for the need of vaccination, date of offer or referral; client/patient response; administration, contraindication ore refusal; and any follow-up activities. If the case where patinet will remember the date of vaccine the clinician will communicate with MD. B) Standardized check-ff recording client/patient specific information, including the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication, or refusal; and any follow-up activities.” 8. The Agency Policy titled: “Pneumococcal pneumonia vaccine”was reviewed on 12/29/21 at 4:15 PM and documented: “….The Agency shall document in each client’s/patient’s medical record that a vaccination against pneumococcal pneumonia was offered and was administered, arranged, refused, or medically contraindicated…. The following shall be considered to be documentation….A)Individual client/patient record entries identifying assessment for the need of vaccination, date of offer or referral; client/patient response; administration, contraindication ore refusal; and any follow-up activities. If the case where patinet will remember the date of vaccine the clinician will communicate with MD. B) Standardized check-ff recording client/patient specific information, including the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication, or refusal; and any follow-up activities.” 9. During entrance interview with Administrator and Agency Supervisor/Director of Nursing on 12/27/21 at 9:15 AM, the Administrator stated Flu and Pneumonia status is initially assessed at SOC and is documented on the SOC assessment. 10. During an interview with Administrator, Agency Supervisor/Director of Nursing and Nursing Supervisor/Quality Assurance Nurse on 12/29/21 from 1:06 PM to 4:30PM, the Administrator confirmed that the Agency staff failed to fully assess immunization status as required by the Agency.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: A. Based on clinical record review, interviews during a home visit, Agency policy and staff interview, it was determined the Agency failed to implement discharge planning, as required by the Agency. This was found in 1 of 3 (Pt. #1) home visits conducted. Findings include 1. Pt. #1. SOC 9/1/21. Diagnoses: Hypertensive Chronic Kidney Disease with Stage 1 to 4 / Unspecified Chronic Kidney Disease, Left Hip Unilateral Primary Osteoarthritis and Malignant Neoplasm of Unspecified Site of Right Female Breast. The clinical record was reviewed on 12/28/21 at 9:35 AM. The record contained the POC for the certification period of 10/31/21 to 12/29/21, multiple SN visit notes (latest dated 11/17/21) physician orders, communication notes and other documents. The record lacked any documentation of discharge planning with the Pt./patient’s caregiver and/or physician. The record lacked a physician order to continue services after 12/29/21 and a recertification comprehensive assessment to continue services after 12/29/21. 2. A home visit was conducted on 12/29/21 at 9:00 AM with Employee #1. During the home visit an interview was conducted with Employee #1 and the patient’s caregiver. Employee #1 stated the office told me this is my last visit, they are discharging from the agency.” The patient’s caregiver was present and stated, “No one called me from the Agency to tell me this. Why are they discharging…, shouldn’t someone had called me to tell me this? Why?” The Agency failed to implement discharge planning to include the Pt./patient’s caregiver and the physician. 3. The Agency’s Pt. booklet contained the policy titled, “Patient Rights and Responsibilities” reviewed on 12/27/21 at 10:30 AM. The policy included: “Decision Making – You have the right to: Be given three (3) working days’ advance notice of discharge including the reason for discharge.” 4. The Agency’s policy titled, “Discharge Criteria and Planning” was reviewed on 12/30/21 at 12:00 PM and included: “…2. The patient is informed of discharge plan in a timely manner and acknowledges understanding reason…” 5. During an interview with the Administrator, Agency Supervisor/Director of Nursing and the Nursing Supervisor/Quality Assurance on 12/29/21 at 1:06 PM. The administrative staff confirmed discharge planning was not implemented, and the Physician was not contacted to continue services after 12/29/21.

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 a review of clinical record and staff interview, it was determined the Agency failed to ensure services and treatments were provided as ordered by the Physician in the PsOC. This was found in 3 of 7 (Pts.#2, 4, 1) clinical records reviewed. 3. Pt. #1. SOC 9/1/21. Diagnoses: Hypertensive Chronic Kidney Disease with Stage 1 to 4 / Unspecified Chronic Kidney Disease, Left Hip Unilateral Primary Osteoarthritis and Malignant Neoplasm of Unspecified Site of Right Female Breast. The clinical record was reviewed on 12/28/21 at 9:35 AM. The record included the POC for the certification period of 10/31/21 to 12/29/21 requiring the SN to provide service “1 week 9”. As of 12/28/21, the record lacked documentation the SN provided any service after 11/17/21. 4. During an interview with the Administrator, Agency Supervisor/Director of Nursing and the Nursing Supervisor/Quality Assurance on 12/29/21 at 1:06 PM. The administrative staff confirmed staff failed to comply with the POC. Findings include: 1. Pt. #2. SOC 11/13/21. Diagnoses: Encounter for Surgical Aftercare following surgery on digestive system and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/28/21 at 9:30 AM. The POC for certification episode 11/13/21 to 01/11/22 included “….SN to check and report FBS >200 mg/dl, RBS>250 mg/dl, FBS/RBS 160/90 or <90/60….” The SN note dated 12/14/21 lacked documentation of BP as required in POC.

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 a review of clinical records, observation during a home visit, Agency policy review and staff interview, it was determined the Agency failed to ensure the clinical documentation entered into the clinical record was complete. This was found in 5 of 7 (Pts. #1, 3, 2, 4 and 5) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/1/21. Diagnoses: Hypertensive Chronic Kidney Disease with Stage 1 to 4 / Unspecified Chronic Kidney Disease, Left Hip Unilateral Primary Osteoarthritis and Malignant Neoplasm of Unspecified Site of Right Female Breast. The clinical record was reviewed on 12/28/21 at 9:35 AM. The record contained the form titled, “Notice of Medicare Non-Coverage” signed by patient’s caregiver and dated 9/1/21 (SOC date). The form included, "I have been notified that my services will end on the effective date indicated on this notice..." this section was left blank informing the patient’s caregiver of when the services would end. The form titled, “Home Health Change of Care Notice (HHCCN) signed by the patient’s caregiver and dated 9/1/21. The form required Agency staff to document the items/services not covered, reason for the change, and measures the Agency made in the patient’s care plan. All these required sections were left blank. The form titled, “Advance Beneficiary Notice of Non-coverage (ABN) signed by the patient’s caregiver and dated 9/1/21. The form required Agency staff to document care and/or services provided by the Agency that Medicare will not pay, estimated cost of care or service, and options for the patient/caregiver to choose. All these required sections were left blank. 2. Pt. #3. SOC 10/1/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. A home visit was conducted on 12/29/21 at 10:00 AM with Employee #1. During the home visit, the patient’s home binder contained documents provided by the agency and included the form titled, “Notice of Medicare Non-Coverage” signed by Pt. and dated 10/1/21. The form included, "I have been notified that my services will end on the effective date indicated on this notice..." The form lacked the date that services would end. 3. Pt. #2. SOC 11/13/21. Diagnoses: Encounter for Surgical Aftercare Following Surgery on Digestive System and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/28/21 at 9:30 AM. The form titled: “Notice of Medicare Non-Coverage”, signed by the Pt and dated 11/13/21. The form included: “ I have been notified that my services will end on the effective date indicated on this notice…” The form lacked the date that services will end, as required by the form. The form titled: “Advance Beneficiary Notice of Non-coverage (ABN)” signed by Pt and dated 11/13/21. The form included: “We expect Medicare may not pay for the ……below” The form lacked any service or care that Medicare does not cover and the reason, as required by the form. The form titled “Home Health change of Care Notice (HHCCN) signed by pt. dated 11/13/21. The form included: “Your Home health care is going to change…” The form lacked services that were changed and reason for change, as required by the form. 4. Pt. #4. SOC 12/4/21. Diagnoses: Rheumatoid Arthritis and Hypertensive Kidney Disease. The clinical record was reviewed on 12/28/21 at 2:00 PM. The form titled: “Notice of Medicare Non-Coverage”, signed by the Pt and dated 12/4/21. The form included: “ I have been notified that my services will end on the effective date indicated on this notice…” The form lacked the date that services will end, as required by the form. The form titled: “Advance Beneficiary Notice of Non-coverage (ABN)” signed by pt and dated 12/4/21. The form included: “We expect Medicare may not pay for the ……below” The form lacked any service or care that Medicare does not cover and the reason, as required by the form. The form titled “Home Health Change of Care Notice (HHCN) signed by pt. dated 12/4/21. The form included: “Your Home health care is going to change…” The form lacked date services were changed and reason for change, as required by the form. 5. Pt. #5. SOC 9/17/21. Diagnoses: Hypertensive Heart Disease and Acute Embolism and Thrombosis of Unspecified Deep Veins of Proximal Lower extremity. The clinical record was reviewed on 12/29/21 at 10:00 AM. The form titled: “Notice of Medicare Non-Coverage”, signed by the Pt and dated 9/17/21. The form included: “ I have been notified that my services will end on the effective date indicated on this notice…” The form lacked the date that services will end, as required by the form. The form titled “Home Health change of Care Notice (HHCN) signed by pt. dated 9/17/21. The form included: “Your Home health care is going to change…” The form lacked date services were changed and reason for change, as required by the form. 6. Agency policy titled: ”Medical Record Entries and Authentication” was reviewed on 12/29/21 at 2:00 PM. The policy stated: “All entries in patient records will be.... clear, complete....” 7. During an interview with Administrator, Agency Supervisor/Director of Nurisng and Nursing Supervisor/Quality Assurance Nurse on 12/29/21 from 1:06 PM to 4:30 PM, the Administrator confirmed that the Agency staff failed to ensure clinical records were complete and accurate.