Every finding on record at Chicago Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/18/26. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 06/18/26, Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients RN = Registered Nurse SOC = Start of Care POC = Plan of Care

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 for the last 12 months and staff interview, the Agency failed to submit 70 of 631 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 06/16/25 to 06/16/26, was reviewed on 06/16/26. The report documented 70 of 631 (11.09 %) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator / Alternate Clinical Manager on 06/17/26 at 1:30 PM, the Administrator confirmed the above findings.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on Agency's admission folder review, clinical records review and staff interview, the Agency failed to provide patients a copy of the Agency's transfer and discharge policy on admission. 1. The Agency's patient admission folder was reviewed on 06/17/26. The admission folder lacked written information of the Agency's transfer and discharge policy. 2. The following clinical records were reviewed between 06/15/26 and 06/17/26 - Pt. #1 SOC 05/21/26 Pt. #2 SOC 04/14/26 Pt. #3 SOC 03/05/26 Pt. #4 SOC 04/15/26 Pt. #5 SOC 04/17/26 Pt. #6 SOC 02/05/26 Pt. #7 SOC 01/28/26 The clinical records lacked evidence that a copy of the Agency's transfer and discharge policy was provided to the patients/patient representative on admission. 3. During interviews with the Administrator and alternate Clinical Manager on 06/17/26 between 11:45 AM an 2:15 PM, the above finding was confirmed.

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: Based on a review of clinical records and staff interview, for 2 of 7 clinical record reviews, (Pts. #1 and 5), the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. Findings include: 1. Pt. #1 was admitted to home health on 05/21/26 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 06/16/26 and included the document “Encounter – Home Visit Date of Service: 05/01/26 (Pt. #1)", which was faxed to the Agency on 05/07/26. The initial comprehensive assessment was conducted by the RN on 05/21/26. The record lacked a specific Physician ordered SOC date. The record lacked documentation the Agency initiated services within 48 hours of the referral date. 2. Pt. #5 was admitted to home health on 04/17/26 with the diagnosis of Paraplegia. The clinical record was reviewed on 06/16/26 and included the document “Encounter – Home Visit Date of Service: 03/31/26 (Pt. #5)", which was faxed to the Agency on 04/02/26. The initial comprehensive assessment was conducted by the RN on 04/17/26. The record lacked a specific Physician ordered SOC date. The record lacked documentation the Agency initiated services within 48 hours of the referral date. 3. During an interview with the Administrator and Alternate Clinical Manager on 06/17/26 at 11:30 AM, the above findings were confirmed.

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 observation and interviews during home visits, clinical records review and staff interviews, for 3 of 7 Pts. (Pts. #1, 2 and 7), the Agency failed to ensure that the Plans of Care included all the requirements. 3. Pt. # 7 was admitted to home health services on 01/28/26 with Diagnoses: Low back pain and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 06/16/26, the clinical record included weekly SN visit notes for certification period 03/29/26 to 05/27/26 that include documented blood sugar assessments. The POC for same certification period lacked blood sugar parameters for patient and SN to follow. 4. During interviews on 06/17/26 between 11:45 AM and 1:30 PM with the Administrator and alternate Clinical Manager the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health on 05/21/26 with the diagnosis of Hypertensive Heart Disease with Heart Failure. A home visit was conducted with an RN on 06/15/26 and during the visit, the RN had asked Pt.’s family member if there was special footwear to support Pt. #1’s right foot due which had a fracture. Pt.#1’s family presented an orthotic shoe that was prescribed for Pt. #1 but stated that they were not using it because the straps were too long. The clinical record was reviewed on 06/16/26 and included a POC effective 05/21/26. The POC lacked documentation of the description of the footwear, its care and instructions for use. 2. Pt. #2 was admitted to home health on 04/14/26 with the diagnosis of Other Seizures. A home visit was conducted with the Home Health Aide (HHA) on 06/16/26 and during the visit, the HHA assisted Pt. #2 with a shower, and while in the bathroom, the HHA described the medical equipment Pt. #2 uses. Pt. #2’s bathroom was observed to have grab bars, a commode over the toilet and Pt. #2 was sitting on the shower bench. The clinical record was reviewed on 06/16/26 and included a POC effective 04/14/26. The POC lacked documentation of the above-mentioned DME (Durable Medical Equipment).

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical records reviews and staff interviews, for 3 of 7 clinical records reviewed (Pts. #1, 2 and 5), the Agency failed to ensure physician orders were followed. Findings include: 1. Pt. #1 was admitted to home health on 05/21/26 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 06/16/26 and included a physician order: “Assessment: …the following services are medically necessary home health services: Skilled Nursing…Physical Therapy…MSW (Medical Social Worker) …” The record lacked documentation that any Physical Therapy (PT) visits or MSW services were provided. 2. Pt. #2 was admitted to home health on 04/14/26 with the diagnosis of Other seizures. The clinical record was reviewed on 06/16/26 and included a physician order: “Home Health PT/OT/RN.” The record lacked documentation that any Occupational Therapy (OT) services were provided. 3. Pt. #5 was admitted to home health on 04/17/26 with the diagnosis of Paraplegia. The clinical record was reviewed on 06/16/26 and included a physician order: “Qualifying services: Skilled Nursing…Physical Therapy…Occupational Therapy…MSW…The record lacked documentation that any OT or MSW services were provided. 4. During an interview with the Administrator and Alternate Clinical Manager on 06/17/26 at 11:30 AM, the above findings were confirmed.

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 Agency's admission folder review and staff interview, the Agency failed to provide the name and contact information of the Clinical Manager to the patients on Admission. Findings include: 1. The Agency's patient admission folder was reviewed on 06/16/26, the admission folder did not include the name and contact information of the Agency Clinical Manager, to whom the patients can contact with any questions about their services. 2. During an interview with the Administrator and Alternate Clinical Manager on 06/17/26 at 1:45 PM, the above finding was confirmed.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 6/22/23. The Agency was not in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

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 the review of the Agency's Emergency Preparedness Plan, policy review, and Staff interview, it was determined that the Agency failed to have a communication plan that included an accurate list of required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/21/23. The plan lacked a communication plan that meets the following requirements: Current list of names and contact information for staff members and entities providing service under contract. 2. The Agency’s policy titled, “Emergency Preparedness Plan/Policy" was reviewed on 6/21/23. The policy required: "Planning: The Home Health Agency will keep and maintain a current information for staff…contact providers.” 3. During an interview with the Administrator and Alternate Director of Nursing on 6/21/23 at 2:45 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, and staff interview, it was determined the Agency failed to ensure the Agency conducted the required facility and community-based exercises to ensure the effectiveness of the Agency's Emergency Preparedness Plan. This has the potential to affect all patients receiving Home Health Care services. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/21/23. The Plan lacked documentation the Agency conducted testing of emergency preparedness procedures biannually. The Agency also was unable to provide documentation that full-scale or tabletop testing exercises were conducted for the years 2021 and 2022. 2. During an interview with the Administrator and the Alternate Director of Nursing on 6/21/23 at 2:45 PM, the Administrator confirmed the Agency failed to provide Emergency Preparedness testing of its Emergency Plan for the years 2021 and 2022.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirement on 6/22/23. Abbreviations: POC= Plan of Care Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Afternoon/ Evening RN= Registered Nurse SN = Skill Nurse PO = By mouth MG/mg = Milligram # = number

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 a review of clinical records, observation during home visits, and staff interviews, it was determined that the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 6/20/23 at 1:20 PM to 6/21/23 at 4:00 PM: Pt. #1. SOC 5/17/23. Pt. received SN, PT and Home Health Aide services. Pt. #2. SOC 6/12/23. Pt. received SN, PT and Home Aide services. Pt. #3. SOC 5/9/23. Pt. received SN and PT services. Pt. #4. SOC. Pt. received SN, PT and Home Health Aide services. Pt. #5. SOC 8/11/22. Pt. received SN and Home Health Aide services. Pt. #6. SOC 8/11/22. Pt. received SN service. Pt. #7. SOC 8/13/22. Pt. received SN service. The records lacked documentation that the Pt. or legal guardian was notified in writing of the services to be provided and the frequency. 2. The following home visits were conducted from 6/21/23 at 9:00 AM and 3:30 PM. Pt. #1. SOC 5/17/23. Pt. #2. SOC 6/12/23. Pt. #3. SOC 5/9/23. During the home visits, the patient's admission folder was observed and lacked documentation of the services provided, and the frequency of the visits. 3. The clinical record of Pt. #3 lacked a written service agreement. As of 6/21/23, the Agency was unable to provide a written agreement signed by Pt. #3, authorizing the Agency to initiate service on 5/9/23. 4. During interviews with the Administrator on 6/21/23 at 1:05 PM, the Administrator and the Alternate Director of Nursing on 6/21/23 from 2:00 PM to 3:15 PM, both confirmed the Agency does not inform Pts. in writing of the frequency of visits, failed to specify all disciplines to provide service, and that the Agency was unable to provide a written service agreement for Pt. #3.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. are advised of the extent of their financial liability for care, and/or services before care is initiated. This was found in 2 of 7 (Pts. #3 and 5) clinical records reviewed. 2. Pt. #5 was admitted for Home Health Services on 5/25/23 with diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 6/20/23. The record included the “Admission Service Agreement Home Health” which was signed by Pt. #5 at the start of care. The section with the statement “Liability of Payment” was left blank. The record lacked documentation of the patient’s financial liability. 3. The above findings were confirmed during an interview with the Administrator, Alternate Director of Director of Nursing on 6/21/23 from 1:05 PM to 3:15 PM. Findings include: 1. Pt. #3 was admitted to home health services on 5/9/23 with the primary diagnosis of Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. The clinical record was reviewed on 6/20/23 and lacked a written service agreement to start services on 5/9/23. During an interview with the Administrator on 6/21/23, the Administrator stated when a Pt. is admitted for service, it is the responsibility of the clinician to have the Pt. sign the form titled, "Admission Service Agreement Home Health", which includes the patient's financial liability. As of 6/21/23, the Agency lacked Pt. #3's Service Agreement form.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to ensure complete information regarding the State Hotline was provided to Pts. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The patient's admission folder was reviewed on 6/20/23 at 10:20 AM. The folder lacked the hours of operation and an address to forward a written complaint with the Illinois Department of Public Health. 2. The following clinical records were reviewed from 6/20/23 at 1:20 PM to 6/21/23 at 4:00 PM. The records lacked the hours of operation and an address to forward a written complaint with the Illinois Department of Public Health. Pt. #1. SOC 5/17/23. Pt. #2. SOC 6/12/23. Pt. #3. SOC 5/9/23. Pt. #4. SOC 4/27/23. Pt. #5. SOC 5/25/23. Pt. #6. SOC 8/11/22. Pt. #7. SOC 8/12/22. 3. The following home visits were conducted on 6/21/23 at 1:05 PM and 3:30 PM: Pt. #1. SOC 5/17/23. Pt. #2. SOC 6/12/23. Pt. #3. SOC 5/9/23. During the home visits, the Pt. admission folders were observed and lacked the hours of operation, and an address for which the Pt./patient's representative may submit a complaint in writing to the State Complaint Hotline. 4. During interviews with the Administrator on 6/21/23 from 1:05 PM to 3:15 PM, the Administrator confirmed the Agency failed to provide complete information regarding the State Hotline.

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: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 3 of 7 (Pts. #3, 4 and 6) clinical records reviewed. 3. Pt. #6. SOC 8/11/22. Primary Diagnosis: Non-Pressure Chronic ulcer of other part of lower leg with unspecified severity. The clinical record was reviewed on 6/21/23 and included a SOC comprehensive assessment dated 8/11/22. The record included a “Face to Face note” signed by Physician Assistant dated 8/2/22 with order for skilled nursing services. The Agency failed to start service within 48 hours of the face-to-face fax received by Agency on 8/3/22. 4. During an interview with the Administrator and the Alternate Director of Nursing on 6/21/23 from 1:00 PM to 3:15 PM, the Administrator confirmed that the patients should have been admitted within 48 hours of referral. Findings include: 1. Pt. #3 was admitted to home health services on 5/9/23 with the primary diagnosis of Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. The clinical record was reviewed on 6/20/23. The record contained the Physician's order/referral dated 3/15/23 and emailed to the Agency on 3/20/23, requiring the Pt. to receive SN and PT services. The SOC comprehensive assessment form completed by the RN was dated 5/9/23 (50 days after receiving the referral). As of 6/20/23, the record lacked documentation the Agency initiated service within 48 hours after receipt of the referral. 2. Pt. #4 was admitted to home health services on 4/27/23 with the primary diagnosis of (Left Shoulder Primary Osteoarthritis. The clinical record was reviewed on 6/20/23 and lacked a referral for the Agency to initiate service on 4/27/23. During an interview with the Administrator on 6/21/23 at 1:05 PM, a request was made to review the referral or Physician's order to initiate service on 4/27/23. The Administrator presented the "Face to Face encounter" dated and signed by the Physician on 4/17/23 and faxed to the Agency on 5/3/23. As of 6/20/23, the Agency lacked a referral/physician's order to initiate service on 4/27/23.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on a review of closed clinical records and staff interview, it was determined the Agency failed to ensure the comprehensive assessment was updated at discharge. This was found in 1 of 2 (Pt. #7) closed clinical records reviewed. Findings include: 1. Pt. #7 was admitted to Home Health Services on 8/13/22 with the primary diagnosis of Generalized Osteoarthritis. The clinical record was reviewed on 6/21/23. The record contained a Physician order dated 9/10/22, indicating Pt.#7 was discharged from the Agency. The record lacked documentation of an updated comprehensive assessment upon discharge. 2. During an interview with the Administrator and the Alternate Director of Nursing on 6/21/23 at 3:00 PM, it was confirmed the comprehensive assessment was not updated at discharge. During the same interview, the above finding was confirmed.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record and staff interviews, it was determined the Agency failed to obtain a physician order for the frequency of the Home Health Aide visits. This was found in 1 of 4 (Pt. #1) clinical record reviewed, wherein the Pt. received Home Health Aide services. Findings include: 1. Pt. #1 was admitted to Home Health Services on 5/17/23 with the primary diagnosis of General Osteoarthritis. The clinical record was reviewed on 6/21/23. The record included the Home Health Aide visit notes for services provided on 5/18/23, 5/25/23, 6/1/23, 6/8/23 and 6/15/23. As of 6/21/23, the record lacked documentation of a Physician order indicating the frequency of the Home Health Aide visits. 2. On 6/21/23 at 3:00 PM, during an interview conducted with the Administrator and Alternate Director of Nursing, it was stated that a Physician order is needed for the frequency of the Home Health Aide visits. During the same interview, the above finding was confirmed.

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: Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to fully assess Patients' Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency. This was found in 3 of 7 (Pts. #3, 1 and 5) records reviewed. 2. Pt. #1 was admitted to Home Health Services on 5/17/23 with primary diagnosis of General Osteoarthritis. The clinical record was reviewed on 6/21/23. The record included a form “Flu/Pneumonia Vaccine” dated 5/17/23. The form lacked information on influenza and pneumonia status of Pt. #1. 3. Pt. #5 was admitted to Home Health Services on 5/25/23 with primary diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 6/20/23. The record included the form “Flu/Pneumonia Vaccine” dated 5/25/23. The form lacked information on influenza and pneumonia status of Pt. #5. 4. The Agency Policy “Vaccination” which was reviewed on 6/22/23 required: “Upon initiation of home health services, the admitting clinician will complete an assessment to determine the patient’s influenza and pneumococcal vaccination status. The clinician will assess for indications and contraindications and advise the patient of the CDC recommendations. A form shall be completed indicating the need, patient response, and follow-up activities and included in the patient’s medical record." 5. During an interview with the Administrator and Alternate Director of Nursing on 6/21/23 from 1:05 PM to 3:15 PM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to home health services 5/9/23 with the primary diagnosis of Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. The clinical record was reviewed on 6/20/23. The record lacked any documentation indicating the SN assessed the patient's need to receive the Influenza and Pneumococcal Pneumonia vaccines. During an interview with the Administrator on 6/21/23 at 1:05 PM, the Administrator was unable to provide the Agency's Influenza and Pneumococcal Pneumonia form and stated the SN for Pt. #2 had not submitted the form.

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 a review of the Agency's Pt. admission folder, observation and interview during home visits, clinical record review and staff interview, it was determined the Agency failed to provide information regarding the Director of Nursing. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 6 and 7) clinical records reviewed. Findings include: 1. The patient's admission folder was reviewed on 6/20/23 at 10:20 AM. The folder lacked the name and contact information of the Director of Nursing (Clinical Manager). 2. The following home visits were conducted on 6/21/23 at 9:00 AM and 3:30 PM: Pt. #1. SOC 5/17/23. Pt. #2. SOC 6/12/23. Pt. #3. SOC 5/9/23. During the home visits, the patient's admission folder was observed and lacked the name and contact information of the Director of Nursing. During the home visits interviews were conducted, and the Pt./patient's representative did not know the name and contact information of the Director of Nursing. 3. The following clinical records were reviewed from 6/20/23 at 1:20 PM to 6/21/23 at 4:00 PM and lacked the name and contact information of the Agency Supervisor. Pt. #1. SOC 5/17/23. Pt. #2. SOC 6/12/23. Pt. #3. SOC 5/9/23. Pt. #4. SOC 4/27/23. Pt. #5. SOC 5/25/23. Pt. #6. SOC 8/11/22. Pt. #7. SOC 8/13/22. 4. During interviews with the Administrator on 6/21/23 at 1:05 PM, the Administrator and the Alternate Director of Nursing on 6/21/23 from 2:00 PM to 3:15 PM, both confirmed the Agency failed to provide Pts. with the name and contact information of the Director of Nursing.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the RN conducted Home Health Aide supervisory visits every 14 days. This was found in 3 of 4 (Pts. #1, 5 and 4) clinical records reviewed, wherein the Pt. received Home Health Aide services. 3. Pt. #4 was admitted to home health services 4/27/23 with the primary diagnosis of Left Shoulder Primary Osteoarthritis. The clinical record was reviewed on 6/20/23. The record contained the Home Health Aide visit notes for 2 times a week from 5/2/23 to 6/8/23 which included documentation that personal care was provided. As of 6/20/23, the record lacked documentation the RN conducted any Home Health Aide supervision between 5/2/23 to 6/8/23 (total of 37 days without Aide supervision). 4. During interviews with the Administrator on 6/21/23 at 1:05 PM, the Administrator and Alternate Director of Nursing on 6/21/23 at 2:30 PM, both confirmed the RN failed to supervise the Home Health Aide every 14 days. Findings include: 1. Pt. #1 was admitted to Home Health Services on 5/17/23 with primary diagnosis of General Osteoarthritis. The clinical record was reviewed on 6/21/23. The record included the Home Health Aide visit notes for services provided on 5/18/23, 5/25/23, 6/1/23, 6/8/23 and 6/15/23. The record lacked documentation an RN conducted any Home Health Aide Supervision. 2. Pt. #5 was admitted to Home Health Services on 5/25/23 with primary diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 6/20/23. The record included the Home Health Aide visit notes dated 5/31/23, 6/7/23 and 6/14/23. The record lacked documentation an RN conducted any Home Health Aide Supervision. 3. During an interview with the Administrator and the Alternate Director of Nursing on 6/21/23 at 3:00 PM, it was stated that when Home Health Aide services are ordered, the intake generates a Home Health Aide task for the RN to complete. During the same interview, the Administrator stated that it was not generated for Pts. #1, 4 and 5.

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 observations and interviews during home visit, review of clinical records and staff interview, it was determined the Agency failed to ensure the information contained in the clinical records were accurate. This was found in 2 of 7 (Pts. #1 and 3) clinical records reviewed. 2. Pt. #3 was admitted to home health services 5/9/23 with the primary diagnosis of Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. The clinical record was reviewed on 6/20/23. The record contained the form titled; "Medication Profile" completed by the RN for the certification period of 5/9/23 to 7/7/23. The form included: "Meloxicam 15 MG Oral Tablet 1 tablet Daily as needed By mouth (PO), Simvastatin 20 MG Oral Tablet 1 tablet Bedtime by mouth (PO)". A home visit was conducted with Employee #10 on 6/21/23. During the home visit, a list of the patient's medications created by the family was present and observed. The patient's medications were observed and cross-checked with the medications recorded on the patient's personal medication list and the Agency's "Medication Profile" effective 5/9/23, and an interview was conducted with Pt. #3. Observed four (4) prescription bottles dated "12/7/22, 2/14/23, 3/20/23 and 4/24/23" all were labeled, Meloxican 7.5 MG Tablet Take 1 tablet by mouth every day. The patient reported that Simvastatin was discontinued and stated, "It's been a long time since I've taken that". Simvastatin was not on the patient's personal medication list. Observed a prescription bottle labeled Furosemide 20 MG Tablet Take 1 tablet my mouth every day, the bottle had "Date filled: 6/23/22", the Pt. stated that's my water pill, I've been taking that for a long time." Lasix (also called Furosemide) was on the patient's personal medication list. During the same interview with Pt. #3, the Pt. pointed at her (personal) medication list created by her family and stated: "These are all the medicines I should be taking, right here on this list.... (her family) fill my pillbox... sometimes the nurse fill my pillbox too, but only with these pills (pointing at the medication list created by her family). As of 6/20/23, the Medication Profile form lacked Furosemide, the correct dose of Meloxican and included Simvastatin (a medication the Pt. no longer take). 3. During interviews with the Administrator on 6/21/23 at 1;05 PM, the Administrator and Alternate Director of Nursing on 6/21/23 at 2:30 PM, both confirmed the Agency's Medication Profile forms indicated above were inaccurate. Findings include: 1. Pt. #1 was admitted to Home Health Services on 5/17/23 with primary diagnosis of General Osteoarthritis. A home visit was conducted on 6/21/23 at 9:00 AM with the Home Health Aide (E#4). During the home visit, Pt#1's medications were reviewed. The following medication bottles were found at Pt #1’s home: Amoxicillin 500 mg take 1 tablet by mouth every 8 hours for 90 days (bottle dated 6/8/23) and Ibuprofen 600 mg take 1 capsule by mouth every 6 hours as needed. During the home visit, E#4 stated Pt. #1 takes Ibuprofen occasionally as needed for pain. The clinical record was reviewed on 6/21/23 and included a form “Medication Profile” for the episode/period of 5/17/23 to 7/15/23. The “Medication Profile” form listed the medication Amlodipine 10 mg take 1 tablet by mouth daily, but the medication bottle at Pt. #1’s home was labeled Amlodipine 5 mg take 1 tablet by mouth daily. The “Medication Profile” also did not include the medications Amoxicillin and Ibuprofen which were found at Pt. #1’s home. The Medication Profile was not complete and accurate.

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 interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. 2. Pt. #7 was admitted to Home Health Services on 8/13/22 with diagnosis of Generalized Osteoarthritis. The clinical record was reviewed on 6/21/23. The record contained a Physician order dated 9/10/22, indicating Pt.#7 was discharged from the Agency. The clinical record lacked documentation the Agency sent a copy of the discharge summary was sent to the physician. 3. During an interview with the Administrator and the Alternate Director of Nursing on 6/21/23 at between 2:00 PM to 3:00 PM, the above findings were confirmed. 1.. Pt. #6. SOC 8/11/22. Primary Diagnosis: Non-Pressure Chronic ulcer of other part of lower leg with unspecified severity. The clinical record was reviewed on 6/21/23 and included a Physician order dated 11/8/22 to discharge Pt. from Agency. The clinical record lacked documentation a discharge summary copy was sent to the physician.