Every finding on record at Guaranteed Medical Services, Inc.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to develop strategies to address potential emergencies identified as risks. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan, last revised on 4/30/21 was reviewed on 5/25/21 at 3:15 PM. The plan included a Hazard Vulnerability Assessment, indicating the Agency's population was at risk for a variety of natural and man-made emergencies, including tornados, flooding, civil disturbance, etc. The plan lacked strategies to address each of the potential emergency situations it identified as a risk. 2. During an interview with the Administrator and the Clinical Supervisor on 5/25/21 at 2:25 PM, the Administrator confirmed the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on the review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 5/25//21 at 3:15 PM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement, Patients' Physicians, and Volunteers. 2. The Agency's "Emergency Preparedness Plan" policy was reviewed on 5/25/21 at 3:45 PM. The policy required: "...Each office will keep and maintain a current list of contact information for staff, staff family members, vendors, emergency services, hospitals, and other appropriate community resources..." 3. During an interview with the Administrator and Clinical Supervisor on 5/26/21 at 2:25 PM, the Administrator confirmed the above findings.

. Recertification survey was conducted. Standard level deficiencies cited. Focused Infection Control Survey was conducted. Standard level deficiencies cited. Abbreviations: AM= Morning PM= Afternoon Pt./Pts. = Patient/Patients SOC= Start of Care SN = Skilled Nurse POC = Plan of Care mg = Milligrams mcg = Micrograms x = By - = To cm = Centimeters R = Right Humulin R = Humulin Regular Insulin nss = Normal Saline Solution

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: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure the POC contained wound care treatment orders for 1 of 1 (Pt. #7) reviewed for wound care and treatment. Findings include: 1. Pt. #7. SOC 9/10/20. Primary Diagnosis: Pressure Ulcer of Sacral Region, Stage 4. The clinical record was reviewed on 5/25/21 at 1:20 PM. The record contained documentation Pt. #7 had a stage 4 pressure ulcer, first noted on the SN visit note dated 9/17/20, although this note indicates the onset of this wound was 5/14/19. This pressure ulcer measured 1 cm long x 1 cm in wide x 1.0 cm deep. The treatment given by the SN on this visit was to "cleanse the wound with wound cleanser, fill with medihoney gel, skin prep pads, 6 x 6 silicone foam border dressing 24/7, use hypafix or similar tape to border this and prevent dressing loss, change every 2 days or sooner if soiled." This pressure ulcer measured 1 cm long x 1 cm in wide x 1.0 cm deep. On the same SN visit note dated 9/17/20, Pt. #7 was also found to have a right lateral breast stage 2 pressure ulcer wound, which measured 1 cm long x 1 cm wide x 0.1 cm deep, although this note indicates the onset of this wound was 5/14/19. The treatment given by the SN on this visit was to "cleanse with wound cleanser, fill with Medihoney gel, skin prep pads, island dressing 4 x 4. Rotate side to side off wound every 2 hours 24/7." The record contained a POC for the recertification period effective 11/9/20 to 1/7/21. This POC lacked wound treatment orders, and there were no additional Physician orders for wound treatment. However, the record included documentation Pt. #7 was seen weekly by the SN during this time, who had continued to provide wound care to the sacral and right lateral breast ulcer as indicated above, although there were no Physician's orders for this treatment. 2. During an interview with the Administrator and the Clinical Supervisor on 5/26/21 at 2:25 PM, the Clinical Supervisor confirmed the POC effective 11/9/20 to 1/7/21 lacked Physician orders for wound care and treatment.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure it obtained Physician orders for wound care treatment for 1 of 1 (Pt. #7) reviewed for would care and treatment. Findings include: 1. Pt. #7. SOC 9/10/20. Primary Diagnosis: Pressure Ulcer of Sacral Region, Stage 4. The clinical record was reviewed on 5/25/21 at 1:20 PM. The record contained documentation Pt. #7 had a stage 4 pressure ulcer, first noted on the SN visit note dated 9/17/20, although the onset date was noted as 5/14/19. This pressure ulcer measured 1 cm long x 1 cm in wide x 1.0 cm deep. The treatment given by the SN on this visit was to "cleanse the wound with wound cleanser, fill with medihoney gel, skin prep pads, 6 x 6 silicone foam border dressing 24/7, use hypafix or similar tape to border this and prevent dressing loss, change every 2 days or sooner if soiled." This pressure ulcer measured 1 cm long x 1 cm in wide x 1.0 cm deep. Pt. #7 was also found on the 9/17/20 SN visit to have a right lateral breast stage 2 pressure ulcer wound, which measured 1 cm long x 1 cm wide x 0.1 cm deep, although the onset date was noted as 5/14/19. The treatment given by the SN on this visit was to "cleanse with wound cleanser, fill with Medihoney gel, skin prep pads, island dressing 4 x 4. Rotate side to side off wound every 2 hours 24/7." The record lacked documentation of a Physician's order for the above wound care and treatment to Pt. #7's sacral and right breast wounds. The record included documentation Pt. #7 was seen weekly by the SN from 9/17/20 through 1/28/21, who had continued to provide wound care to the sacral and right lateral breast ulcer as indicated above, without a Physician's order for this treatment. 2. During an interview with the Administrator and the Clinical Supervisor on 5/26/21 at 2:25 PM, the Clinical Supervisor confirmed the lack of a Physician orders for wound care and treatment as provided by the SN.

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: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure Pts. were assessed for the status of the Influenza and/or Pneumococcal vaccine at the (SOC) Start of Care per Agency policy. This was found in 7 of 7 (Pts. #3, 4, 5, 1, 2, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #3. SOC 02/03/21. Primary Diagnosis: Other Sequela of Cerebral Infarction. The clinical record was reviewed on 05/24/21 at 3:00 PM. The record form for Influenza and Pneumonia verification was left blank, and documented that the patient had been informed that arrangements have been offered to Pt., and that the Pt. elected to see their Primary Physician and have their Physician administer the vaccination(s). 2. Pt. #4. SOC 05/04/21. Primary Diagnosis: Chronic Obstructive Pulmonary disease, Unspecified. The clinical record was reviewed on 05/25/21 at 11:30 AM. The record form for Influenza and Pneumonia verification was left blank, and documented that the Pt. had been informed that arrangements have been offered to Pt., and that the Pt. elected to see their Primary Physician and have their Physician administer the vaccination(s). 3. Pt. #5. SOC 11/04/20. Primary Diagnosis: Essential (primary) Hypertension. The clinical record was reviewed on 05/25/21 at 2:00 PM. The record form for Influenza and Pneumonia verification was left blank for Pneumonia vaccine verification. 4. Pt. #1. SOC 4/9/21. Primary Diagnosis: Chronic Atrial Fibrillation. The clinical record was reviewed on 5/24/21 at 3:10 PM. The record contained a form signed by the Pt. on 4/9/21 that contains areas to indicate the Patient's Influenza and Pneumococcal vaccination status. The boxes indicating Pt. #1's influenza and pneumonia vaccine verification were both left blank. 5. Pt. #2. SOC 1/19/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 5/24/21 at 3:55 PM. The record contained a form signed by the Pt. on 1/19/21 that contains areas to indicate the Patient's Influenza and Pneumococcal vaccination status. The box indicating Pt. #2's pneumonia vaccine verification was left blank. 6. Pt. #6. SOC 6/13/20. Primary Diagnosis: Major Depressive Disorder, Recurrent, Unspecified. The clinical record was reviewed on 5/25/21 at 11:00 AM. The record contained a form signed by the Pt. on 6/13/20 that contains areas to indicate the Patient's Influenza and Pneumococcal vaccination status. The box indicating Pt. #6's pneumonia vaccine verification was left blank. 7. Pt. #7. SOC 9/10/20. Primary Diagnosis: Pressure Ulcer of Sacral Region, Stage 4. The clinical record was reviewed on 5/25/21 at 1:20 PM. The record contained a form signed by the Pt., but not dated, that contains areas to indicate the Patient's Influenza and Pneumococcal vaccination status. The box indicating Pt. #7's pneumonia vaccine verification was left blank. 8. The Agency policy titled "Vaccinations" was reviewed on 5/26/21 at 1:00 PM. The policy required: "...Upon initiation of home health services, the admitting clinician will complete an assessment to determine the Patient's influenza and pneumococcal vaccination status...A form will be completed indicating the need, Patient response, arrangement, and follow-up activities, and included in the Patient's medical record..." 9. During an interview with the Administrator and Clinical Supervisor on 5/26/21 to 1:45 PM and 2:25 PM, the Clinical Supervisor confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on review of the Agency Home Health Policy, Covid-19 Informational binders. Director of Nursing/Agency Supervisor Policy and staff interview, it was determined the Agency failed to maintain and implement a surveillance program to identify, prevent, control, monitor and track staff and Pts. This has the potential to affect all Pts. receiving services from the Agency. Findings: 1. The Agency's Home Health Policy and COVID-19 Informational Covid-19 binders were reviewed on 5/26/21 at 10:00 AM. These binders lacked any data related to infection control surveillance. The Agency also lacked any Infection Logs tracking staff and Pt. infections. The "Agency Home Health Policy" binder contained the "Infection Disease Control" policy which required: "...The Director of Nursing shall monitor infection statistics through employee and patient infection reports, which will be kept in a separate binder...Infection control tracking shall be used to collect and trend data, which shall be utilized to assess the effectiveness of the infection control program...The Infection Surveillance program activities will be conducted quarterly by any designated by the Administrator and shall be reviewed by (QAPI) Quality Assurance and Performance Improvement Group and Governing Body at least annually to evaluate its effectiveness...The Data collection activities will be performed quarterly, a comprehensive quality report will be presented to governing body annually..." 2. The Agency's Director of Nursing/Agency Supervisor policy documents under: Policy Statement: 4. q. "Retain an up-to date knowledge of clinical practice standards and disease management. 3. During interview with the Administrator and Clinical Supervisor on 5/25/21 between 1:45 PM and 2:25 PM, the Clinical Supervisor stated surveillance procedures are not being followed and confirmed the above findings.

Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: This STANDARD is not met as evidenced by: . A. Based on staff interview, review of personnel file and review of the most recent Illinois Department of Health (IDPH) renewal Licensure Application, not dated, it was determined that the Agency failed to notify IDPH of a recent change in management. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. Entered the Agency on 5/24/21 at 10:00 AM and was greeted by staff #6, who identified self as being the Clinical Supervisor. During the entrance interview with the Clinical Supervisor, it was confirmed Staff #6 was the Agency Supervisor (Clinical Supervisor) since 2016. 2. The personnel file of Staff #1 was reviewed on 5/26/21 at 11:00 AM. The file included an application dated 12/05/16. The application documented: "Position Category": "HCC". The file also included a copy of "Job Description": Registered Nurse. Responsible To: Director of Nursing. This document was signed by staff #1 on 7/9/17. 3. The personnel file of Staff #6 was reviewed on 5/26/21 at 11:15 AM. The file included an application dated 11/01/16. The application documented: "Position Category": Assistant Administrator/RN". The file also included a copy of "Job Description": Director of Nursing. Responsible To: Administrator. This document was signed by staff #6 on 2/9/21, becoming the new Clinical Supervisor. 4. The most recent Agency Licensure Renewal Application, not dated, documents as Clinical Supervisor staff #1 and not #6 as stated by staff #6 who is the actual Clinical Supervisor. 5. During an interview with the Administrator on 5/26/21 at 12:15 PM, the Administrator confirmed The Agency's new Clinical Supervisor is Staff # 6, since February of 2021. An inquiry was made to whether IDPH was notified of the new Clinical Supervisor, the Administrator responded "No". As of 5/26/21, the Administrator has not presented documentation indicating IDPH was notified Staff # 6 is the new Clinical Supervisor for the Agency. On 5/27/21 at 11:00 AM. Staff #6 informed survey team that the Administrator was not going to be present at the Agency today.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: . A. Based on review of the most recent Illinois Department of Public Health (IDPH) Renewal Licensure Application, not dated, and staff interview, it was determined the Agency failed to ensure the administrator employed qualified staff to provide Home Health Aide services. This has the potential to affect all patients requiring Home Health Aide services. Findings include: 1. On 5/26/21 at 12:00 PM, the Administrator presented the Illinois Department of Public Health (IDPH) Home Health Agency Renewal Application, not dated and with information missing. The application included initials (PU) documenting Staff #7 was employed by the Agency to provide Home Health Aide services. A request was made to review the personnel file of Staff #7, the Administrator responded: "The Home Health Aide (HHA) no longer works here, patients prefer a homemaker instead of HHA. If patients need services from HHA, I can hire a HHA then." 2. The HHA original license number 1011913 posted in hallway, indicated the Agency can provide Home Health Aide services. As of 5/26/21, the Agency lacked a Home Health Aide to provide personal care for patients. 3. During an interview with the Administrator on 5/26/21 at 12:15 PM, the Administrator confirmed the Agency has not employed a Home Health Aide and has not provided Home Health Aide services within the past year. On 5//27/21 at 1:00 PM, the Clinical Supervisor confirmed the above Administrator's statement.

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 observations and interviews during home visits, review of clinical records, Agency policy review, and staff interview, it was determined that the Agency failed to ensure that Patients' medication profile was accurate and contained all medications the Pts. are currently taking. This was found in 3 of 7 (Pts. #1, 2 and 3) clinical records reviewed. Findings include: 1. Pt. #3. SOC: 2/03/2. Primary Diagnosis: Other Sequela of Cerebral Infarction. A home visit was conducted on 5/25/21 at 9:30 AM with the Physical Therapist. During the home visit observation and review of medications, the Patient's Caregiver did not present medication bottles for "Cipro 250 mg oral tablet" and "Enalapril 5 mg tablet." The Patient's Caregiver stated that the Pt. was not taking those two medications because they had been discontinued. The clinical record of Pt. #3 was reviewed on 05/24/21 at 3:00 PM. The record included a Medication Profile for the episode effective 4/4/21 to 6/2/21, and the above medications were under the "Active Medications" list. 2. Pt. #1. SOC 4/9/21. Primary Diagnosis: Chronic Atrial Fibrillation. The clinical record was reviewed on 5/24/21 at 3:10 PM. A home visit was conducted on 5/25/21 at 9:30 AM, along with E #1. During this home visit, Pt. #1's medications were observed and reconciled along with Pt. #1's Medication Profile. Pt. #1's Medication Profile included the Physician's order for "Ibuprofen 800 mg tablet three times daily by mouth;" however, Pt. #1 stated this medication was discontinued by the Physician "one month ago, due to my stomach was upset." This Medication Profile also contained the Physician's order for "Meclizine 12.5 mg twice daily by mouth;" however, Pt. #1 stated "I take it only if needed." The medication profile was inaccurate. 3. Pt. #2. SOC 1/19/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 5/24/21 at 3:55 PM. A home visit was conducted on 5/25/21 at 12:00 PM, along with E #2. During this home visit, Pt. #2's medications were observed and reconciled along with Pt. #2's Medication Profile. Pt. #2's Medication Profile contained the Physician's order for "Humulin R (Insulin) 100 Unit/ML injection solution 38 units twice daily subcutaneous;" however, Pt. #2 stated "I take Humulin R insulin per sliding scale coverage for the last 2 months." Pt. #2 provided a copy of the sliding scale coverage for Humulin R subcutaneously, for blood glucose levels taken before each meal and at bedtime, which read: "blood sugar 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units." This Medication Profile also included the Physician's order for "Lantus subcutaneous solution 10 units in morning/noon/night when blood sugar level is elevated, follow sliding scale subcutaneous." Pt. #2 stated "I take 20 units of Lantus insulin each night at bedtime, for the last 2 months." This medication profile also contained the Physician's order for "Levothyroxine Sodium 25 mcg tablet 1 tablet daily by mouth;" however, Pt. #2 stated "I take 75 mcg of Levothyroxine every day, for years." The medication profile was inaccurate. 4. The Agency's policy titled "Drugs and Biologicals" was reviewed on 5/26/21 at 1:00 PM. The policy required: ".... The Medication Profile shall be reviewed, updated, and resigned by a registered nurse at least every 30 days and whenever there is a change or discontinued medications..." 5. During interviews with the Administrator and Clinical Supervisor on 5/25/21 between 1:45 PM and 2:25 PM, the Clinical Supervisor stated the medication list should be up to date and confirmed the above findings.