Every finding on record at Chicagoland Home Health Provider, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/31/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/31/25. Standard level deficiencies were cited. Abbreviations: Pt./Pts. = Patient/Patients HHA = Home Health Aide SOC = Start of Care RN = Registered Nurse AM = Morning PM = Afternoon SN = Skilled Nursing % = Percent 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 review of the Error Summary report and staff interview, it was determined that in 233 of 705 reports submitted for the last 12 months, the Agency failed to submit the report within 30 days after the assessment was completed resulting in a warning. Findings include: 1. The OASIS Error Summary report for 10/01/24 to 12/19/25 was reviewed on 12/29/25. The report included a warning for the error of 233 of the 705 assessments were submitted late; 33.05% of the OASIS reports were submitted more than 30 days after the assessment was completed. 2. During staff an interview with the Director of Nursing, on 12/31/25 at 9:30 AM, the above findings were confirmed.

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, Agency policy, and staff interview, in 2 of 7 (Pts. #4 and 6) clinical records reviewed, the Agency failed to obtain consent for treatment prior to providing Pt. care and/or services. Findings include: 1. Pt. #4 was admitted for Home Health service on 11/25/25 with the diagnosis of, but not limited to, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 12/30/25. The clinical record contained the SOC assessment completed by the SN and dated 11/25/25, weekly SN visit notes from 12/04/25 to 12/18/25, PT evaluation dated 12/06/25, and weekly PT visit notes from 12/13/25 to 12/21/25. As of 12/30/25, the clinical record lacked a consent for treatment. 2. Pt. #6 was admitted for Home Health service on 08/25/25 with the diagnosis of, but not limited to, Muscular Dystrophy Unspecified. The clinical record was reviewed on 12/29/25. The clinical record contained the SOC assessment form completed by the PT and dated 08/25/25; PT and/or PTA visit notes for 1 to 2 times a week from 09/03/25 to 09/17/25, and 09/26/25 to 10/21/25; PT re-assessment form dated 09/19/25, weekly Home Health Aide visit notes from 08/29/25 to 10/21/25, and the Agency’s discharge assessment form completed by the PT on 10/27/25. As of 12/29/25, the clinical record lacked a consent for treatment. 3. The Agency policy titled; “Consent” was reviewed on 12/30/25 at 12:45 PM. The policy included, “…1. All care provided by the Agency requires consent for care. 2. At time of admission, the RN or appropriate therapist will obtain consent for care…” 4. During an interview with the Director of Nursing on 12/30/25 at 12:30 PM, the Director of Nursing confirmed the Agency failed to obtain consent for treatment.

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 staff interview, and a review of clinical records, in 3 of 7 (Pts. #4, 7, and 3) clinical records reviewed, the Agency failed to assess the patient’s need for the Pneumonia and/or Influenza vaccines. Findings include: 1. During the entrance interview with the Director of Nursing on 12/29/25 at 9:30 AM, the Director of Nursing stated that during the SOC visit, the clinician (RN or PT) is required to assess the patient’s need for the Pneumonia and Influenza vaccines during the SOC visit. The patient/patient’s caregiver response is documented on a standardized form which is entered in the patient’s clinical record. 2. Pt. #4 was admitted for Home Health service on 11/25/25 with the diagnosis of, but not, limited to, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 12/30/25. As of 12/30/25, the clinical record lacked documentation the admitting clinician (RN) assessed the patient’s need for the Pneumonia and Influenza vaccines. 3. Pt. #7 was admitted for Home Health service on 03/14/25 with the diagnosis of, but not, limited to, Constipation Unspecified. The closed clinical record was reviewed on 12/29/25. As of 12/29/25, the closed clinical record lacked documentation the admitting clinician (RN) assessed the patient’s need for the Pneumonia vaccine. 4. During an interview with the Director of Nursing on 12/30/25 at 12:30 PM, a request was made to review the Agency’s policy pertaining to Pneumonia and Influenza vaccinations of Pts. As of 12/30/25, the Agency was unable to provide a policy. 5. Pt. #3 was admitted for Home Health services on 08/27/25 with the diagnosis of Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only. The clinical record was reviewed on 12/29/25. As of 12/29/25, the clinical record lacked documentation of Pneumococcal inquiry and or the patient’s need for the Pneumonia vaccine. 6. During an interview with the Director of Nursing on 12/30/25 at 12:30 PM and 1:45 PM, the Director of Nursing confirmed the above findings. Findings include: 1. During the entrance interview with the Director of Nursing on 12/29/25 at 9:30 AM, the Director of Nursing stated that during the SOC visit, the clinician (RN or PT) is required to assess the patient’s need for the Pneumonia and Influenza vaccines during the SOC visit. The patient/patient’s caregiver response is documented on a standardized form which is entered in the patient’s clinical record. 2. Pt. #4 was admitted for Home Health service on 11/25/25 with the diagnosis of, but not limited to, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 12/30/25. As of 12/30/25, the clinical record lacked documentation the admitting clinician (RN) assessed the patient’s need for the Pneumonia and Influenza vaccines. 3. Pt. #7 was admitted for Home Health service on 03/14/25 with the diagnosis of, but not limited to, Constipation Unspecified. The closed clinical record was reviewed on 12/29/25. As of 12/29/25, the closed clinical record lacked documentation the admitting clinician (RN) assessed the patient’s need for the Pneumonia vaccine. 4. Pt. #3 was admitted for Home Health services on 08/27/25 with the diagnosis of Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only. The clinical record was reviewed on 12/29/25. As of 12/29/25, the clinical record lacked documentation of Pneumococcal inquiry and or the patient’s need for the Pneumonia vaccine. 5. During an interview with the Director of Nursing on 12/30/25 at 12:30 PM, a request was made to review the Agency’s policy pertaining to Pneumonia and Influenza vaccinations of Pts. As of 12/30/25, the Agency was unable to provide a policy. 6. During an interview with the Director of Nursing on 12/30/25 at 12:30 PM and 1:45 PM, the Director of Nursing confirmed the above findings.

If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) The supervisory assessment must be completed onsite (that is, an in person visit), or on the rare occasion by using two-way audio-video telecommunications technology that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed 1 virtual supervisory assessment per patient in a 60-day episode. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, in 1 of 1 (Pt. #6) clinical record reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure onsite supervision was conducted. Findings include: 1. Pt. #6 was admitted for Home Health service on 08/25/25 with the diagnosis of, but not limited to, Muscular Dystrophy Unspecified. The clinical record was reviewed on 12/29/25. The clinical record contained documentation that PT and Home Health Aide services were provided during the certification period of 8/25/25 to 10/23/25. The Home Health Aide provided service weekly from 08/29/25 to 10/21/25. The Home Health Aide supervisory visit notes completed by the PT and dated 09/12/25, 09/26/25, and 10/10/25 included documentation that there was “Telephone feedback” from the Pt. and/or family member. The clinical record lacked documentation that the PT conducted Home Health Aide supervision in-person. 2. During an interview with the Director of Nursing on 12/30/25 at 12:30 PM, the Director of Nursing confirmed the Agency failed to ensure onsite Home Health Aide supervision was conducted.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: CMS = Centers for Medicare and Medicaid Services CDC = Centers for Disease Control and Prevention COVID- 19 = Coronavirus Disease 2019 PT = Physical Therapy/Physical Therapist PTA = Physical Therapist Assistant RN = Registered Nurse Pt/Pts = Patient/Patients

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: A. Based on review of Agency’s Emergency Operations Plan, Agency In-service Binder and Staff interview, it was determined that the Agency failed to conduct staff training relative to Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s undated Emergency Operations Plan was reviewed on 10/12/2022 at 2:00 PM. The undated “Emergency Operations Plan” included “…15. All new staff will be oriented to the emergency operations plan. Ongoing staff education will occur annually…” The records lacked documentation that the Agency conducted staff training after 2019 pertaining to Emergency Preparedness Disaster Plan. 2. On 10/12/22 at 3:00 PM, during interview with the Assistant Administrator, it was confirmed that the Agency failed to provide staff training regarding the Emergency Preparedness Disaster Plan.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: CMS = Centers for Medicare and Medicaid Services CDC = Centers for Disease Control and Prevention COVID- 19 = Coronavirus Disease 2019 PT = Physical Therapy/Physical Therapist PTA = Physical Therapist Assistant RN = Registered Nurse Pt/Pts = Patient/Patients

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on the clinical record review and Staff interviews, it was determined the Agency failed to ensure the Patients were assessed within 48 hours of the referral. This was found in 3 of 7 records (Pts. #3, 2 and 4) reviewed. Findings include: 1. Pt. #3 SOC 05/02/22 Diagnosis: Acute on chronic diastolic (congestive) heart failure. The clinical record was reviewed on 10/12/22 at 8:30 AM and included a late RN assessment dated 05/02/22. The record included a referral date of 04/29/22 (more than 48 hours). 2. Pt. #2 SOC 09/02/22 Diagnosis: Muscular Dystrophy. The clinical record was reviewed on 10/11/22 at 12:00 PM. The record included a referral order for Physical Therapy dated 08/27/22. The clinical record documented a late Physical Therapist assessment dated 09/02/22 (more than 48 hours of referral). 3. Pt. #4 SOC 08/25/22 Diagnosis: Type 2 Diabetes. The clinical record was reviewed on 10/11/22 at 3:00 PM. The record included a referral for Occupational Therapist dated 08/17/22. The clinical record documented a late Occupational Therapist assessment dated 08/25/22 (more than 48 hours of referral). 4. During interviews with the Assistant Administrator and Director of Nursing on 10/12/22 at 2:00 PM and on 10/13/22 at 9:30 AM, the Assistant Administrator confirmed that the initial assessments for the patients mentioned above was more than 48 hours of referral.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on the Staff interviews, review/observation of vaccination records, policy review, observations and review of CMS rules, it was determined the Agency failed to follow the vaccination policy and failed to require weekly COVID-19 testing results of the non-vaccinated Employee. This was found in 1 of 13 (Employee #16) providing Patient Care. Findings include: 1. On 10/11/22 at 10:20 AM, during the interviews with the Assistant Administrator and Director of Nursing (Employee #16), it was stated that Employee #16 (religious exemption) was not vaccinated and provides care to 8 patients. 2. On 10/11/22 at 1:00 PM, the Agency’s vaccination records were reviewed and lacked the required documentation to verify the proof of the weekly COVID-19 test results for Employee #16 (hired: 08/21/22). 3. On 10/11/22 at 1:30 PM, the Agency’s policy titled “COVID-19 Mandatory Vaccination Policy” was reviewed and required: “…24. Staff who are not fully vaccinated will be required to: Be reassigned to non-patient care areas ….be tested at least weekly… “Use a NIOSH-approved N95 or equivalent or higher-level respirator…” 4. It was observed on 10/11/22 between 10:20 AM – 3:30 PM, Employee #16 was not following precautions of wearing the required mask included in the Agency’s policy titled “COVID-19 Mandatory Vaccination Policy” (“NIOSH- approved N95 or equivalent or higher-level respirator”). It was also observed that the Agency lacked documentation of orienting or providing Employee #16 with the approved N95 masks or equivalent or higher-level respirator. 5. On 10/11/22 at 1:30 PM, the CMS rule was reviewed and expects “all providers’ and suppliers’ staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute noncompliance under the rule.” 6. On 10/11/22 at 2:45 PM, during the interview with the Director of Nursing and Assistant Administrator, it was confirmed, that the vaccination policy was not followed and the documentation of the weekly COVID-19 test results were not met.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: A. Based on the clinical record review, contract review and Staff interviews, it was determined the Agency failed to ensure the PTA was supervised every 4-6 visits. This was found in 1 of 3 records (Pts. #3) reviewed with the PTA services. Findings include: 1. Pt. #3 SOC 05/02/22 Diagnosis: Acute on chronic diastolic (congestive) heart failure. The clinical record was reviewed on 10/12/22 at 8:30 AM. The record included a PT visit dated 05/05/22 and 7 PTA visits (05/07, 05/10, 05/13, 05/17, 05/20, 05/25, and 05/27/22). The record lacked the PTA supervision by the PT every 4-6 visits. 2. On 10/12/22 at 1:00 PM, the therapy contract (Contract A) was reviewed and failed to specify the State requirements for the PTA supervision. 3. On 10/12/22 at 2:00 PM, during the interview with the Assistant Administrator and Director of Nursing, it was confirmed the PTA was not assessed every 4-6 visits.

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: A. Based on the clinical record review and Staff interviews, it was determined the Agency failed to ensure the Aide was supervised every 14 days by the RN. This was found in 3 of 4 records (Pts. #3, 2 and 6) reviewed with the Aide services. Findings include: 1. Pt. #3 SOC 05/02/22 Diagnosis: Acute on chronic diastolic (congestive) heart failure. The clinical record was reviewed on 10/12/22 at 8:30 AM and lacked the Aide supervision every 14 days. The Aide provided care 05/05, 05/13, 05/19/22. The RN documented a supervisory visit on 05/24/22 (more than 14 days). 2. Pt. #2 SOC 09/02/22 Diagnosis: Muscular Dystrophy. The clinical record was reviewed on 10/11/22 at 12:00 PM. The clinical record documented Home Health Aide visits 1 time a week for 8 weeks for period of 09/02/22 to 10/31/22. The record lacked documentation any Home Health Aide supervision after 9/23/22. 3. Pt. # 6 SOC 01/04/22 Diagnosis: Osteoarthritis. The clinical record was reviewed on 10/12/22 at 10:30 AM. The clinical record documented Home Health Aide visits 1 time a week for 9 weeks for period of 07/03/22 to 08/31/22. The record included a blank “HHA Supervisory Visit” form dated 07/19/22. 4. During interviews with the Assistant Administrator and Director of Nursing on 10/12/22 at 2:00 PM and on 10/13/22 at 9:30 AM, the Assistant Administrator confirmed the above findings.

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 and staff interview, it was determined the Agency failed to ensure the clinical record contained documentation relative to the patient’s response to interventions. This was found in 4 of 7 (Pts. # 2, 4, 3 and 7) clinical records reviewed. 3. Pt. #3 SOC 05/02/22 Diagnosis: Acute on chronic diastolic (congestive) heart failure. The clinical record was reviewed on 10/12/22 at 8:30 AM. The RN failed to document the patient’s weight and the patient/family responses for the visit dated 05/10/22 and 09/07/22. 4. Pt. #7 SOC 04/25/22 Diagnosis: Unspecified Cirrhosis of Liver. The clinical record was reviewed on 10/12/22 at 10:30 AM. The RN failed to document the patient/family responses regarding the delay of the initial Aide visit. 5. On 10/12/22 at 2:00 PM and on 10/13/22 at 9:30 AM, during the interviews with the Assistant Administrator and Director of Nursing, the above findings were confirmed. 1. Pt. #2 SOC 09/02/22 Diagnosis: Muscular Dystrophy. The clinical record was reviewed on 10/11/22 at 12:00 PM. The Start of Care (SOC) assessment with a drug regimen review dated 09/02/22 was completed by the Physical therapy. The record also included a “Medication Profile” effective 09/02/22 but lacked documentation of the clinician signature and date of review. The records lacked documentation of drug interactions review by a nurse. 2. Pt. #4 SOC 08/25/22 Diagnosis: Type 2 Diabetes. The clinical record was reviewed on 10/11/22 at 3:00 PM. The Start of Care (SOC) assessment with a drug regimen review dated 08/25/22 was completed by the Occupational therapy. The record also included a “Medication profile” that was signed and dated by an Occupational therapist. The records lacked documentation of drug interactions review by a nurse.