Every finding on record at Galesburg Home Care LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 4/22/22. 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 an Emergency Preparedness survey on 04/22/22. The Agency was in compliance with the requirements for Emergency Preparedness, for this survey. The Agency was not in compliance with the Standards, 42 CFR 484, for Home Health Agencies as evidenced by: Abbreviations: 2X- two times E- Employee MD- Medical Doctor OT- Occupational Therapist POC- Plan of Care Pt- Patient PT- Physical Therapist r- right SN- Skilled Nurse SOC- Start of Care ST- Speech Therapist

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 document review and interview, it was determined for 2 of 3 (Pt #6, Pt #8) patients records reviewed, the Agency failed to ensure the Plan of Care (POC) included all the pertinent information. This has the potential to affect all patients who receive care by the Agency with a current census of 92 patients. Findings include: 1. Pt #6 Start of Care (SOC): 7/8/20 Diagnosis: Chronic Obstructive Pulmonary Disease. The record was reviewed on 4/20/22 at approximately 1:30 PM. The Home Health Aide records noted Pt #6 wore depends for incontinence, had a lifeline necklace and utilized a shower chair. The Plan of Care lacked the depends, lifeline necklace and shower chair as durable medical equipment. The Plan of Care noted there were concerns related to bugs, although lack what type of bugs and if any precautions were to be implemented. The Plan of Care noted Pt #6 had an amputation, although lacked to identify the affected body part. 2. Pt #8 SOC: 10/24/19 Diagnosis: Chronic Obstructive Pulmonary Disease. The record was reviewed on 4/20/22 at approximately 12:30 PM. The Plan of Care noted in the medication section "02-oxygen 2 Liters Continuous".10 of 10 Home Health Aide notes between 2/10/22 through 3/22/22 noted Pt #8 used a portable oxygen tank and a concentrator was utilized Pt #8. The Plan of Care lacked the portable oxygen tank and concentrator as durable medical equipment. The Plan of Care noted there were concerns related to previous bed bug infestation, although lacked documentation if any precautions were to be implemented. 3. During an interview on 4/21/22 at approximately 10:15 AM, the Patient Care Manager (E#2) reviewed Pt #6 and Pt #8's records and verbally agreed the Plan of Cares lacked documentation of all the durable medical equipment, type of bugs or if precautions were required and the body part which had been amputated and should have been.

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: Based on document review and interview, it was determined for 2 of 10 (Pt #5, Pt#7) patients record reviewed, the Agency failed to ensure care was provided as ordered. This has the potential to affect all patients who receive care by the Agency with a current census of 92 patients. Findings include: 3. Pt #7 SOC: 2/22/22 Diagnoses: Non Pressure Ulcer of Left Calf. The record was reviewed on 4/21/22 at approximately 11:00 AM. The POC dated 2/22/22 noted Skilled Nurse (SN) to perform...procedure of wound care to left lower extremity...cleanse with normal saline apply Unna boot. The SN admission visit note dated 2/22/22 lacked the wound was assessed or wound care was provided. 4. During an interview with the Executive Director (E#1) and the Clinical Manager (E#2) on 4/21/22 at approximately 12:00 PM. E#1 and E#2 verbally confirmed the the record lacked wound care being conducted or a change in the physician's order. 1. Pt #5 Start of Care (SOC): 1/12/22 Diagnosis: Right Femur Fracture. The record was reviewed on 4/20/22 at approximately 10:00 AM. A Physician's order dated 3/20/22 note Physical Therapy was to visit the patient 1 time weekly for 3 weeks. The record lacked documentation a Physical Therapy visit was conducted the week of 3/27/22. The Physical Therapy reassessment conducted on 4/8/22 noted "... continue with PT (Physical Therapy) 2x (twice a week) for 3 weeks..." The record lacked documentation a Physical Therapy visit was conducted between 4/10/22 through 4/22/22. The record lacked an order for the PT visits. 2. During an interview on 4/21/22 at approximately 10:15 AM, the Patient Care Manger (E#2) reviewed Pt #5's record and verbally agreed PT visits were not conducted as ordered for the week of 3/27/22. E#2 stated "I emailed the therapist and told... we needed an order for the therapy visits as noted in the 4/8/22 note." E#2 reviewed the PT calendar and stated no PT visits were scheduled. E#2 verbally agreed it was unable to be determined the services and frequency of services needed to care for the patient and should have been clarified.

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 document review and interview, it was determined for 3 of 3 patients (Pt #5, Pt #6, Pt #8) patients records reviewed, the Agency failed to ensure care was coordinated between all disciplines. This has the potential to affect all patients who receive services by the Agency with a current census of 92 patients. Findings include: 1. Pt #5 Start of Care (SOC): 1/12/22 Diagnosis: Right Femur Fracture. The record was reviewed on 4/20/22 at approximately 10:00 AM. The Physical Therapy note dated 3/17/22 noted a "Vital Sign Alert" box which noted Pt #5's pain level was an 8 which was outside of normal limits. The Vital Sign Alert box noted a comment by the nurse "continue to monitor per MD (Medical Doctor) verbal follow-up... on 4/8/22" 23 days after the abnormal finding. The Physical Therapy note dated 4/8/22 noted "Patient reports... has been out of Norco (Narcotic medication for pain) for a week but... hasn't been able to pick it up." The Skilled Nurse note dated 4/12/22 noted "Describe lower extremities... swelling, ran out of medication... Complains of fatigue today... is pale... Pain rated 7/10 leg and r (right) hip... Pt (patient) states that the pharmacy and insurance has messed up all... medication, as of now it is fixed." The record lacked documentation the Physical Therapist communicated with the nurse the patient was unable to refill the medication and why; the nurses note lacked documentation of which medications the patient ran out of nor the nurse notified the physician of the missed medications and physical condition of Pt #5. 2. Pt #6 SOC: 7/8/20 Diagnosis: Chronic Obstructive Pulmonary Disease. The record was reviewed on 4/20/22 at approximately 1:30 PM. The Home Health Aide visit note dated 3/7/22 noted Pt #6 had poked his/her thumb with a screwdriver and had bandaged his/her thumb. The record lacked documentation the nurse was notified of Pt #6's injury. The Skilled Nurse visit note dated 3/8/22 lacked documentation the hand injury was assessed. 3. Pt #8 SOC: 10/24/19 Diagnosis: Chronic Obstructive Pulmonary Disease. The record was reviewed on 4/20/22 at approximately 12:30 PM. The Plan of Care for certification period 2/10/22 to 4/10/22 noted "In addition to skilled care... personnel care due to respiratory status... considered unstable as evidenced by... pain, dyspnea, vital signs, knowledge deficit that shows medical instability... unstable caregiver situation over the past 60 days, recent changes to the treatment regimen... the patient will need continued PT (Physical Therapy)/ OT (Occupational Therapy)/ ST (Speech Therapy) due to unresolved therapy needs..." The Home Health Aide visit note dated 3/15/22 noted Pt #8's cleaning lady quit and Pt #1's sister (Power of Attorney and primary caregiver) was in the hospital, although the niece was able to assist with getting groceries until sister was available. The record lacked documentation the nurse was notified of Pt #8's change in resources. The Skilled Nurse Discharge Summary dated 3/22/22 noted Pt #8 was discharged to Hospice. The record lacked documentation there was a change in Pt #8's condition or what predisposed the discharge to Hospice. 4. During an interview on 4/21/22 at approximately 10:05 AM, the Patient Care Manager (E#2) reviewed Pt #5, Pt #6 and Pt #8's records. E#2 verbally agreed Pt #5's record lacked documentation the Physical Therapist communicated with the nurse the patient was unable to refill the medication and why; the nurses note lacked documentation of which medications the patient ran out of nor the nurse notified the physician of the missed medications and physical condition of Pt #5 and should have been. E#2 verbally agreed the record lacked documentation the Home Health Aide notified the nurse about the injury to Pt #6's hand and lacked documentation of the nurse’s assessment and it should have been. E#2 verbally agreed the record lacked documentation the nurse was notified of Pt #8's change in resources if there was a change in Pt #8's condition or what predisposed the discharge and should have been.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on document review, it was determined for 3 of 3 (Pt #6, Pt #7, Pt #8 ), patients records reviewed who received home health aide services, the Agency failed to ensure a COVID screening was conducted prior to the patient visit. this has the potential to affect all staff and patients who receive care by the Agency with a current census of 92 patients. Findings include: 1. Pt #6 Start of Care (SOC): 7/8/20 Diagnosis: Chronic Obstructive Pulmonary Disease. The record was reviewed on 4/20/22 at approximately 1:30 PM. The record lacked documentation a COVID screen was conducted for 15 of 15 home health aide visits conducted between 2/26/22 through 4/20/22. 2. Pt #7 SOC: 2/22/22 Diagnosis: Non-pressure Ulcer Left Calf. The record was reviewed on 4/21/22 at 11:00 AM. The record lacked documentation a COVID screen was conducted 4 of 4 home health aide visits conducted between 3/1/22 through 3/22/22. 3. Pt # 8 SOC: 10/24/19 Diagnosis: Chronic Obstructive Pulmonary Disease: The record was reviewed on 4/20/22 at approximately 12:30 PM. The record lacked documentation a COVID screen was conducted for 11 of 11 home health aide visits conducted between 2/10/22 through 3/22/22. 4. During an interview on 4/20/22 at approximately 2:30 PM, the Patient Care Manager (E#2) reviewed Pt #6, Pt #7 and Pt #8's home health aides visit records and verbally agreed the visit notes lacked documentation a COVID screen was conducted and should have been. 5. During an interview on 4/20/22 at approximately 2:30 PM, the Executive Director (E#1) reviewed the electronic health record and stated "I thought we built the COVID screen into all disciplines documentation. That's an error on our part. They are doing the screenings. I do supervisory visits."

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 2 of 3 (Pt #6, Pt #8) patients records reviewed, the Agency failed to ensure assessments were accurately conducted and/or documented. This has the potential to affect all patients who receive care by the Agency with a current census of 92 patients. Findings include: 1. Pt #6 Start of Care (SOC): 7/8/20 Diagnosis: Chronic Obstructive Disease. The record was reviewed on 4/20/22 at approximately 1:30 PM. The Plan of Care noted Pt #6 was on oxygen, had a functional limitation due to an amputation (right leg), utilized Lidocaine patches every 12 hours for pain and was incontinent of urine and wore depends. The Skilled Nurse visit noted dated 3/8/22 and 4/5/22 noted the following assessments: "Does Patient Report Pain? No- Does Patient Have Medication Ordered For Pain? No... Indicate Respiratory Findings: ... No Problems Identified... Indicate Genitourinary Findings: ... No Problems Identified... Functional- no problems identified". The Skilled Nurse visit note dated 3/22/22 and 4/19/22 noted the following assessments: "Does Patient Report Pain? No- Does Patient Have Medication Ordered For Pain? No... Indicate Respiratory Findings: ... No Problems Identified..." 2. Pt #8 SOC: 10/24/19 Diagnosis: Chronic Obstructive Pulmonary Disease. The record was reviewed on 4/20/22 at approximately 12:30 PM. The Plan of Care dated 2/10/22 noted "In addition to skilled care the patient needs the following: personal care due to respiratory status... also considered unstable as evidenced by:... pain, dyspnea, vital signs, knowledge deficit that shows medical instability)... unstable caregiver situation over the past 60 days, recent changes to treatment regimen that requires instruction... the patient will need continued PT (Physical Therapy)/OT (Occupational Therapy)/ ST (Speech Therapy) due to unresolved therapy needs..." The Plan of Care noted Pt #8 utilized oxygen continually, noted "Functional Limitations: Endurance: Dyspnea with Minimal Exertion Safety Measures: Activity Intolerance, Fall Precautions, Oxygen Precautions/Safety..." The Home Health Aide visit note dated 3/15/22 noted "... Total Assistance with his/her personnel care due to he/she tires easily with activity and needs to rest often..." The Home Health Aide care plan noted "Bathing (Partial Sponge Bath) ..." The Discharge visit note dated 3/22/22 noted "Bathing: Current Ability to Wash Entire Body... Able to Bathe Self in Shower or Tub Independently, Including Getting In and out of Tub/Shower... Self-Care Shower/Bathe Self Discharge Performance... Independent- Patient Completes the Activity by Him/Herself With No Assistance From a Helper... Indicate Discharge Teaching Provided:... Medication Dosages, Routes, Frequencies, and Way in Which Patient Received Medication Pharmacy Name and Number... Care Management... No Assistance Needed..." 3. During an interview on 4/20/22 at approximately 10:15 AM, the Patient Care Manager (E#2) reviewed Pt #8's record and verbally agreed patient assessments were inaccurate and the patient should have been accurately assessed and documented.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on document review and interview, it was determined in 1 of 3 (Pt#7) patient records reviewed, who received home health aide (HHA) services, the Agency failed to ensure a home health aide care plan was accurate per policy. This has the potential to affect all patients who receive HHA services. Findings include: 1. The policy titled "Personal Care (revised date: 12/01/11)" was reviewed on 4/21/22 at approximately 1:30 PM. The policy noted "...Procedure: 1. The home health aide (HHA) care plan will specify specific personal care and bath modality to be provided..." 2. Pt #7 Start of Care (SOC): 2/22/22 Diagnosis: Non Pressure Ulcer of Left Calf. The record was reviewed on 4/21/22 at approximately 11:00 AM. The Aide Care Plan dated 2/23/22 noted "bathing (bed/bath) every visit and bathing-shower every visit." The care plan lacked the specific personal care to be provided. 3. During an interview with the Executive Director (E#1) and the Clinical Manager (E#2) on 4/21/22 at approximately 12:00 PM. E#1 and E#2 verbally confirmed the care plan lacked the specific type of bath modality and should have been included.