Every finding on record at Apple Home Healthcare, Ltd.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 01/03/2025. Standard deficiencies cited.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a current communication plan that meets the requirements for the Agency's contact information. 1. The Agency's Emergency Preparedness Plan was reviewed on 01/02/25. The plan lacked a communication plan that included the current names and contact information for the staff and the entities providing services under the arrangement. 2. During an interview with the Administrator on 01/02/25 at 10:30 AM, the above findings were 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 Plan and Staff interview, it was determined that the Agency failed to ensure that the Agency conducted/participated in full-scale community-based exercise or facility-based exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. 1. The Agency's Emergency Preparedness Plan was reviewed on 01/02/25. The plan lacked documentation indicating the Agency participated in a full-scale community-based exercise, facility-based exercise, or implemented the Emergency Preparedness Plan since 2021. 2. During an interview with the Administrator on 01/02/25 at 10:30 AM, it was confirmed that the Agency failed to conduct/participate in the full-scale exercise.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 01/03/25. Standard level deficiencies cited. Abbreviations: AM = morning PM = afternoon/evening POC=Plan of Care PsOC=Plans of Care Pt./Pts. = Patient/Patients PT = Physical Therapist SN = Skilled Nurse 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 Agency’s Error Summary report and Staff interview, it was determined for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 12/01/23 through 11/30/24, was reviewed on 12/31/24 at 10:00 AM, and included error # -3330. The Error summary report included 50.25 % of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator on 12/31/24 at 11:30 AM.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observations during home visits, and staff interview, it was determined the Agency failed to provide the Pt./Pt.'s representative information regarding the Administrator. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 12/30/24 and lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 12/31/24: Patient #1. SOC 09/28/23. Patient #2. SOC 12/09/24. Patient #3. SOC 11/12/24. During the home visits of Pts. #1, #2, and #3, the patient's admission folder was observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed on 12/31/24: Pt. #1. SOC 09/28/23. Pt. #2. SOC 12/09/24. Pt. #3. SOC 11/12/24. Pt. #4. SOC 09/11/24. Pt. #5. SOC 12/20/24. Pt. #6. SOC 06/29/24. Pt. #7. SOC 03/20/24. The clinical records lacked documentation that the Pt./Pt.'s representative was provided the name and contact information of the Administrator to file a complaint or grievance. 4. During an interview with the Administrator on 01/02/25 at 8:30 AM, she confirmed the Agency failed to provide the Pt./Pt.’s representative with the Administrator's name and contact information.

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 reviewed and staff interviews, it was determined for 3 of 7 (Pt. #4, 5, and 7) clinical records reviewed, the Agency failed to ensure care and/or services were provided as ordered by the Physician in the POC. 2. Pt. #5 was admitted to the Home Health Services on 12/20/24 with the diagnosis of: “Infect/Inflm Reaction due to Internal Left Hip Prosth, Init.”. The clinical record was reviewed on 12/31/24. The clinical record contained a POC dated 12/20/24, that required the PT to assess the patient 1 time a week for 1 week. As of 12/31/24, the PT failed to visit/ assess the patient. The same POC required the SN 1 time a week for 10 weeks and included to assess the patient’s blood glucose. The SN failed to assess the blood glucose on 12/24/24 (week #2). 3. Pt. #7 was admitted to the Home Health Services on 03/20/24 with the diagnoses of: Malignant Neoplasm of Tail of Pancreas. The clinical record was reviewed on 12/31/24. The clinical record contained POC dated 03/20/24, that required the SN to assess the patient 1 time a week for 1 week and 1 every 2 weeks for 8 weeks. The SN failed to visit/assess the patient during the week of 04/30/24. The same POC required the PT to visit/assess the patient 1 time a week for 1 week , 2 weeks for 6 weeks and 1 week for 2 weeks. The PT failed to visit week of 03/24/24 (week #2) and 03/31/24 (week #3). 4. The above findings were confirmed, during the interview with the Administrator and Clinical Supervisor, on 12/31/24 at 11:30 AM and on 01/02/25 at 11:00 AM with the Administrator. 1. Pt. #4 was admitted to the Home Health Services on 09/11/24 with the diagnosis of: Pressure Ulcer of Sacral Region, Stage 3 and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/30/24. The clinical record contained a POC dated 11/15/24 that required PT frequency of 1 time a week for 1 week and OT frequency of 1 time a week for 1 week. The record lacked PT and OT visit/assessment notes.

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 records reviewed and the Staff interviews, it was determined in 4 of 7 (Pts. #3, 4, 5, and 7) clinical records reviewed, the PsOC failed to include Pt. specific interventions and treatments. 3.Pt. #5 was admitted to the Home Health Services on 12/20/24 with the diagnosis of: “Infect/Inflm Reaction due to Internal Left Hip Prosth, Init.”. The clinical record was reviewed on 12/31/24. The clinical record contained a POC dated 12/20/24, that required the SN to assess the patient’s Intravenous (IV) therapy 1 time a week for 10 weeks. The POC lacked the dosage and amount of the IV flushes. 4.Pt. #7 was admitted to the Home Health Services on 03/20/24 with the diagnoses of: Malignant Neoplasm of Tail of Pancreas. The clinical record was reviewed on 12/31/24. The clinical record contained POC dated 03/20/24, that required the SN to assess the patient 1 time a week for 1 week and 1 every 2 weeks for 8 weeks. The POC lacked the Heparin dosage and amount of the Port a Cath-IV flushes. 5.The above findings were confirmed, during the interviews with the Administrator and Clinical Supervisor, on 12/31/24 at 11:30 AM and on 01/02/25 at 11:00 AM with the Administrator. 1. Pt. #3 was admitted to the Home Health Services on 11/12/24 with the diagnoses of: Metabolic Encephalopathy and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/30/24. The clinical record contained SN visit notes dated 11/20, and 11/26/24, which included blood sugar assessments. The POC for Pt. #3 lacked patient-specific blood sugar parameters. 2. Pt. #4 was admitted to the Home Health Services on 09/11/24 with the diagnosis of: Pressure Ulcer of Sacral Region, State 3 and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/30/24. The clinical record contained a POC dated 11/15/24. The clinical record contained SN visit notes dated 11/14, 11/22, and 11/29/24, which included blood sugar assessments. The POC for Pt. #4 lacked patient-specific blood sugar parameters.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder and Staff interviews, it was determined that the Agency failed to provide information regarding the Clinical Manager. This was observed in 3 of 3 home visits (Pts. #1, 2 and 3). 3. The following home visits were conducted on 12/31/24: Patient #1. SOC 09/28/23. Patient #2. SOC 12/09/24. Patient #3. SOC 11/12/24. During the home visits of Pts. #1, #2, and #3, the patient's admission folder was observed, and lacked the name and contact information of the Administrator. 4. The findings were confirmed during the interview, with the Administrator, on 01/02/25 at 9:00 AM. Findings include: 1. The Pt. admission folder was reviewed on 12/30/24. The folder lacked the name and information to contact the Clinical Manager. 2. During an interview with the Administrator and Clinical Manager on 12/31/24 at 12:30 PM, the Administrative team confirmed the Agency failed to provide information regarding the Clinical Manager.

Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This STANDARD is not met as evidenced by: Based on documents review, clinical records review and Staff interview, it was determined that the Agency failed to disclose a consistent legal name for the Agency. Findings include: 1. The current Agency’s IDPH License expiring 10/31/25 was reviewed on 01/02/25 and stated Agency name as “Apple Home Healthcare, LTD dba Journey Care Home Health – Chicago”. 2. The Agency's patient home packet was reviewed on 12/31/24 and has the Agency name as “Journey Care Home Health”. 3. The following clinical records were reviewed between 12/30/24 to 01/02/25 and contain PsOC with Agency name of “Apple Home Healthcare LLC”. Pt #1 SOC 09/28/23 Pt # 2 SOC 12/09/24 Pt # 3 SOC 11/12/24 Pt # 4 SOC 09/11/24 Pt # 5 SOC 12/29/24 Pt # 6 SOC 06/29/24 Pt # 7 SOC 03/20/24 4. During an interview with the Administrator on 01/02/24 at 10:30 AM, the Administrator confirmed the inconsistent use of Agency name.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records, and staff interviews, it was determined that 2 of 2 (Pts. # 6 and 7) discharge records, the Agency failed to complete and send a discharge summary to the primary care practitioner or other health care professional, within five (5) business days of discharge. 1. Pt.# 6 was admitted to Home Health Services on 06/29/24 with diagnosis of Chronic Obstructive Pulmonary disease, unspecified. The clinical record was reviewed on 12/31/24 and included a POC dated 06/29/24. A Visit Note Report dated 07/23/24 documents: visit type: PT Discharge from Agency signed by PT. The clinical record lacked evidence a discharge summary was sent to the Physician. 2. Pt. #7 was admitted to the Home Health Services on 03/20/24 with the diagnoses of: Malignant Neoplasm of Tail of Pancreas. The clinical record was reviewed on 12/31/24. The clinical record contained POC dated 03/20/24. The clinical record lacked a completed discharge summary. 3. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/31/24 between 11:30 AM and 1:00 PM.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care SN = Skilled Nurse RN = Registered Nurse POC = Plan of Care PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist HHA - Home Health Aide ST = Speech Therapy/Therapist MSW = Medical Social Worker AM = Morning PM = Afternoon, Evening EMR = Electronic Medical Record CDC = Centers for Disease Control COVID-19 = Coronavirus 2019 x = Times wk = Week PRN = As Needed

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on review of Agency in-service training, staff interview and clinical record review, it was determined the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. care and/or services. This was found in 14 of 17 (Pts. #3, 4, 10, 13, 14, 5, 6, 8, 15, 7, 12, 2, 9 and 17) clinical records reviewed. Pt. #2. SOC 10/7/21. Primary Diagnosis: Urinary Tract Infection. The clinical record was reviewed on 10/19/21 at 2:00 PM. The record included documentation the HHA provided service to the Pt. on 10/12/21 and 10/14/21. The record lacked documentation the Pt. was screened for signs and symptoms of COVID-19 prior to these visits. Pt. #9. SOC 9/26/21. Primary Diagnosis: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 10/18/21 at 1:00 PM. The record included documentation the OT provided twice weekly service to the Pt. from 9/28/21 to 10/14/21. The record lacked documentation the Pt. was screened for signs and symptoms of COVID-19 prior to these visits. The record also included documentation the PT provided service to the Pt. on 9/30/21. The record lacked documentation the Pt. was screened for signs and symptoms of COVID-19 prior to this visit. Pt. #17. SOC 11/25/20. Primary Diagnosis: Myalgia, Unspecified Site. The clinical record was reviewed on 10/18/21 at 3:00 PM. The record contained documentation the SN provided service on 11/25/20 and 12/4/20. The record lacked documentation the Pt. was screened for signs and symptoms of COVID-19 prior to these visits. The record also included documentation the PT provided service to the Pt. on 12/1/20 and 12/3/20. The record lacked documentation the Pt. was screened for signs and symptoms of COVID-19 prior to these visits. During meetings with the Director of Clinical Services and the Director of Clinical Services in Training on 10/20/21 from 11:20 AM, and 1:50 PM to 4:30 PM, the Director of Clinical Services confirmed the above findings. ___ Pt. #7. SOC 10/2/21. Primary Diagnosis: Cellulitis of Left Lower Limb. The clinical record was reviewed on 10/19/21 at 1:50 PM. The record included documentation the SN provided service once weekly on the week of 10/1/21 to 10/2/21 and three times weekly from 10/3/21 to 10/23/21. The record lacked documentation that during those dates, the Pt./caregiver were screened for signs and symptoms of COVID-19 prior to the visits. ___ Pt. #12. SOC 8/24/21. Primary Diagnosis: Mechanical Complication of Implanted Electronic Neurostimulator, Generator Sequela. The record included documentation the SN provided service three times a week from 8/29/21 to 10/26/21 and that the PT provided services twice weekly from 8/22/21 to 9/11/21 The record lacked documentation that during those dates, the Pt./caregiver were screened for signs and symptoms of COVID-19 prior to the visits. The same record also contained HHA visit notes indicating that services were provided once weekly from 9/17/21 to 10/16/21 and MSW notes indicating that services were provided for 8/30/21 and 9/15/21. The record lacked documentation that during those dates, the Pt./caregiver were screened for signs and symptoms of COVID-19 prior to the visits. x. Pt. #5. SOC 8/16/21. Primary Diagnosis: Anxiety Disorder. The clinical record was reviewed on 10/19/21 at 9:00 AM. The record includes documentation the OT provided service on 8/17/21, 8/19/21, and 8/26/21. The OT visit notes lacked documentation the OT screened the Pt. for COVID-19 symptoms prior to providing service on these dates. x. Pt. #6. SOC 8/19/21. Primary Diagnosis: Chronic Pain. The clinical record was reviewed on 10/19/21 at 10:00 AM. The record includes documentation the SN provided service on 8/19/21, 8/27/21, 9/3/21, 9/10/21, 9/13/21, 9/15/21, 9/17/21, 9/20/21, 9/22/21, 9/24/21, 9/27/21, 9/29/21, 10/01/21, 10/4/21, 10/6/21, 10/8/21, 10/11/21, 10/13/21, and 10/15/21. The SN visit notes lacked documentation the SN screened the Pt. for COVID-19 symptoms prior to providing service on these dates. x. Pt. #8. SOC 9/27/21. Primary Diagnosis: Bilateral Osteoarthritis of the knee. The clinical record was reviewed on 10/18/21 at 3:15 PM. The record includes documentation the PT provided service on 10/4/21, 10/6/21, and 10/11/21. The PT visit notes lacked documentation the PT screened the Pt. for COVID-19 symptoms prior to providing service on these dates. The MSW provided service on 9/28/21 and the visit note lacked documentation the MSW screened the Pt. for COVID-19 symptoms prior to providing service on this day. x. Pt. #15. SOC 7/24/21. Primary Diagnosis: Spinal Stenosis Lumbar region. The clinical record was reviewed on 10/18/21 at 2:13 PM. The record includes documentation the SN provided service on 7/24/21, 7/27/21, 7/30/21, 8/6/21, 8/9/21, 8/10/21, 8/17/21, 8/20/21, 8/26/21,9/1/21, 9/8/21, and 9/14/21. The SN visit notes lacked documentation the SN screened the Pt. for COVID-19 symptoms prior to providing service on these dates. The record includes documentation the PT provided service on 7/31/21, 8/2/21, 8/4/21, 8/5/21, 8/9/21, 8/11/21, 8/13/21, 8/17/21, 8/19/21, 8/24/21, 8/24/21, and 8/126/21. The PT visit notes lacked documentation the PT screened the Pt. for COVID-19 symptoms prior to providing service on these dates. Findings include: 1. The Agency’s staff education titled, “August 2020 In-service…” included: “CDC COVID-19 - symptoms for daily screening of patients and caregivers prior to visit. CDC Added Symptoms- Chills, Shaking chills, Headache, Sore Throat, New loss of taste and smell…” 2. During an interview with the Director of Clinical Services on 10/20/21 at 9:47 AM, the Director of Clinical Services stated: Staff are required to “call the Pt. before the visit, ask the COVID screening questions, and document this in their visit note, in the narrative or care plan section. 3. Pt. #3. SOC 10/31/20. Diagnoses: Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposed. The clinical record was reviewed on 10/19/21 at 9:30 AM. The record contained SN visit notes dated 9/2/21, 9/7/21, 9/9/21 and 9/16/21, indicating service was provided. These visit notes lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing service as required by the Agency. 4. Pt. #4. SOC 10/13/21. Primary Diagnosis: Displaced Subtrochanteric Fracture of Left Femur Sequela. The clinical record was reviewed on 10/19/21 at 9:15 AM. The record contained the SOC comprehensive assessment form completed by the SN and dated 10/13/21, indicating service was provided. The SOC assessment form lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to initiating service. 5. Pt. #10. SOC 6/28/21. Primary Diagnosis: Encounter for Change or Removal of Surgical Wound Dressing. The clinical record was reviewed on 10/18/21 at 12:35 PM. The record contained the SN recertification comprehensive assessment form dated 8/23/21; SN visit notes dated 8/24/21, 8/27/21, 9/3/21 and 9/9/21 which included documentation service were provided. The assessment form and SN visit notes lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing service. The record included the HHA visit notes, 1 to 2 times a week from 8/28/21 to 10/16/21 indicating care was provided. These visit notes lacked documentation the HHA screened the Pt. for COVID-19 symptoms, prior to providing service as required by the Agency. 6. Pt. #13. SOC 1/14/21. Primary Diagnosis: COVID-19. The clinical record was reviewed on 10/19/21 at 4:30 PM. The record contained a copy of the patient’s hospital progress note dated 1/12/21 which included: “COVID-19 positive 12/18/20 (per EMR). Has now completed 20 day quarantine…” The PT visit notes dated 1/19/21, 1/21/21, 2/9/21, 2/11/21, 2/18/21, 2/25/21, 3/2/21; and OT evaluation dated 1/15/21, OT visit notes dated 1/20/21, 1/22/21 and 1/27/21, indicating service was provided. These PT visit notes and OT evaluation lacked documentation, the PT and OT assessed whether the Pt. still exhibited COVID-19 symptoms, after the 20-day quarantine period. 7. Pt. #14. SOC 1/18/21. Primary Diagnosis: COVID-19. The clinical record was reviewed on 10/19/21 at 10:30 AM. The record contained a copy of the hospital Discharge Summary completed by a Physician and dated 1/16/21 which included, “Admission Date: 1/10/2021, Discharge Date: 01/16/21… Pneumonia due to COVID19 Infection: Onset: 1/5 Diagnosed: 1/10”. The record included the PT visit notes for 1 to 3 times a week from 1/21/21 to 3/10/21, and the PT discharge comprehensive assessment dated 3/15/21. These visit notes and the assessment lacked documentation, the PT assessed whether the Pt. still exhibited COVID-19 symptoms.

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 clinical record review and staff interview, it was determined the Agency failed to provide services ordered in the POC. This was found in 3 of 17 (Pts. #17, 12, and 10) clinical records reviewed. __. Pt. #10. SOC 6/28/21. Primary Diagnosis: Encounter for Change or Removal of Surgical Wound Dressing. The clinical record was reviewed on 10/18/21 at 12:35 PM. The record contained the POC effective 8/27/21 requiring: “Skilled Nursing 1 wk 1 wk; 3 wk 8 wk 2 PRN: Complications of wound status…” The record lacked documentation the SN provided a third visit during the weeks of 9/26/21 to 10/2/21, 10/3/21 to 10/9/21 and 10/10/21 to 10/16/21. __. During an interview with the Director of Clinical Services and the Director of Clinical Services in-training on 10/20/21 at 11:20 AM, 1:50 PM and 3:45 PM, the Director of Clinical Services confirmed Agency staff failed to provide service, as indicated on the POC. ___ Pt. #12. SOC 8/24/21. Primary Diagnosis: Mechanical Complication of Implanted Electronic Neurostimulator Generator Sequela. The clinical record was reviewed on 10/20/21 at 9:30 AM. The clinical record included documentation that Pt. #12 received skilled ST services 1 time a week for 5 weeks from 8/22/21 to 9/25/21. The record lacked an ST visit for the week of 9/5/21 to 9/11/21. The record lacked documentation that the physician was notified of the missed visit. 1. Pt. #17. SOC 11/25/20. Primary Diagnosis: Myalgia, Unspecified Site. The clinical record was reviewed on 10/18/21 at 3:00 PM. The record contained the POC effective 11/25/20 to 1/23/21. This POC included the Physician’s order: “Skilled Nursing 1 wk 3.” The record lacked an SN visit for the week of 12/6/20 to 12/12/20. The record also lacked documentation Pt. #17’s Physician was notified of this missed SN visit. The POC also included the Physician’s order: “Occupational Therapy 1 wk 1, 2 wk 3.” The record lacked documentation the Pt. received two visits for the week of 12/6/21 to 12/12/20, as well as for the week of 12/13/20 to 12/19/20. The record also lacked documentation Pt. #17’s Physician was notified of the missed OT visits. The POC also contained the Physician’s order for “Physical Therapy 2 wk 4.” The record lacked documentation the Pt. received two PT visits for the week of 12/13/20 to 12/19/20. The record also lacked documentation Pt. #17’s Physician was notified of the missed PT visits.

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: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure documentation pertaining to wounds was complete. This was found in 5 of 6 (Pts. #10, 6, 2. 7, and 12) clinical records reviewed of Pts. requiring wound care. ___ Pt. #7. SOC 10/2/21. Primary Diagnosis: Cellulitis of Left Lower Limb. The clinical record was reviewed on 10/19/21 at 1:50 PM. The clinical record included documentation that the RN was providing wound care from 10/2/21 to 10/16/21 but lacked documentation of wound measurement of the wound for the week of 10/3/21 to 10/9/21 and lacked documentation of the description of the wound from 10/2/21 to 10/16/21. ___ Pt. #12. SOC 8/24/21. Primary Diagnosis: Mechanical Complication of Implanted Electronic Neurostimulator Generator Sequela. The clinical record was reviewed on 10/20/21 at 9:30 AM. The clinical record included documentation that the RN was providing wound care from 8/22/21 to 10/16/21 but lacked documentation of wound measurements from 8/22/21 to 10/14/21. __The Agency Policy “Clinical Visit Documentation” was reviewed on 10/20/21 at 2:30 PM. The Policy requires, “Documentation of wound care treatments should include at least the following components: a. Measurements (At least weekly unless specific patient situation prevent measurement. b. Description of the wound (location, amount and color of exudate, condition of surrounding skin, any maceration, tunneling, presence of eschar, granulation status and c. Treatment provided. ___An interview was conducted with the Director for Clinical Services and Director for Clinical Services in Training on 10/20/21 at 11:20 AM, 1:50 PM to 4:30 PM. Both confirmed the above findings and stated the RN should accurately record the documentation of wound treatment. Pt. #2. SOC 10/7/21. Primary Diagnosis: Urinary Tract Infection. The clinical record was reviewed on 10/19/21 at 2:00 PM. The record contained the 10/18/21 SN note, which included “…Pt. says she has a new skin tear and doesn’t know how she got it…wound was cleansed with wound cleanser and dried with 2 x 2 gauze, with a 4 x 4 applied over the area and secured with paper tape…” This note described the wound as a “left lower leg skin tear” with a “small amount of sanguineous/bloody drainage.” The record lacked documentation of the wound measurements, Physician notification of the new wound, and Physician’s orders for subsequent wound treatment. x. Pt. #6. SOC 8/19/21. Primary Diagnosis: Chronic Pain. The clinical record was reviewed on 10/19/21 at 10:00 AM. The record included wound care documentation notes starting 9/10/21 to 10/13/21. The SN notes lacked documentation of the wound measurements; wound measurements were obtained until 10/15/21. Findings include: 1. Pt. #10. SOC 6/28/21. Primary Diagnosis: Encounter for Change or Removal of Surgical Wound Dressing. The clinical record was reviewed on 10/18/21 at 12:35 PM. The record contained the SN visit notes during the week of 9/12/21 to 9/18/21 (on 9/13/21, 9/15/21 and 9/17/21); week of 9/19/21 to 9/25/21 (on 9/20/21, 9/22/21 and 9/24/21); week of 10/3/21 to 10/9/21 (on 10/4/21 and 10/7/21); and the week of 10/10/21 to 10/16/21 (on 10/15/21). As of 10/18/21, the record lacked weekly measurements of the anal/rectal wound during the weeks of 9/12/21, 9/19/21, 10/3/21 and 10/10/21, as required by the Agency.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. 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 ensure Discharge Summaries were completed and sent to the Physician in a timely manner. This was found in 3 of 5 (Pts. #, 13, 14 and 17) closed records reviewed. Findings include: 1. Pt. #17. SOC 11/25/20. Primary Diagnosis: Myalgia, Unspecified Site. The clinical record was reviewed on 10/18/21 at 3:00 PM. The record contained a “Discharge Summary,” which documented the Pt. was discharged from the Agency on 12/15/20, and included “Summary: Patient was seen following hospitalization due to severe back pain. Re-hospitalized due to cardiac failure.” This discharge summary also contained “Physician Contacted: No” and “Patient Agreed: No.” This discharge summary was completed on 1/26/21, 42 days after the Pt. was discharged. The record also included the POC effective 11/25/20 to 1/23/21, which included the Physician’s order: “Physical Therapy 2 wk 4.” The record contained the PT provided service to the Pt. on 12/1/20 and 12/3/20. The record lacked a PT discharge summary. This POC also contained the Physician’s order: “Occupational Therapy 1 wk 1, 2 wk 3.” The record contained documentation the OT provided service on 12/1/20. The record lacked an OT discharge summary. __. Pt. #13. SOC 1/14/21. Primary Diagnosis: COVID-19. The closed clinical record was reviewed on 10/19/21 at 4:30 PM. The record contained the Agency’s Discharge Summary form (last skilled visit 3/2/21) completed by the RN on 10/18/21, and sent to the Physician on 10/18/21. This is over 7 months after the last skilled visit. The Agency failed to complete the Discharge Summary within 2 calendar days, and forward a copy of the Summary to the Physician within 5 business days of the Agency’s discharge, as required by the Agency. __. Pt. #14. SOC 1/18/21. Primary Diagnosis: COVID-19. The closed clinical record was reviewed on 10/19/21 at 10:30 AM. The record contained the Agency’s Discharge Summary indicating the last skilled visit was conducted on 3/15/21. The Discharge summary form was completed by the PT and dated 3/21/21 (6 days after the last skilled visit). The form was forwarded to the Physician on 10/8/21. This is over 6 months after the last skilled visit. The Agency failed to complete the Discharge Summary within 2 calendar days, and forward a copy of the Summary to the Physician within 5 business days of the Agency’s discharge. __. The Agency policy titled, “Discharge and Transfer of Patients” was reviewed on 10/20/21 at 3:25 PM. The policy required: “11. The Discharge, Transfer to Inpatient Facility, or Death at Home assessment shall be completed by a qualified clinician with two (2) calendar days of the discharge, transfer, or death at home… 12… a) A discharge summary shall be sent to the PCP or other healthcare professional who will be responsible for providing care to the patient after discharge within 5 business days of the discharge…” __. During an interview with the Director of Clinical Services and the Director of Clinical Services in-training on 10/20/21 at 11:20 AM and 1:50 PM, the Director of Clinical Services confirmed Agency staff failed to complete the discharge summary within 2 calendar days and/or forward to physician within 5 business days of the discharge date.