Every finding on record at Alliedcare Home Health of Illinois, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/04/25. 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 Emergency Preparedness requirements on 09/04/25. Standard level deficiencies cited. Abbreviations: OASIS = Outcome and Assessment Information Set lbs = pounds % = percentage & = and SOC = Start of Care POC = Plan of Care Pt / Pts = Patient / Patients SN = Skilled Nurse PT = Physical Therapy

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 and staff interview, in 18 of 157 assessments submitted for the last 12 months, the Agency failed to submit reports timely, resulting in a warning. Findings include: 1. The Error Summary report for 09/01/24 to 09/01/25, was reviewed on 09/02/25. The report included error # -3330 for 18 of 150 (11.46 %) OASIS reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Agency Supervisor on 09/03/25 at 1:30 PM, the Agency Supervisor 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: Based on review of Agency’s Pt. Admission folder, clinical record review, observation during home visits, and staff interviews, the Agency failed to ensure that the Pt. / representative was informed in writing of the services to be provided and the frequency of visits for 7 of 7 (Pts. # 1,2 ,3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 09/02/25 to 09/03/25 and lacked documentation the pts./representatives were informed in writing of the service(s) to be provided and visit frequencies prior to receiving services. Pt. #1 SOC 08/07/25. Received SN and PT services. Pt. #2 SOC 07/09/25. Received PT services. Pt. #3 SOC 08/12/25. Received SN and PT services. Pt. #4 SOC 07/19/25. Received SN and PT services. Pt. #5 SOC 06/05/25. Received PT services. Pt. #6 SOC 11/18/24. Received SN and PT services. Pt. #7 SOC 03/15/25. Received SN services. 3. The following home visits were conducted on 09/02/25 and 09/03/25: Pt. #1 SOC 08/07/25. Pt. #2 SOC 07/09/25. Pt. #3 SOC 08/12/25. During the home visits, the Pt. admission folders were observed and lacked documentation indicating the Pt. / representative was notified of the discipline (s) to provide service, and the frequency of visits in writing prior to receiving services. 4. During interview with the Agency Supervisor on 09/03/25 between 1:30 PM to 3:30 PM, the Agency Supervisor confirmed the above findings.

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 clinical records review and staff interviews, the Agency failed to ensure that the staff provided service as ordered in the POC for 2 of 7 (Pts. # 4 and 7) clinical records reviewed. 2. Pt. #7 was admitted to home health services on 03/15/25 with diagnosis of Cellulitis of Right Lower Limb. The clinical record was reviewed on 09/03/25. The clinical record included a POC for certification period 03/15/25 to 05/13/15. The wound care orders in the POC are "each SN visit Cleanse wound on right leg with soap and water / wound wash, pat dry, place 1 application of Mupirocin 2% twice daily as ordered, then cover with several nonstick absorbent gauze, then secure with rolled gauze & tape." The clinical record included SN visits dated 03/25, 03/31/25 that have documentation of wound care "Cleansed wound with wash, pat dry apply calcium alginate with silver dressing on wound, covered with nonstick gauze & secure with tape." 3. During interviews with the Agency Supervisor on 09/03/25 between 1:30PM and 3:30 PM the above findings were confirmed. Findings include: 1.Pt. #4 was admitted to home health services on 07/19/25 with diagnosis of Pressure Ulcer of Sacral Region, Stage 3. The clinical record was reviewed on 09/03/25. The clinical record included a POC effective 07/19/25 to 09/16/25, that required: “SN to assess patient for fluid retention. Weigh patient every week and report to MD weight gain of 2 lbs. in 24 hours or 5 lbs. or more in 1 week or per parameters set by MD.” The SN visits dated 08/08/25, 08/10/25, 08/15/25, 08/22/25 and 08/29/25, lacked documentation of pt’s weekly weight, as ordered in the POC. .