Every finding on record at Eh Home Health of the Midwest LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 10/18/24. 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 10/18/24. Standard deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon LPN = Licensed Practical Nurse RN = Registered Nurse SN = Skilled Nurse # = number % = percent > = greater than RBS = Random Blood Sugar FBS = Fasting Blood Sugar Ag = Silver POC / PsOC = Plan of care / Plans of Care SOC = Start of care PT = Physical Therapy/Therapist PTA = Physical Therapy Assistant OT = Occupational Therapy/Therapist ST = Speech Therapy/ Therapist OASIS = Outcome and Assessment Information Set CDC = Centers for Disease Control and Prevention OSHA = Occupational Safety and Health Administration HIV = Human Immunodeficiency Virus MSWA = Medical Social Worker Assistant MSW = Medical Social Worker CEDA = Community and Economic Development Association of Cook County, Inc LIHEAP = Low-Income Home Energy Assistance Program

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 Error Summary report and staff interview, it was determined in 116 of 1960 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 07/2023 to 06/2024, was reviewed on 10/15/24 at 11:30 AM. The report included error # -3330 for 116 of 1960 late submissions, 5% of the OASIS reports submitted, were more than 30 days after the M0090. 2. During an interview with the Administrator and the Director of Nursing on 10/17/24 at 10:30 AM, it was confirmed that the error occurred.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview, it was determined in 5 of 17 (Pts. #2, 17, 1, 7 and 11) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 4. Pt. #7 was admitted to Home Health Services on 9/11/24 with the diagnoses of: Unspecified Atrial Fibrillation, Hypertensive Heart Disease with Hear Failure and Type 2 Diabetes Mellitus. The clinical record was reviewed on 10/16/24. The clinical record contained a POC dated 9/11/24, required: “….Skilled nurse to observe/assess cardiovascular status related to heart failure. SN may provide teaching/reinforcement including some or all of these best practices: vital sign monitoring, daily weights…Licensed professional to report vital signs falling outside the following established parameters:….weight > 170 RBS 180….” The SN visit notes dated 9/23/24 and 10/2/24, lacked a weight assessment, to report to Physician as ordered. The SN visit notes from 9/11/24 to 10/10/24, lacked blood sugar assessments, to report to Physician if falling outside established parameters as ordered. 5. Pt. #11 was admitted to Home Health Services on 7/10/24 with the diagnoses of: Parkinson’s disease without Dyskinesia and Type 2 Diabetes Mellitus with Other Circulatory Complications. The clinical record was reviewed on 10/16/24. The clinical record contained a POC dated 9/8/24, required: “Licensed Professional to report vital signs falling outside the following established parameters: …. FBS 350 RBS 350….” The PT/ PTA notes from 8/20/24 to 10/8/24, lacked blood sugar assessments to report to physician if falling outside the established parameters as ordered. 6. During interviews with the Regional Vice President, Administrator and Director of Nursing on 10/17/24 between 12:00 PM to 1:30 PM, the Administrator and Director of Nursing confirmed the above findings. 3. Pt. #1 was admitted to Home Health Services on 9/27/24 with the diagnoses of: Parkinson's Disease, Type 2 Diabetes Mellitus with other Circulatory Complications. The clinical record was reviewed on 10/15/24. The clinical record contained a POC dated 09/27/24 with only PT, OT, ST (Speech Therapy) services. The POC required Licensed Professional to report fasting blood sugar or random blood sugar less than 70 or greater than 180. The weekly PT, OT and ST visits starting week 1 of certification period lack blood sugar assessment. Findings include: 1. Pt. #2 was admitted to the Home Health Services on 09/28/24 with the diagnosis of: Sepsis due to Escherichia Coli and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 10/15/24. The POC dated 09/28/24, required the SN to assess the patient’s blood glucose 1 time a week for 3 weeks. The SN visit notes, dated 09/28/24, 10/02/24 and 10/09/24, lacked the assessment of the blood glucose. 2. Pt. #17 was admitted to the Home Health Services on 05/03/24 with the diagnosis of: Acute Upper respiratory Infection, Unspecified, Unspecified Systolic (Congestive) Heart Failure and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 10/16/24. The POC dated 05/03/24, that required the SN to assess and reinforce daily weights. The SN visit notes, dated 05/10/24, lacked the assessment of the patient’s weight for week #2.

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 review of clinical records, observation during a home visit, policy review and staff interviews, it was determined that for 1 of 2 Pts. (Pt. #3) who were receiving wound care, the Agency failed to ensure that the wound treatment provided was ordered by the Physician. Findings include: 1. Pt. #3 was admitted for skilled home health on 08/29/24 with a Diagnosis of Pressure Ulcer of Right Lower Back, stage III. Pt. #3’s clinical record was reviewed on 10/16/24. The skilled nurse visit report on 09/20/24 included the documentation, “Wound care provided: Right buttock stage III pressure injury, cleansed with wound cleanser or normal saline. Patted dry with gauze, applied collagen to wound bed and secured with bordered foam dressing.” The Physician order on 09/10/24 included the documentation, “Right buttock: Cleanse with normal saline, pat dry wit gauze, apply Mesalt impregnated gauze to wound bed and cover with Optifoam dressing.” The RN did not follow wound treatment as ordered by the Physician; the Physician order for the use of collagen as wound treatment was dated 09/25/24. During a home visit, the LPN (E#2) on 10/16/24 performed wound care. E#2 cleansed Pt. #3’s right buttock area with normal saline, pat it dry with gauze and applied a piece of collagen with silver into the wound. E#2’s skilled visit note report on 10/16/24 included the documentation, “Right buttock stage III pressure injury: Cleansed with wound cleanser or normal saline, patted dry with gauze. Applied Collagen Ag to wound bed and secured with bordered foam dressing.” The clinical record also included a Physician order on 09/25/24: “Updated wound care orders received, interventions: Skilled Nurse to perform/instruct patient/caregiver on wound care to right buttocks stage III pressure injury: Cleanse with wound cleanser or normal saline, pat dry with gauze, apply collagen to wound bed and secure with bordered foam dressing….” The record lacked an order for the wound treatment using collagen with silver. 2. The Agency policy “ Service Delivery -Physician’s Role” was reviewed on 10/17/24 and required, “Staff administers medications and treatments only as ordered by the physician.” 3. During an interview with the Administrator and Director of Nursing on 10/17/24 at 10:30 AM, the above findings were 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 clinical record review, Agency policy review and Staff interview, it was determined that in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) patients, the Agency failed to ensure Pts. were assessed for the Influenza and / or Pneumonia vaccination status per Agency policy. Findings include: 1. The following clinical records were reviewed from 10/15/24 to 10/17/24: Pt. #1 SOC 09/27/24 Pt. #2 SOC 09/28/24 Pt. #3 SOC 08/29/24 Pt. #4 SOC 05/30/24 Pt. #5 SOC 10/11/24 Pt. #6 SOC 09/22/24 Pt. #7 SOC 09/11/24 Pt. #8 SOC 06/26/24 Pt. #9 SOC 08/24/24 Pt. #10 SOC 09/30/24 Pt. #11 SOC 07/10/24 Pt. #12 SOC 05/26/23 Pt. #13 SOC 09/19/24 Pt. #14 SOC 03/29/24 Pt. #15 SOC 04/01/24 Pt. #16 SOC 01/17/22 Pt. #17 SOC 05/03/24 The records lacked documentation that the Pts. were assessed for Influenza and / or Pneumonia vaccine. 2. The policy for Influenza and Pneumonia vaccination was requested. The Director of Nursing presented the policy titled: "Infection Surveillance Infection Prevention and Control Plan. 3. The Agency’s policy titled: “Infection Surveillance Infection Prevention and Control Plan” was reviewed on 10/17/24 and indicated: “…3.0 Policy…3.1 It is the policy that the Agency’s employees and contracted staff will follow the CDC guidelines and OSHA Standards regarding infection prevention and control….3.2.1… Based on current analysis, the following priorities have been set based on geographic locations, communities served and population of patients….Illinois… Tuberculosis, Hepatitis A, B and C, West Nile Virus, HIV, Influenza and Coronavirus (COVID-19)....4.4 Staff and patients will be encouraged to receive inoculations as needed to assist with the prevention of these diseases…4.5 Influenza vaccination rates will be tracked and trended during the flu season to reach the national goal….” The policy does not address the Patient’s Pneumonia vaccination assessment. 4. During interviews with the Director of Nursing and Office Coordinator on 10/16/24 at 11:30 AM and with the Regional Vice President, Administrator and Director of Nursing on 10/17/24 between 10:30 AM to 1:30 PM, the above findings were confirmed.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interviews, it was determined that for 1 of 1 (Pt. #15) Pt. wherein MSW services were provided, the Agency failed to communicate/coordinate concerns within the healthcare team to ensure that Pt. needs were identified and addressed. Findings include: 1. Pt. #15 was admitted for Home Health Services on 04/01/24 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 10/15/24 at 3:00 PM. The MSW assessment note dated 04/05/24 included documentation that Pt. #4 was referred to “LIHEAP” to request an increase in energy service benefits. The MSW progress note included documentation, “MSWA gave pt number for LIHEAP.” The clinical record lacked documentation that there was coordination between the MSW and RN regarding the service need verbalized by the Pt. to the MSW. 2. During the interview with the Administrator and the Director of Nursing on 10/17/24 at 11:15 AM, the Director of Nursing stated that the MSW documented concerns on their progress note, but it was not coordinated with the RN. The above findings were confirmed in the same interview.