Every finding on record at Genesis Health System

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 1/6/24 through 1/9/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 1/6/24 through 1/9/24. The recertification survey found the agency operating out of compliance with the Condition of Participation 42 CFR 484.50 Patient Rights (See G462, G464, G466 and G470). The survey also found the agency operating out of compliance with other standard level deficiencies. The agency reported a census of 597 patients at the time of the survey, including 349 who received services from the Bettendorf office, 68 who received services from the Clinton office and 180 who received services from the Illinois office. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 1/9/25 and ending on 1/9/27.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observations, staff and patient interviews, clinical record review and policy review The agency : 1) failed to comply and follow through with the policy set by the agency of addressing discharge for cause (G462): 2) failed to advise the patient and health care professional who would be responsible for providing care and services to the patient after discharge from the agency that a discharge for cause is being considered (G464): 3) failed to make efforts to resolve the problems presented by the patients behavior, the behavior of other persons in the patient's home, or situation (G466) and 4) failed to document the problem and efforts made to resolve the problem and enter this documentation into its clinical records (G470). The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on observations, family interviews, staff interviews, record review and policy review, the agency failed to document the patient's behaviors and circumstances that warranted patient's discharge for cause and the agency's efforts to resolve the problems prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #17) Failure to completely document the patient's behaviors and circumstances that warranted patient's discharge, prevented the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include: According to the policy titled Discharge/Transfer, dated 9/2024, possible reasons for discharge for cause include non-compliance, verbal abuse by patient and/or patient’s family/caregiver(s), or behavior that is disruptive, or abusive, and physical safety of the patient or home care staff is endangered. Whenever service is discontinued for cause, the Clinical Manager, or designee shall notify the patient in writing of the action, the reason for the action, the patient's right to appeal, and provide a copy of the appeal process. The ordering or primary provider and other disciplines involved in the patient’s care will be notified if a patient is referred, transferred or discharged. Patient #17 had a start of care date of 8/24/24 and was discharged for cause on 9/20/24. Patient #17 received services from the Clinton Office. a. The Plan of Care (POC), dated 8/24/24 to 10/22/24, included diagnosis of acute congestive heart failure (CHF), atrial fibrillation (abnormal heartbeat/rhythm) , acute kidney failure, and a diagnosis of a unspecified mood disorder secondary to a history of a traumatic brain injury (TBI). The POC included physician orders for a skilled nurse visit weekly for assessment of the cardiac (heart) status and other comorbidities ( other related health conditions ). The POC also included Physician orders to teach and monitor how to use the Zoll LIfe Vest (a vest worn and designed to detect certain life-threatening rapid heart rhythms and automatically deliver a treatment shock to save a life). The POC also included physician orders for Physical Therapy and Occupational Therapy to evaluate and treat. b. The initial comprehensive assessment, completed by Staff J, Registered Nurse (RN), dated 8/24/24, revealed no concerns with disruptive, aggressive or threatening behavior by the patient. c. The Skilled Nurse notes, completed by Staff L, RN, dated 8/26/24, 8/28/24, and 9/3/24, revealed no concerns with disruptive, aggressive or threatening behavior by the patient. d. The Occupational Therapy initial evaluation, dated 8/26/24, completed by Staff M, Occupational Therapist, revealed no concerns with disruptive, aggressive or threatening behavior by the patient. e. The Physical Therapy initial evaluation, dated 8/30/24, completed by Staff N, Physical Therapist (PT), revealed no concerns with disruptive, aggressive or threatening behavior by the patient. f. The Skilled Nurse Note, dated 8/30/24, completed by Staff G, RN, revealed no concerns with disruptive, aggressive or threatening behavior by the patient. g. The Skilled Nurses Noted, dated 9/5/24, completed by Staff O, RN, revealed no concerns with disruptive, aggressive or threatening behavior by the patient. h. The Physical Therapy note, dated 9/10/24, completed by Staff P, PT, revealed no concerns with disruptive, aggressive or threatening behavior by the patient. i. The Skilled Nurse note, dated 9/12/24, completed by Staff G, RN indicated the patient became verbally aggressive and was shouting at the nurse and making verbal threats against the Physical therapist that had been there there two days earlier. The Skilled Nurse note indicated patient #17 was pacing and did not want to answer questions or stop for an assessment to be completed. At one point, Patient #17 was shaking his/her fist towards the paper on the wall with recorded weights. Staff G, RN attempted redirection and noted it was not very successful. Staff G, RN indicated that the patient #17 did calm down towards the end of the visit but did follow her out to the car. j. A clinical coordination note, dated 9/20/24, Staff G, RN, documented patient #17 called the triage line and inquired when the next home health visit would be, and Staff G, RN indicated she informed patient #17, the discharge for cause had already been completed, due to his/her verbal aggression on the last nursing visit (dated 9/12/24). k. During an interview on 1/9/24, at 9:27 AM, Staff G, RN stated she was concerned for her safety as the patient seemed manic and very nervous. Staff G, RN stated patient had some sort of history with mental health issues but did not specifically know what. Staff G, RN indicated attempts at redirecting the Patient's frustration during the visit were not effective and stated "patient #17 was angry with the physical therapist" but she could not get the patient to tell her why. Staff G, RN stated she completed patient #17's assessment and left the visit. She placed calls to both the primary physician and the cardiologist to determine if any of the recent medication changes could have affected patients behavior in this way. Staff G, RN stated the primary physician and the cardiologist both stated medications would not be contributing to any new behaviors. Staff G, RN stated she also called her supervisor and it was decided to put all visits on hold, effective 9/12/24, until more information could be determined. Staff G, RN stated messages were left with the patient's daughter with no response requesting a call back as to if this is normal behavior for the patient but stated the patients daughter did not return the calls. Staff G, RN stated the supervisor made the decision to call and get a discharge order and discharge the patient for cause. Staff G, RN stated she could not talk to the patient directly as she did not have a phone number for the patient, only for the daughter who didn't respond to messages left. Staff G, RN stated the patient #17 did call the triage line on 9/20/24 and was requesting to know when the next visit from the agency would be and did leave his/her phone number. Staff G, RN reported she called patient #17 back to explain he had been discharged for the verbal aggression on the last visit. l. During an interview on 1/8/24 at 3:50 PM, with Staff P, Physical Therapist (PT), stated a different therapist had completed the first evaluation visit and that he went to complete the second physical therapy visit on 9/10/24. Stated patient #17 was really in too much pain to be able to participate very well, but overall felt that visit went good. Stated patient #17 was not at all aggressive, just didn’t want to participate with therapy with him. Stated the Patient seemed pretty nervous during the visit and just didn’t want to answer very many questions or interact with him. Staff P, PT, decided he would just come back and try again on the next scheduled visit. Staff P, PT, stated he received an email message from the case manager RN, telling him patient #17 was upset with him, and didn’t want him to come back. Staff P, PT stated he didn’t know if the patient was discharged from the agency or it was just a staffing change, but that was the end of his interactions with and about Patient #17. m. During an interview on 1/8/24 at 3:40 PM, staff I, Clinton Supervisor, at the Clinton office, stated there was no additional visits attempted after the incident was reported on 9/12/24. Staff I, Clinton Supervisor, stated she attempted to call the patient's daughter, but didn't get a response so the agency called the physician for an order to discharge patient #17. Staff I, Clinton Supervisor, acknowledged this was the first incident or behavior reported by staff in relation to Patient #17, but stated the agency did not want to attempt a different nurse in the home if the environment was not safe. Staff I, Clinton Supervisor, stated she did not talk directly to patient #17 before discharging the patient. Staff I, Clinton Supervisor, stated what she knew from the discharge policy that the patient/ patient family had to be notified as well as the primary physician. She could not say if the expectation was to send written notice without looking at the policy. Staff I, Clinton Supervisor, stated there was no written notice sent to patient #17 and no appeal process in writing was given to patient #17. Staff I, Clinton Supervisor, stated " because the daughter didn't respond to her messages and the daughter was notified through voice mail that patient #17 was being discharged." Staff I, Clinton Supervisor, stated the agency did not have patient #17's phone number, as the daughter had requested everything go through her. Staff I, Clinton Supervisor, did acknowledge that patient #17 is alert and oriented, and signed all of his/her own admission paperwork. n. During an interview on 1/8/24 at 4:30 PM, Patient #17's daughter stated she did receive a voice mail from a nurse that stated they would need to discharge patient #17 for aggressive behavior. The daughter stated she called back the number and left a message but never heard back from the agency. The daughter stated the only specific details she did receive were from patient #17's primary physician office when they called to see if there was anything they could help with after hearing the agency discharged patient. #17. The daughter stated, patient #17 occasionally has some explosive episodes that started happening from time to time following the patient's traumatic brain injury. She stated that if patient #17 gets frustrated, sometimes he/she gets loud and shouts and will calm down after he/she is able to vent his/her frustrations or that sometimes if patient #17 is having pain, he/she will get loud." The daughter stated she was not contacted in writing or given any choice in the matter. The agency discharged patient #17 before having a conversation with her or patient #17. o. The clinical record lacked a discharge order from the physician at the time of discharge from the agency on 9/20/24. The Physician's order was entered late, (during the survey) dated on 1/7/24, with an effective date of 9/20/24. The agency documented only one visit out of the nine visits completed, where the patient displayed any disruptive or aggressive behaviors, and failed to document the agency's efforts to resolve the issues prior to discharge for cause. The above findings were reviewed with the Administrator/Clinical Manager and the Compliance Specialist.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on agency staff interviews and caregiver interviews, clinical record review, and agency policy review, the agency failed to notify the patient prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #17) Failure to provide patients with notification that discharge for cause is being considered denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge and left the patient at risk for not receiving needed care. Findings Include: See G462 The agency failed to notify patient #17 of discharge for cause prior to the discharge date. The above findings were reviewed with the Administrator/Clinical Manager and the Compliance Specialist.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #17) Failure to attempt to initiate any efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings Include: See G462 The agency failed to attempt to initiate efforts to resolve the problems before patient #17 was discharged for cause. The above findings were reviewed with the Administrator/Clinical Manager and the Compliance Specialist.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to document any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #17) Failure to document efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge for cause. Findings Include: See G462 The Agency failed to document efforts made to resolve the problems prior to Patient #17's discharge for cause. The above findings were reviewed with the Administrator/Clinical Manager and the Compliance Specialist.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, agency staff interview, patient interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment and failed to identify patient specific medication issues for 4 of 17 sampled patients (Patients #3, #4, #11 and #15). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency Medication Management Policy, dated January 2024, a drug regimen review is completed using the patient's prescriptions, over the counter medications and herbal/alternative therapies. A comparison is made between the physician's orders and all known medications the patient is using. Any discrepancies or contraindications will be reported to the prescribing provider for resolutions. During an interview on 1/8/25 at 9:21 AM, Staff A, Clinical Manager reported a drug regimen review (DRR) is completed by the admitting clinician in the home at start of care, recertification, resumption of care, significant change in condition and discharge. 1.Patient #3 had a start of care date of 12/19/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 12/19/24 to 2/16/25, identified the patient had a diagnosis of Sepsis, unspecified organism. The POC included physician orders for medications, skilled nursing services, occupational therapy services and physical therapy services. b. The start of care comprehensive assessment, dated 12/19/24, completed by Staff J, Registered Nurse (RN), included documentation a DRR was completed and no issues were found during review. c. During a home visit observation on 1/7/25 at 10:00AM, with Staff D, Occupational Therapist (OT), interview with Patient #3 stated he/she sets up his/her own medication. The following medication discrepancies were identified: 1) The patient identified he/she takes Sertraline Hydrochloride (HCL) 50 milligram (mg) tablets one time a day. The POC lacked documentation of an order for Sertraline HCL. The Sertraline HCL was filled on 11/4/24. 2) The patient identified he/she takes Rosuvastatin 10mg tablets one tablet twice daily. The POC lacked documentation of an order for Rosuvastatin. The Rosuvastatin was filled on 9/16/24. 3) The patient identified he/she takes Pepcid 20mg tablets (over the counter) one tablet daily (for over a year). The POC lacked documentation of an order for Pepcid. 4) The POC identified the patient takes Amlodipine 5mg tablets with instructions to take one tablet by mouth daily. The bottle in the home is Amlodipine 10mg tablets take one tablet by mouth daily. The bottle in the home was filled on 9/16/24. Patient reported taking medication per instruction on the bottle. 5) The POC identified the patient takes Famotidine 20mg tablets with instructions to take one tablet by mouth daily. Patient reported he/she has not taken that medication for over a year. 6) The POC identified the patient takes Acetaminophen 325mg tablets with instructions to take two tablets every six hours as needed not to exceed 3000mg. The patient reported he/she takes Acetaminophen 500mg tablets as needed. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #4 had a start of care date of 12/15/24. Clinical record review revealed the following: a. The POC, dated 12/15/24 to 2/13/25, identified the patient had a diagnosis of hypertensive heart and chronic kidney disease with heart failure and stage 1-4/unspecified chronic kidney disease. The POC included orders for furosemide and spironolactone (diuretics). b. The start of care comprehensive assessment, dated 12/15/24, completed by Staff K, RN, included documentation a DRR had been completed and no issues were found during review. The note lacked documentation of the duplicate diuretic medications. The completed DRR failed to identify the duplicate medications the patient was taking. 3. Patient #11 had a start of care date of 11/27/24. Clinical record review revealed the following: a. The updated POC, dated 11/27/24 to 1/25/25, identified the patient had several diagnoses including Encounter for orthopedic aftercare following surgical amputation, Type II Diabetes Mellitus with Diabetic Neuropathy and Gastro-Esophageal Reflux Disease without Esophagitis. The POC included orders for Famotidine and Metoclopramide (gastrointestinal medications). b. The resumption of care comprehensive assessment, dated 12/20/24, completed by Staff F, Physical Therapist (PT), included documentation a DRR had been completed and identified duplicate medication: yes. The note lacked documentation of the duplicate gastrointestinal medications. The completed DRR failed to identify the duplicate medications the patient was taking. 4.Patient #15 had a start of care date of 7/3/24 and a discharge date of 7/15/24 . Clinical record review revealed the following: a. The POC, dated 7/3/24 to 8/31/24, identified the patient had a diagnosis of Sprain of ligaments of lumbar spine, subsequent encounter. The POC included orders for Aleve and Tramadol (pain medications). b. The start of care comprehensive assessment, dated 7/3/24, completed by Staff Q, PT, included documentation a DRR had been completed and no issues were found during review. The note lacked documentation of the duplicate pain medications. The completed DRR failed to identify the duplicate medications the patient was taking. The above findings were reviewed with the Administrator/Clinical Manager and the Compliance Specialist.

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 home visit observation, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 2 of 7 sampled patients (Patient #1 and #7) with home visits. Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: According to agency policy, titled Nursing Bag Technique, dated 2019, staff place the bag on a clean, dry surface with a water-resistant barrier placed between the bag and the surface. Remove containers and all necessary equipment and supplies that will be used during the visit. Return all cleaned items to the proper section of the bag and close the bag. During an interview on 1/9/25 at 1:35 PM, with the Administrator/Clinical Manager, the agency expectation is for the agency staff to remove equipment from the nursing bag and place on barrier, use the equipment and return to barrier, at the end of the visit staff clean the equipment with disinfecting wipe, allow to dry for appropriate time frame and then return to the nursing bag. Staff are to delineate a clean area on the barrier and a dirty area on the barrier. Staff should not put equipment on the barrier, clean the equipment and place on the barrier in the same spot. 1. Patient #1 had a start of care date of 4/11/22 and received services from the Clinton office. On 1/7/25 at 10:00 AM, the surveyor accompanied Staff G, Registered Nurse (RN) to the patient’s home. Staff G removed thermometer, pulse oximeter, blood pressure cuff and stethoscope from nursing bag and placed on the plastic barrier in front of the bag and to the right. Staff G obtained the temperature and pulse oximeter readings for the patient, the thermometer and pulse ox were placed on the barrier in front of the bag and to the left side. Staff G obtained the blood pressure for the patient, the blood pressure cuff was removed from the patient’s arm and placed on the plastic barrier in front of the bag and to the right. Staff G used the stethoscope to listen to patient’s heart, lungs and abdomen. Staff G removed a disinfecting wipe from container, cleaned thermometer, returned thermometer to the left side of barrier, cleaned pulse oximeter, returned pulse oximeter to the left side of barrier, cleaned blood pressure cuff, returned blood pressure cuff to the right side of barrier, cleaned stethoscope, returned stethoscope to the right side of plastic barrier. At end of visit, thermometer, pulse oximeter, stethoscope and blood pressure cuff were returned to the nursing bag. The agency failed to ensure infection control standards were followed during patient care. 2. Patient #7 had a start of care date of 4/20/24 and received services from the Bettendorf office. On 1/7/25 at 1:15 PM, the surveyor accompanied Staff H, Physical Therapist (PT) to the patient’s home. Staff H removed thermometer, pulse oximeter, blood pressure cuff and stethoscope from nursing bag and placed on the plastic barrier in to the right of the bag. Staff H obtained the temperature and pulse oximeter readings for the patient, the thermometer and pulse ox were placed on the barrier to the left of the bag. Staff H obtained the blood pressure for the patient, the blood pressure cuff was removed from the patient’s arm and placed on the plastic barrier to the right of the bag. Staff H used the stethoscope to listen to patient’s heart, lungs and abdomen and placed on the barrier to the right of the bag. Staff H removed a disinfecting wipe from container, cleaned thermometer, returned thermometer to the left side of barrier, cleaned pulse oximeter, returned pulse oximeter to the left side of barrier, cleaned blood pressure cuff, returned blood pressure cuff to the right side of barrier, cleaned stethoscope, returned stethoscope to the right side of barrier. At end of visit, thermometer, pulse oximeter, stethoscope and blood pressure cuff were returned to the nursing bag. The agency failed to ensure infection control standards were followed during patient care. The above findings were reviewed with the Administrator/Clinical Manager and the Compliance Specialist.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services (Patients #9 and #16). The agency reported 128 patients who received home health aide services. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: According to the agency policy, titled Home Health Aide Services, dated 3/2023, a registered nurse or therapist will complete an initial assessment and determine the need for home health aide services. Tasks are delegated to the home health aide through the home health aide plan of care, which is developed in consultation with physician and patient. During an interview on 1/8/25 at 9:21 AM the Administrator/Clinical Manager stated if the aide cannot complete the task the aide will call the case manager or supervisor to get direction. 1. Patient #9 had a start of care date of 4/24/24. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 10/21/24 to 12/19/24 and 12/20/24 to 2/17/25, identified the patient had a diagnosis of a fractured femur and included physician orders for physical therapy and home health aide services. b. The Aide Care Plan, dated 10/21/24 to 12/19/24 and12/20/24 to 2/17/24, included direction to the aide to transfer the patient with a gait belt every visit. c. Home health aide visit note, dated 12/24/24, Staff S, Home Care Aide, failed to include documentation the aide performed the task of transferring with the use of a gait belt. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. 2. Patient #16 had a start of care date of 5/4/24 and discharge date of 6/27/24. Review of the clinical record revealed the following: a. The POC, dated 5/4/24 to 7/2/24, identified the patient had a diagnosis of a fractured right pubis and included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. a. The Aide Care Plan, dated 5/4/24 to 7/2/24, included direction to the aide to perform the task of bathing shower and partial sponge bath. b. Home health aide visit notes, dated 5/7, 5/9, 5/13, 5/20/24, Staff T, Home Care Aide, failed to include documentation the aide performed the task of shower and failed to document why the task was not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the Administrator/Clinical Manager and Compliance Specialist.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 3 of 5 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patients #9, #13 & #16). The agency reported 98 patients who received home health aide services with every 14 day supervision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency's policy titled Home Health Aide (HHA) Services, revised 3/2023, a registered nurse or therapist will case manage the patient and supervise services as defined by the regulations of the specific admissions type. Skilled home health: the nurse or therapist must make a HHA supervisory visit at least every fourteen days, or more frequently if needed. During an interview on 1/8/25 at 9:21 AM the Clinical Manager stated the HHA supervision is documented in the visit notes. 1. Patient #9 had a start of care date of 4/24/24. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 10/21/24 to 12/19/24 and 12/20/24 to 2/17/25, identified the patient had a diagnosis of a fractured femur and included physician orders for physical therapy and home health aide services. b. The physical therapy note, dated 11/25/24, Staff V, Physical Therapist (PT), included documentation of home health aide supervision. c. The physical therapy note, dated 12/12/24, Staff V, PT, included documentation of home health aide supervision (3 days late). The agency failed to provide home health aide supervision every 14 days. 2. Patient #13 had a start of care date of 9/6/24 and discharge date of 9/25/24. Review of the clinical record revealed the following: a. The POC, dated 9/6/24 to 11/4/24, identified the patient had a diagnosis of a fractured femur and included physician orders for physical therapy, occupational therapy and home health aide services. b. The physical therapy note, dated 9/20/24, Staff V, PT, included documentation of physical therapy aide supervision only. The clinical record lacked home health aide supervision and the agency failed to provide home health aide supervision every 14 days. 3. Patient #16 had a start of care date of 5/4/24 and discharge date of 6/27/24. Review of the clinical record revealed the following: a. The POC, dated 5/4/24 to 7/2/24, identified the patient had a diagnosis of a fractured right pubis and included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. The skilled nurse note, dated 5/15/24, Staff U, Registered Nurse (RN), included documentation of home health aide supervision. c. The skilled nurse note, dated 5/31/24, Staff U, RN, included documentation of home health aide supervision (2 days late). The agency failed to provide home health aide supervision every 14 days. The findings were reviewed with the Administrator/Clinical Manager and Compliance Specialist.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to complete provide wound assessments on a weekly basis per agency policy for 2 of 4 sampled patients with wounds (Patients #6 and #12). Failure to accurately and thoroughly complete wound assessments put patients at an increased risk of unidentified condition changes. Findings include: 2. Patient #6 had a Start of Care date of 12/17/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 12/14/24 to 2/14/25 identified the patient had a wound related to a diagnosis of a hernia. The POC included orders for skilled nursing services 2x weekly. b. Wound Nurse visit dated 12/23/24, identified 2 wounds to the abdomen, both as the result of protruding hernia. The wound to the Left Upper Quadrant (LUQ) measured 3 centimeters length(cm), by 1.3 cm width, by 0.1 cm in depth. The wound to the Left Lower Quadrant (LLQ) measured 3.5 cm length, by 4 cm width, by 0.1 cm depth. c. Skilled Nurse Visit Notes, dated 121/27/24 and 12/30/24 completed by Staff W, documented measurements of the LLQ wound but did not address the second wound of the LUQ. The agency nurse failed to obtain complete wound assessment and measurements weekly per agency policy. The surveyor reviewed the above findings with the Administrator/Clinical Manager and the Compliance Specialist. According to the agency policy titled Wound Care Guidelines, revised 3/2024, wound assessments will be done at every visit using the Integumentary Command Center and wound measurements must include length, width and depth. Measurements must be done weekly, with every attempt to be on the first visit of the week. During an interview on 1/8/25 at 9:21 PM the Administrator/Clinical Manager stated staff document in the electronic medical record weekly wound measurements, which include length, width and depth. 1.Patient #12 had a Start of Care date of 11/15/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/15/24 to 1/13/25, identified the patient had a diagnosis of aftercare following surgery for neoplasm with wound. The POC included orders for skilled nursing services weekly. b. The skilled nurse note, dated 12/16/24, Staff R, Registered Nurse (RN) included documentation of a wound to the anterior left subclavian due to trauma. The measurements included 2 centimeters (cm) length, by 1 cm width by 0.01 cm depth. c. The skilled nurse visit notes, dated 12/22/24 and 12/31/24, Staff R, RN failed to include documentation of an assessment including measurements of the wound to the anterior left subclavian area. The agency nurse failed to obtain complete wound assessment and measurements weekly per agency policy.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 1/18/2022 through 1/25/2022 . The survey found the agency operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 1/18/2022 through 1/25/2022 . The survey found the agency operating in substantial compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a current patient census of 802 patients, including 493 patients receiving services from the parent office, 119 patients receiving services from the Clinton branch office and 119 patients receiving services from the Illinois branch office.

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 record review, agency policy review, patient/family and agency staff interview and home visit observation, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 10 of 17 sampled patients (Patients #1, #2, #4, #5, #7, #9, #10, #11, #15 and #16). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 6. Patient #2 had a start of care date of 8/31/21 and received services from the Bettendorf parent office. The Plan of Care, dated 12/29/21 to 2/26/22, included physician orders for acetaminophen every 4 hours prn (as needed) pain/fever. During a home visit observation, on 1/18/22 at 3:10 PM, with Staff E, registered nurse, the surveyor received a copy of the patient current medication administration record that included physician orders for acetaminophen every 6 hours prn effective 11/19/21. The Plan of Care failed to identify the correct medication frequency for acetaminophen. 7. Patient #5 had a start of care date of 4/21/21 and received services form the Clinton branch office. Clinical record review revealed Plans of Care, dated 10/18/21 to 12/16/21 and 12/17/21 to 2/14/22, included adaptive living aids, personal care, raised toilet seat, ostomy, physical therapy, specialty dressings and urologicals as medical equipment and supplies used by the patient. During a home observation visit on 1/19/22 at 8:00 AM, with Staff F, registered nurse (RN), Patient #5 reported having several pieces of medical equipment that had belonged to the patient’s deceased mother, including a raised toilet seat, reacher, sock aid, dressing stick, and 2 types of walkers. Patient #5 reported never using the raised toilet seat, reacher, sock aid or dressing stick but had them available if needed in the future. During an interview with Staff F, RN, at above home observation visit, Staff F reported identifying all medical equipment in the home even if not being used currently; adding specific categories for staff to order needed equipment or supplies during services, such as physical therapy for physical therapist or occcuptional therapist therapy bands; personal care for shampoos, conditioner and lotion used by patient; ostomy for possible wound care supplies to contain drainage but never used; specialty dressings for wound vac used in the past; and urologicals for wound drain supplies used in the past. The nurse failed to update the Plan of Care with the specific medical equipment and supplies currently used by the patient. 8. Patient #11 had a start of care date of 11/21/21 and received services from the Bettendorf parent office. Clinical record review revealed: a. Plans of Care, dated 11/21/21 to 1/19/22 and 1/20/22 to 3/20/22, included shower/tub equipment, personal care, respiratory equipment, and specialty dressings, as medical equipment and supplies used by the patient. b. Medical Record Coordination Note type, Admission/ROC (resumption of care) Summary, dated 11/21/21, included documentation the patient had a commode in the home. The Plan of Care failed to identify specific medical equipment and supplies the patient used at the start of care and at the recertification of care. 9. Patient #15 had a start of care date of 9/2/21, a discharge date of 11/12/21 and received services from the Illinois branch office. Clinical record review revealed: a. Plans of Care, dated 9/2/21 to 10/31/21 and 11/1/21 to 12/30/21, included gait belt, med planner, reaching device, shower chair, rolling walker and physical therapy as medical equipment and supplies used by the patient. b. PTA (physical therapy assistant) visit note, dated 9/16/21, included documentation the patient’s sibling had obtained a single point cane for patient to use and patient was working on proper use of the cane. The Plan of Cares failed to identify specific medical equipment and supplies the patient used at the start of care and at the recertification of care. 10. Patient #16 had a start of care date of 9/14/21, a discharge date of 12/11/21 and received services from the Illinois branch office. Clinical record review revealed Plans of Care, dated 9/14/21 to 11/12/21 and 11/13/21 to 1/11/22, included vital signs equipment as medical equipment and supplies used by the patient. The Plans of Care failed to identify the specific medical equipment and supplies used by the patient. The Administrator, Clinical Manager, Staff C, Compliance Specialist, Staff D, Clinical RN (registered nurse), Staff L, Nursing Supervisor Illinois office, Staff M, Rehab Manager, Staff N, Clinical Supervisor Clinton office, Staff O, Clinical Supervisor parent office, and Staff P, Clinical Supervisor parent office, received the above findings and the agency provided no additional information prior to the end of the survey. 4. Patient #7 had a start of care date of 10/22/21 and received agency services from the Bettendorf parent office. Review of the clinical record revealed the following: The Plans of Care (POC), dated 10/22/21 to 12/20/21 and 12/21/21 to 2/18/22, identified the patient used the following medical equipment and supplies: gastrostomy tube, oxygen supplies, pump/monitors. On 1/19/22 at 12:00 PM, during a home visit observation with Staff I, Registered nurse (RN), the surveyor observed the patient had a floor chair with straps, oxygen concentrator and nebulizer machine. The surveyor observed the patient using the floor chair and oxygen concentrator. During an interview with the patient’s caregiver during the same home visit observation he/she identified the patient uses the nebulizer machine. The POC’s dated 10/22/21 to 12/20/21 and 12/21/21 to 2/18/22 failed to identify the patient used a floor chair with straps, oxygen concentrator and nebulizer machine. The same plan of care identified orders for medications: Albuterol sulfate 2.5mg/3ml solution for nebulization take every 4 hours, Bosentan 32mg tablet take 1 tablet 2 times daily and Acetaminophen 160mg/5ml take 3.1ml every 6 hours as needed. During the same home visit observation Staff I, RN reviewed the medications with the family and the surveyor. Family stated the Albuterol sulfate 2.5mg/3ml solution for nebulization take every 4 hours is incorrect and the correct order is for every 4 hours as needed (PRN) when the patient has wheezing. Family stated the doctor discontinued Bosentan 12/2021 and changed the dose of Acetaminophen 160mg/5ml take 5ml every 6 hours PRN 11/23/21. During an interview with the patient’s family during the same home visit observation he/she identified the patient uses tube feedings/formula pedialite peptide. The POC’s dated 10/22/21 to 12/20/21 and 12/21/21 to 2/18/22 identified nasogastric tube feeds and gastrostomy tube feedings. The POC’s dated 10/22/21 to 12/20/21 and 12/21/21 to 2/18/22 lacked parameters including amount and frequency of ordered feedings. 5. Patient #1 had a start of care date of 8/22/21 and received agency services from the Bettendorf parent office. Review of the clinical record revealed the following: The Plans of Care (POC), dated 10/21/21 to 12/19/21 and 12/20/21 to 2/17/22, identified the patient used the following medical equipment and supplies: Compression garment/device, oxygen supplies, rails/grab bars, respiratory supplies, walker, gauzes/dressings/specialty dressings, syringes/needles. On 1/18/22 at 2:30 PM, during a home visit observation with Staff H, Registered nurse (RN), the surveyor observed the patient using a portable oxygen concentrator, oxygen tanks, and Cpap machine. During a interview on 1/20/22 at 11:37 AM the patient verbalized having used the Cpap machine since 8/2021. The POC’s dated 10/21/21 to 12/19/21 and 12/20/21 to 2/17/22, failed to identify durable medical equipment (DME); portable oxygen concentrator, oxygen tanks, and Cpap machine. The agency failed to include all medical equipment, supplies and medications used by the patient on the Plan of Care. According to the agency policy titled Admission Criteria and Process, dated 6/2021, a Plan of Care will be developed in consultation with provider and patient. Treatments and services identified in the Plan of Care must be approved by the provider (verbally or with signed order) prior to the initiation of services. 1. Patient #4 had a start of care date of 5/5/21 and received agency services from the Clinton branch office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 12/31/21 to 2/28/22, identified the patient used the following medical equipment and supplies: Glucometer supplies, hand held shower, medication planner, pill cutter, rails/grab bars, scooter, tub chair and rolling walker. On 1/19/21 at 9:15 AM, during a home visit observation with Staff J, Registered nurse (RN), the surveyor observed the patient had a wheelchair and wheelchair cushion. During an interview during the same home visit observation the patient identified using the wheelchair and wheelchair cushion when he/she may become to shaky to ambulate safely and had used since the start of home care services. The POC failed to identify the patient used a wheelchair and cushion. b. The Plan of Care, dated 12/21/21 to 2/28/22, included orders for the following medications: Tylenol extended release 2 tablets. The order failed to include the medication frequency and reason for use. The POC also included the order for glucose 4 tablets prn (as needed). The order failed to include frequency and reason for use. The plan of care failed to correctly identify complete orders for medications used by the patient. 2. Patient #9 had a start of care date of 12/1/21 and received agency services from the Illinois branch office. Review of the clinical record revealed the following: a. The POC, dated 12/1/21 to 1/29/22, identified the patient used the following medical equipment and supplies: Cane, gait belt, rails/bars, raised toilet seat, shower tub equipment, walker, wheelchair and powered wheelchair. Review of the occupational therapy visit note, dated q12/2/21, identified the patient had a shower chair and tub bench. The POC failed to identify the actual equipment used by the patient. 3. Patient #10 had a start of care date of 11/2/21 and received agency services from the Bettendorf parent office. Review of the clinical record revealed the following: a. The POC, dated 11/2/21 to 12/31/22 and 1/1/22 to 3/1/22, identified the patient used the following medical equipment and supplies: gait belt, glucometer, oxygen supplies, respiratory supplies, shower chair, wheelchair, dressing supplies, syringes and needles. Review of the skilled nurse visit note, dated 11/8/21, identified the patient used a bilevel positive airway pressure (BIPAP) machine. The POC failed to identify the actual equipment used by the patient.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 7 sampled patients with wound care. (Patients #5 and #17). Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. 2. Patient #5 had a start of care date of 4/21/21 and received services from the Clinton branch office. The clinical record review revealed: a. The recertification comprehensive assessment visit note, dated 12/16/21, identified an abdominal midline surgical incision with wound measurements identified as 0.5 cm by 0.5 cm by 2.1 cm. b. The skilled nursing visit notes for the week of 12/19/21 through 12/25/21, dated 12/22/21 and 12/24/21, identified an abdominal midline surgical incision wound assessed and wound care provided. The notes failed to include wound measurements. The clinical record lacked weekly wound measurements as required per agency policy on a weekly basis. The Administrator, Clinical Manager, Staff C, Compliance Specialist, Staff D, Clinical RN (registered nurse), Staff L, Nursing Supervisor Illinois office, Staff M, Rehab Manager, Staff N, Clinical Supervisor Clinton office, Staff O, Clinical Supervisor parent office, and Staff P, Clinical Supervisor parent office, received the above findings and the agency provided no additional information prior to the end of the survey. According to the agency policy titled Wound Care Guidelines, dated 3/2021, wound measurements must include: length, width and depth. Measurements must be done weekly on Monday. If no visit is scheduled on Monday, wound measurements should be performed on the first scheduled visit of the week. Wound measurements will be done with every comprehensive/OASIS (outcome and assessment information set) assessment. During an interview on 1/18/22 at 10:55 AM, the Clinical manager stated wounds are measured weekly and should include length x width x depth. 1. Patient #17 had a start of care date of 5/4/21 and a discharge date of 7/26/21 and received services from the Clinton branch office. The clinical record review revealed: a. The skilled nursing visit note, dated 7/8/21, identified an open wound on the patient's left planter foot that measured 2.5 cm (centimeters) by 3.8 cm by 0.2 cm. b. The skilled nursing visit notes for the week of 7/11/21 through 7/17/21, dated 7/15/21 and 7/17/21, identified an open wound on the patient's left planter foot. The notes failed to include wound measurements. The clinical record lacked weekly wound measurements as required per agency policy on a weekly basis.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 2 of 17 sampled patients. (Patient #2 & #12). Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to not receive safe, individualized and consistent care designed to meet each patients' health care needs. 1. Patient #2 had a start of care date of 8/31/21 and received services from the Bettendorf parent office. Clinical record review revealed: a. Interim physician order, dated 12/3/21, to cleanse wound with normal saline, apply triad paste to wound bed and periwound, cover with alginate and 2 layer wrap from base of toes to 2 finger widths below knee. b. Skilled nursing visit note, dated 12/17/21, included documentation wound care provided cleansed with normal saline, applied triad paste into wound bed and periwound, covered with alginate and 2 layer wrap from base of toes to 2 finger widths below knee; and no 2 layer wrap available, cleansed wound, applied triad paste, alginate and covered with foam pad, Dr. informed of no supplies available and used prior order. c. Skilled nursing visit note, dated 12/21/21, included documentation wound care provided cleansed with normal saline, applied triad paste into wound bed and periwound, covered with alginate and 2 layer wrap from base of toes to 2 finger widths below knee; and supplies still not delivered, cleansed wound, applied triad paste, alginate and covered with foam pad, Dr. informed of no supplies available and used prior order. The nurse failed to provide wound care as ordered by the physician. 2. Patient #12 had a start of care date of 7/11/19 and received services from the Bettendorf parent office. Clinical record review revealed: a. Plan of Care, dated 10/28/21 to 12/26/21, included orders for skilled nursing and home health aide services. b. Resumption of Care orders, dated 12/17/21, included orders for occupational therapy effective 12/19/21 for one visit for the week 12/19/21 to 12/25/21. c. Occupational therapy evaluation visit note, dated 12/30/21, included documentation the evaluation visit was completed. The clinical record lacked documentation why the occupational therapy evaluation was not completed the week of 12/19/21 as ordered. The Administrator, Clinical Manager, Staff C, Compliance Specialist, Staff D, Clinical RN (registered nurse), Staff L, Nursing Supervisor Illinois office, Staff M, Rehab Manager, Staff N, Clinical Supervisor Clinton office, Staff O, Clinical Supervisor parent office, and Staff P, Clinical Supervisor parent office, received the above findings and the agency provided no additional information prior to the end of the survey. According to the agency policy titled Care Coordination, dated 10/2021, to ensure continuity of care, the Case Manager will be responsible for ensuring if the home health agency misses a visit or a treatment/service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the agency must notify the responsible provider of such missed treatment or service. The provider decides whether the treatment or service may be skipped or whether additional intervention is required by the home health agency due to the clinical impact on the patient.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure the agency completed documentation including signature, title and time of entry in a timely manner for 5 of 17 sampled patients (Patients #6, #8, #11, #15 and #17). Failure to maintain timely, accurate and appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. 3. Patient #6 had a start of care date of 6/3/19 and received services from the Bettendorf parent office. Clinical record review revealed: a. Plan of Care, dated 11/19/21 to 1/17/22, included orders for skilled nursing visits weekly. b. The electronic medical record included a skilled nurse visit note, dated 1/6/22, with an electronic signature, dated 1/8/22, 1 day late per agency policy. 4. Patient #11 had a start of care date of 11/21/21 and received services from the Bettendorf parent office. Clinical record review revealed: a. Plan of Care, dated 11/21/21 to 1/19/22, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. The electronic medical record included physical therapy visit note, dated 12/2/21, with an electronic signature, dated 12/4/21, 1 day late per agency policy. c. The electronic medical record included physical therapy visit note, dated 12/8/21, with an electronic signature, dated 12/11/21, 2 days late per agency policy. 5. Patient #15 had a start of care date of 9/2/21, a discharge date of 11/12/21 and received services from the Illinois branch office. Clinical record review revealed: a. Plan of Care, dated 9/2/21 to 10/31/21, included orders for skilled nursing, physical therapy and occupational therapy services. b. The electronic medical record included occupational therapy visit note, dated 9/3/21, with an electronic signature, dated 9/5/21, 1 day late per agency policy. c. The electronic medical record included skilled nursing visit note, dated 9/27/21, with an electronic signature, dated 9/29/21, 1 day late per agency policy. d. The electronic medical record included skilled nursing visit note, dated 10/22/21, with an electronic signature, dated 10/24/21, 1 day late per agency policy. According to the agency policy titled, Documentation Timeframe, dated 5/2020, documentation of routine follow-up home visits, add-on evaluations, and discipline discharges must be completed and synchronized by noon of the next calendar day. During an interview on 1/18/22 at 10:55 AM, the Clinical manager stated visit notes should be locked by noon the day after the visit. 1. Patient #8 had a start of care date of 11/3/21 and received services from the Illinois branch office. The Plan of Care, dated 11/3/21 to 1/1/22 and 1/2/22 to 3/2/21, included orders for skilled nursing services. Electronic health record review revealed the skilled nursing visit note, documented the visit occurred on 11/24/21, with an electronic signature indicating completion on 11/26/21, 1 day late according to agency policy. Electronic health record review revealed the skilled nursing visit note, documented the visit occurred on 11/26/21, with an electronic signature indicating completion of 11/28/21, 1 day late according to agency policy. Electronic health record review revealed the skilled nursing visit note, documented the visit occurred on 12/8/21, with an electronic signature indicating completion of 12/10/21, 1 day late according to agency policy. 2. Patient #17 had a start of care date of 5/4/21 and date of discharge of 7/26/21 and received services from the Clinton branch office. The Plan of Care, dated 5/4/21 to 7/2/21 and 7/3/21 to 8/31/21, included orders for skilled nursing and speech therapy services. Electronic health record review revealed the speech therapy visit note, documented the visit occurred on 6/15/21, with an electronic signature indicating completion on 6/20/21, 4 days late according to agency policy.