Every finding on record at Gaffey Home Nursing & Hospice, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 04/23/26. 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 04/23/26. Standard level deficiencies were cited. Abbreviations: Pt./Pts. = patient/patients AM = morning PM = afternoon SN = Skilled Nurse SOC = Start of Care POC = Plan of Care PsOC = Plans of Care

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 review of the Patient's Admission Folder, clinical record review, and staff interview, the Agency failed to ensure Pts. were provided with the correct information to file a concern or complaint with the Illinois Department of Public Health in 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6, and 7). Findings include: 1. The Patient's Admission folder was reviewed on 04/20/26. The booklet included the following information regarding Complaints: “COMPLAINTS, you have the right: 1) ”To make complaints to the home health agency regarding treatment or care that is (or fails to be) furnished…..” 2) “To be free from any discrimination or reprisal for exercising his or her rights or voicing grievances to the home health….” 3) “To be advised of the state toll free home health telephone hot line, its contact information, its hours of operation…” (See page 1 of this booklet). The folder included under Tablet of Contents: Staff information: Complaints to: __________ Administrator’s Name/Title Phone #: ____________ Agency Address: ____________________________________________ State Hotline: 1800-______________________ (If agency is unable to resolve complaint). The Agency failed to provide the Pts. and/or the patients' representatives with the State of Illinois' toll-free home health telephone hotline purpose and its contact information. 2. During an interview with the Agency Supervisor on 04/22/26 at 3:45 PM, the above findings were confirmed.

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 record review, Agency policy review and staff interview, for 1 of 1 (Pt. #1) Pt. receiving wound care, the Agency failed to ensure that wound care measurements were conducted, as per Agency policy. Findings include: 1.Pt. #1 was admitted to home health services with diagnoses of Pressure Ulcer, right heel, stage 3. The clinical record was reviewed on 04/21/26. The clinical record included the POC for the certification period of 03/17/26 to 05/15/26 that required 1 time a week for 1 week and 2 times a week for 8 weeks for wound care. The SN visits dated and wound flowsheet dated 04/06/26, 04/10/26, 04/13/26 and 04/17/26, lack wound care measurements. 2. Agency policy titled: “Wound Measurement” was reviewed on 04/22/26 and required: “….g. Documentation of wound measurements is part of the required documentation for all wound care procedures….” 3. During an interview with the Agency Supervisor and Clinical Director on 04/22/26 at 1:45 PM, the Agency Supervisor stated that Nurses should document a wound measurement weekly and document it in the clinical record. During the same interview, the Administrative team confirmed the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records review, Agency policy review and staff interviews, for 7 of 7 (Pts. # 1, 5, 6, 2, 3, 4 and 7) clinical records reviewed, the Agency failed to ensure that the Plans of Care (PsOC) included Pt. specific interventions. 6. Pt. #4 was admitted to home health services on 04/03/26 with the diagnosis of but not limited to Malignant Neoplasm of overlapping sites of the bladder and Type 2 Diabetes mellitus. The clinical record was reviewed on 04/22/26 and included a POC effective 04/03/26. The POC lacked documentation of vital signs and blood glucose parameters to be reported to the Physician. The clinical record indicated that Pt. #4 uses an indwelling pleural drainage catheter but, lacked documentation of the procedure and supplies used for the care of the drainage catheter and the incision site. The POC also lacked documentation of the amount of drainage to be removed and parameters to be reported to the Physician. The clinical record also indicated Pt. #4 has an access port but also lacked documentation of its care and the frequency and the supplies used. 7. Pt. #7 was admitted to home health services on 07/01/25 with the diagnosis of Traumatic subdural hematoma without loss of consciousness. The clinical record was reviewed on 04/22/26 and included a POC for certification period of 07/01/25 to 08/29/25. The POC lacked documentation of vital signs parameters to be reported to the Physician. The POC also lacked individualized interventions and goals addressing the diagnosis/problems identified. 8. The policy titled “Plan of Care” was reviewed on 04/23/26 and required, “Purpose: To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs… To assure that the plan meets state/federal guidelines, and all applicable laws and regulations. Special instructions…1. An individualized Plan of Care signed by a physician/allowed non-physician practitioner (NPP) shall be required for each client receiving home health…The Plan of Care shall be completed to include: m…procedures….n. Medical supplies and equipment required…” 9. During interviews with the Agency Supervisor and Clinical Director on 04/22/26 from 1:45 PM to 3:30 PM, the above findings were confirmed. Findings: 1.Pt. # 1 was admitted to home health services on 11/17/25 with diagnosis of Pressure Ulcer, right heel, stage 3. The clinical record was reviewed on 04/21/26. The clinical record included PsOC for certification periods of 01/16/26 to 03/16/26 and 03/17/26 to 05/15/26 and lacked individualized vital sign parameters to report to Physician. 2. Pt. # 5 was admitted to home health services on 07/15/25 with diagnosis of Type 2 Diabetes Mellitus with Moderate nonproliferative Diabetic retinopathy. The clinical record was reviewed on 04/21/26. The clinical record included PsOC for the certification periods of 01/11/26 to 03/11/26 and 03/12/26 to 05/10/26 and lacked individualized vital sign parameters and blood sugar parameters to report to Physician. 3. Pt. # 6 was admitted to home health services on 11/11/24 with the diagnosis of but not limited to Malignant Neoplasm of Lower Lobe, right bronchus or lung and Type 2 Diabetes Mellitus. The clinical record was reviewed on 04/21/26. The clinical record included PsOC for certification periods of 11/11/24 to 01/09/25 and 01/10/25 to 03/10/25 and lacked individualized vital sign parameters and blood sugar parameters to report to Physician. 4. Pt. #2 was admitted to home health services on 12/23/20 with diagnoses of atherosclerotic heart disease of the native coronary artery with unspecified angina pectoris and Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 04/21/26. The PsOC dated 01/26/26 to 03/26/26 and 03/27/26 to 05/25/26 lacked documentation of vital signs and blood glucose parameters to report to the physician. 5. Pt. #3 was admitted to home health services on 02/05/26 with diagnoses of Pneumonia and Type 2 diabetes mellitus with diabetic polyneuropathy. The clinical record was reviewed on 04/21/26. The POC dated 02/05/26 to 04/05/2026 lacked documentation of vital signs and blood glucose parameters to report to the physician.

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 reviews, policy review, and staff interviews, for 7 of 7 (Pts. #1,2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to conduct complete assessments of patients' Influenza and Pneumonia vaccination status. Findings include: 1. The following clinical records were reviewed from 04/21/26 to 04/22/26, the records lacked documentation that the Influenza and Pneumonia vaccination was assessed. Pt. #1 SOC 11/17/25 lacked Influenza and Pneumonia vaccination assessment. Pt. #2 SOC 12/22/20 lacked Influenza and Pneumonia vaccination assessment. Pt. #3 SOC 02/05/26 lacked Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 04/03/26 lacked Influenza and Pneumonia vaccination assessment. Pt. #5 SOC 07/15/25 lacked Influenza and Pneumonia vaccination assessment. Pt. #6 SOC 11/11/24 lacked Influenza and Pneumonia vaccination assessment. Pt. #7 SOC 07/01/25, lacked Influenza and Pneumonia vaccination assessment. 2. During staff interviews with the Agency Supervisor and Clinical Director on 04/22/26 from 1:45 PM to 3:45 PM, 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 review of the Agency's Pt. admission folder and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) the Agency failed to provide information regarding the Clinical Manager/Agency Supervisor and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 04/20/26. The folder lacked information identifying the Agency Supervisor's name and contact information. 2. The clinical records of the following Pts. were reviewed from 04/21/26 to 04/22/26 Pt. #1 SOC 11/17/25. Pt. #2 SOC 12/22/20. Pt. #3 SOC 02/05/26. Pt. #4 SOC 04/03/26. Pt. #5 SOC 07/15/25. Pt. #6 SOC 11/11/24. Pt. #7 SOC 07/01/25. The clinical records reviewed lacked information identifying the Agency Supervisor's name and contact information. 3. During a staff interview with the Agency Supervisor and Clinical Director on 04/22/26 at 3:45 PM it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: # = number SN = Skilled Nurse SOC = Start of care POC/PsOC = Plan / Plans of Care RN = Registered Nurse Pt./ Pts. = Patient/Patients BP = blood pressure PT = Physical Therapy / Physical Therapist

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: A. Based on admission packet review, clinical record review and Staff interview, it was determined the Agency's admission consents lacked the disciplines that will furnish care and frequency of visits. This was found in 10 of 10 (Pts. # 1 through 10) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder provided by the Agency was reviewed on 01/11/23 at 11:00 AM. The folder included a consent document titled "Admission Service Agreement Home Health" but did not include frequency of visits and disciplines who will provide care. 2. The admission consents of the following Pts. were reviewed from 01/10/23 at 10:30 AM to 01/11/23 at 3:00 PM and lacked documentation of frequency and disciplines that provided care: Pt. #1 SOC 10/29/22 Pt. #2 SOC 09/22/22 Pt. #3 SOC 12/14/22 Pt. # 4 SOC 10/04/22 Pt. # 5 SOC 12/21/22 Pt. #6 SOC 08/12/22 Pt. #7 SOC 12/15/22 Pt. #8 SOC 10/05/22 Pt. #9 SOC 10/11/22 Pt. #10 SOC 09/06/22 3. During an interview with the Administrator and Assistant Director of Nursing on 01/12/23 at 9:30 AM, the Administrator and Assistant Director of Nursing confirmed the above findings.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: A. Based on a review of Agency's complaint log, review of Agency's policy and staff interview it was determined the Agency failed to document complaint resolution and outcome. Findings include: 1. The Agency's complaint log was reviewed on 01/11/23 at 12:00 PM. The complaint log contained a patient complaint entry dated 12/21/22. The complaint entry describes patient's daughter concern with dressing change. The complaint entry lacked documentation of Agency notifying the complainant of the intervention. The complaint entry also lacked documentation of patient satisfaction with intervention and outcome. 2. The Agency's policy titled "Client / Family Complaint / Grievance Policy" was reviewed on 01/11/23 at 1:30 PM, the policy required "Special Instructions...7... Grievances are considered complete when an approve response has been mailed to the client complainant"....8...A grievance is considered resolved when the client is satisfied with the actions taken on their behalf." 3. During an interview with the Administrator and Assistant Director of Nursing on 01/12/23 at 11:00 AM the Administrator confirmed that the Agency failed to document complaint resolution and outcome.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on clinical record review and Staff interview, it was determined that the Agency failed to ensure that staff provided care as ordered by the physician. This was found in 3 of 10 (Pts. # 8, 5 and 2) clinical records reviewed. 2. Pt #5. SOC 12/21/22 Primary Diagnoses: Hemiplegia, Unspecified Affecting Right Dominant Side and Type 2 Diabetes with Unspecified Diabetic Retinopathy with Macular Edema. The clinical record was reviewed on 01/10/23 at 12:30 PM. The POC 12/21/22 required the RN to notify the Physician if the blood glucose was greater than 250 or less than 70. The RN visit note dated 01/21/23, lacked the assessment of the patient’s blood glucose. The same POC was revised on 12/30/22 to include the Aide to weigh the patient every visit. The Aide failed to weigh the patient on 01/06/23 (week #3). 3. Pt #2 SOC 09/22/22 Diagnoses: Parkinson's Disease, Encounter for fitting and adjustment of urinary device. The clinical record was reviewed on 01/10/23 at 12:30 PM. The clinical record contained a POC for certification period 11/21/2022 to 01/19/23 that required SN to perform Genitourinary assessment with SN visit. The clinical record contained SN visits notes dated 12/12 and 12/14/22 that lacked a Genitourinary assessment. 4. During interviews with the Administrator and Assistant Director of Nursing on 01/12/23 between 9:00 AM and 11:00 AM, the Administrator confirmed that Agency Staff failed to ensure care was provided as ordered by the physician. Findings include: 1. Pt #8 SOC 10/05/22 Primary Diagnosis: Nonrheumatic mitral (valve) prolapse. The clinical record was reviewed on 01/11/23 at 1:00 PM. The signed POC for certification period of 10/05/22 to 11/07/22 required the Skilled Nurse to visit 2 times a week for 9 weeks. The record included 1 SN visit dated 10/17/22 and lacked documentation of any other SN visit for the week of 10/16/22 as ordered. The record also included 1 SN visit dated 10/26/22. The record lacked documentation of any other SN visit for the week of 10/23/22 as ordered.

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 review of clinical records, home visit interview/observations and Staff interview, it was determined that the Agency failed to ensure the Staff documented all interventions/ services and responses to those intervention/ services. This was found in 4 of 10 (Pts. #1, 3, 5 and 8) clinical records reviewed. Findings include: 1.Pt. #1 SOC 10/29/22 Primary Diagnoses: Displaced Bimalleolar Fracture Left Lower Leg Subsequence for Closed Fracture with Routine Healing and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 01/10/23 at 10:30 AM. On 01/10/23 at 11:00 AM, during the PT home visit, Patient #1 stated that she has a Pacemaker and use Tylenol Extra Strength for pain as needed. The plans of care dated 10/29/22 and 12/28/22 lacked documentation of the Pacemaker and Tylenol Extra Strength. 2. Pt. #3 SOC 12/14/22 Primary Diagnoses: Unspecified Open Wound Left Lower Leg Subsequence Encounter and Type 2 Diabetes Mellitus. The clinical record was reviewed on 01/10/23 at 2:00 PM and required the RN 2 times a week. On 01/11/23 at 9:00 AM, during the RN home visit, Patient #3 stated the RN visited 2 times a week for wound care. As of 01/12/23, the RN failed to document the patient status and the patient/family responses, for the 2nd visit dated 01/06/23. 3. Pt #5. SOC 12/21/22 Primary Diagnoses: Hemiplegia, Unspecified Affecting Right Dominant Side and Type 2 Diabetes with Unspecified Diabetic Retinopathy with Macular Edema. The clinical record was reviewed on 01/10/23 at 12:30 PM. The clinical record included an incomplete Aide Care Plan. As of 01/12/23, the RN failed to revise/document the additional Aide duty that was ordered on 12/30/22 for the Aide to weigh the patient every visit. 4. Pt #8 SOC 10/05/22 Primary Diagnosis: Nonrheumatic mitral (valve) prolapse. The clinical record was reviewed on 01/11/23 at 1:00 PM. The signed POC for certification period of 10/05/22 to 11/07/22 required SN to “Notify physician if….Systolic BP….Diastolic BP…..” The SN note dated 10/13/22 lacked documentation of blood pressure reading. The SN note dated 10/26/22 included systolic blood pressure reading of 112 but lacked documentation of a diastolic blood pressure reading. 5. On 01/12/23 at 9:00 AM to 11:30 AM, during interviews with the Administrator and Assistant Director of Nursing, the Assistant Director of Nursing confirmed the above findings.