Every finding on record at Egyptian Health Department

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey, on 01/24/25. 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 01/24/25. The Home Health Agency was not in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies, for this survey.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on document review and interview, it was determined the Home Health Agency failed to implement and maintain an infection control program to identify, prevent, control, monitor and track infectious diseases. Findings Include: 1. On 1/22/25, a document titled, “Tracking of Infections” was reviewed. It noted, “Policy: It is the policy of the (name of facility) Home Health to identify, track and prevent home care acquired infections among our patients and staff. We will set forth surveillance and tracking efforts to help prevent such transmission. Procedure: …3. The Infection Control Nurse will log ALL reported infections on the Home Health Infection Control Log. 4. This log will be reviewed quarterly by the Infection Control Nurse, the Home Health Director and the Home Health Administrator to make sure all follow-up was completed, and all data is current and available for reports. 5. This data will also be given to the Home Health Director for use in Quality Assessment and Performance Improvement…” 2. On 1/22/2024 at approximately 1:30 PM, an interview was conducted with the Home Health Director [Employee (E#3)]. E #3 agreed that the agency does not have an individualized infection control program and was not aware of the “Home Health Infection Control Log” that the agency has in their documents and policies.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 02/02/2022. The Facility was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP), for this survey.

A recertification survey was conducted on 2/2/22. The Facility was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: #-number DNR-Do Not Resuscitate E-employee HHA-home health agency IDPH-Illinois Department of Public Health POC-plan of care Pt-patient

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) 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. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on document review and staff interview it was determined for 2 of 2 (Pt #2, Pt #7) Do-Not-Resuscitate (DNR) records reviewed, the home health agency (HHA) failed to ensure a written notice of advance directives regarding the Uniform DNR form was completed per policy. This has the potential to effect all patients receiving services-current census-35. Findings include: 1. On 2/1/22, the undated policy titled, "ADVANCE DIRECTIVES" was reviewed. Under "PROCEDURE 1. On admission to Home Health each patient is given a copy of the statement of Illinois Law on Advance Directives and DNR orders. 3. The patient is provided with a copy of the Illinois Department of Public Health (IDPH) Uniform Do-Not-Resuscitate (DNR) Advance Directive, Guidance for Individuals during the initial nursing assessment. a. Uniform Do-Not-Resuscitate (DNR) form Completion and signatures are indicated only when the patient indicates desire for other than "Full Code Status"." 2. On 2/1/22, the clinical record of Pt #2 was reviewed. Pt #2 was admitted for services on 7/23/20 with diagnosis of venous insufficiency. The physician plan of care (POC) 1/14/22-3/14/22 was reviewed on 2/1/22. The POC indicated under "Advance Directives" Pt #2 was DNR status effective 1/11/22. The clinical record lacked documentation that the Uniform Do-Not-Resuscitate form was completed. 3. On 2/1/22, the clinical record of Pt #7 was reviewed. Pt #7 was admitted for services on 11/10/21 with diagnosis fatigue fracture vertebrae. The POC 1/9/22-3/9/22 indicated under "Advance Directives" Pt #7 was DNR status effective 11/10/21. The clinical record lacked documentation that the the Uniform Do-Not-Resuscitate form and was completed. 4. On 2/1/22 at 3:00 PM, an interview with the home health director (E# 1) was conducted. E#1 reviewed the clinical records of Pt #2 and Pt #7. E#1 confirmed the Uniform D0-Not-Reuscutate form was not completed on Pt #2 and Pt #7.