Every finding on record at Holistic Health Partners, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 10/24/24. Standard level deficiencies cited. Pt./Pts.= Patient/Patients

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Operations Plan and staff interview, it was determined that the Agency failed to review and update its Emergency Operation Plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan was reviewed on 10/21/24. The Plan included "UPDATED 10/15/2021". The Agency failed to update the plan every 2 years. 2. During an interview with the Administrator, Director of Nursing, and Administrative Assistant on 10/23/24 at 4:30 PM, the Administrator confirmed the Agency’s Emergency Operations Plan was last updated on 10/15/21.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Operations Policies and Procedures and staff interview, it was determined that the Agency failed to review and update its Emergency Operations Policies and Procedures biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan was reviewed on 10/21/24. The Emergency Operations Policies and Procedures lacked the date indicating when it was last reviewed. 2. During an interview with the Administrator, Director of Nursing, and Administrative Assistant on 10/23/24 at 4:30 PM, the Administrator stated the Emergency Operations Policies and Procedures were last reviewed on 10/15/21. The Agency failed to update the Policies and Procedures biennially. During the same interview, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 10/24/24. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care POC = Plan of Care SN = Skilled Nurse AM = morning PM = afternoon % = Percent lbs. = pounds # = number HHA= Home Health Aide PT = Physical Therapy OT = Occupational Therapy RN = Registered Nurse LPN = Licensed Practical Nurse OASIS = Outcome and Assessment Information Set MD = Medical Doctor mgs/dl = milligrams per deciliter FBS = Fasting Blood Sugar RBS = Random Blood Sugar BP = Blood Pressure Wk = week

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interviews, it was determined that in 789 of 2176 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 7/2023 to 6/2024, was reviewed on 10/21/24. The report included error # -3330 for 789 of 2176 late submissions, which was 32.26 % of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Administrator, Director of Nursing, and Administrative Assistant on 10/24/24 at 11:45 AM, the administrative team confirmed that the error occurred.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews, it was determined for 4 of 17 (Pts. #14, #7, #9 and #15) clinical records reviewed, the Agency failed to ensure care and/or services were provided as ordered by the Physician and as indicated in the POC. 2. Pt. #7 was admitted for home health services on 7/9/24 with the diagnosis of Hypertensive Chronic Kidney disease with Stage 1 through Stage 4 Chronic Kidney disease. The clinical record was reviewed on 10/22/24. The clinical record contained a POC effective 7/9/24 to 9/6/24 and effective 9/7/24 to 11/5/24, required PT “Orders for Discipline and Treatment….Vital Sign Parameters….Weight gain more than 5 lbs or weight loss of less than 5 lbs in 1 week Notify MD….” The clinical records contained weekly PT notes from 8/27/24 to 10/16/24 and lacked weight assessments as ordered. 3. Pt. #9 was admitted for home health services on 8/15/24 with the diagnosis of Type 2 Diabetes Mellitus and Encounter for Attention to Cystostomy. The clinical record was reviewed on 10/23/24. The record contained a POC effective 8/15/24 to 10/13/24 and 10/14/24 to 12/12/24, required “….Interventions:….SN to re-assess suprapubic catheter….”. The clinical record contained SN assessments dated 8/31/24 and 9/28/24, and lacked suprapubic catheter assessments as ordered. The POC effective 8/15/24 to 10/13/24, required: SN frequency 1 time per month and "….Vital Sign Parameters….Systolic BP…. Notify MD….Diastolic BP….Notify MD….Weight gain more than 5 lbs or weight loss of less than 5 lbs in 1 week Notify MD…. FBS less than 60 mg/dl or above 200 mg/dl or RBS less than 60 mg/dl or above 300 mg/dl Notify MD….” The SN assessment note dated 8/23/24, lacked a blood sugar assessment and a weight assessment as ordered. The SN assessment note dated 10/12/24, lacked a blood sugar assessment as ordered. The OT note dated 9/6/24, lacked a blood pressure assessment as ordered. 4. Pt. #15 was admitted for home health services on 1/19/24 with the diagnosis of Pressure Ulcer of Sacral Region. The clinical record was reviewed on 10/23/24. The clinical record contained a POC effective 3/19/24, that required SN frequency of “1 WK 9”. The record lacked a SN visit for the week 4/17/24 as ordered. 5. During interviews with the Administrator, Director of Nursing and Administrative Assistant on 10/23/24 at 3:30 PM and with Administrator and Director of Nursing on 10/24/24 at 9:30 AM, the above findings were confirmed. Findings include: 1.. Pt. #14 is admitted for home health services with the diagnosis of Pressure Ulcer of Sacral Region. The clinical record was reviewed on 10/23/24.The POC for the certification period of 11/13/23 to 1/11/24 required, “SN 1WK 9.” The record also included a Physician discharge order from Home Health Services on 1/3/24. The clinical record lacked documentation of SN visits for the weeks of 12/24/24 to 12/30/24 and 12/31/23 to 1/3/24.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of clinical records, and staff interviews, it was determined that for 9 of 17 (Pts. #1, 4, 7, 9, 10, 11, 12, 15 and 16 ) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and Influenza vaccines. Findings include: 1. As of 10/24/24, the following clinical records reviewed lacked documentation of Influenza and/or Pneumococcal Pneumonia inquiry: Pt. #1. SOC 5/26/24 – lacked Influenza immunization assessment. Pt. #4. SOC 9/9/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #7. SOC 7/9/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #9. SOC 8/15/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #10. SOC 8/26/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #11. SOC 10/3/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #12. SOC 6/26/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #15. SOC 1/09/24 – lacked Pneumococcal Pneumonia immunization assessment. Pt. #16. SOC 04/11/24 – lacked Influenza immunization assessment. 2. During an interview with the Administrator, Director of Nursing and Administrative Assistant on 10/23/24 at 3:30 PM, and on 10/24/24 from 9:30 AM to 11:45 AM, the Administrator stated that the Influenza immunization status inquiry is done during the flu season from October to March and documented in the clinical record. The Pneumococcal Pneumonia immunization status inquiry is conducted at SOC and documented in the SOC OASIS. During the same interviews, the above findings were confirmed.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 9/2/21. Standard level deficiencies written. Abbreviations: x = times w = week # = number AM = morning E = Employee Treat = Treatment Eval = Evaluation SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients DON = Director of Nursing NSS = Normal Saline Solution COVID-19 = Coronavirus disease 2019

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service and/or treatment, as indicated in the POC. This was found in 2 of 17 (Pts. #5 and 12) clinical records reviewed. 2. Pt. #12 SOC 08/17/2021. Primary Diagnosis: Mechanical Loosening of other Internal Prosthetic Joint. The clinical record was reviewed on 08/31/2021 at 11:20 AM. The POC for certification period 08/17/2021-10/15/2021 included, “…Physical Therapy: Frequency and Duration: Eval and Treat.” As of 09/01/2021 the record lacked evidence of a physical therapy evaluation as required by the POC. The POC also included … “Infection/inflammation reaction due to other internal joint prosthesis/pyogenic arthritis… RN to perform wound care every RN visit and as needed… SN to demonstrate wound care and teach wound care/frequency: Cleanse affected area with NSS, pat dry, and leave open to air daily until healed.” SN Visit Notes dated 8/19/2021, 08/20/2021 and 08/23/2021 documented, “… right shoulder dressing intact.” During an interview at 11:22 AM the Administrator confirmed the order was in relation to the incision on the Right Shoulder and care should have been provided per the POC. The record lacked evidence of wound care provided to the right shoulder as required by the POC. 3. During an interview with the Administrator, DON, and Business Development Director on 9/01/2021 at 10:33 AM and 11:22 AM, the above findings were confirmed. 1. Pt. #5. SOC 7/9/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 8/31/21 at 7:30 AM. The record contained the POC effective 7/9/21 requiring: “Skilled Nursing – Frequency and Duration: 1w8”. The record lacked documentation the SN provided service during the weeks of 8/8/21 to 8/14/21 and 8/15/21 to 8/21/21.

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 a review of clinical records and staff interview, it was determined the Agency failed to ensure the POC included wound care interventions. This was found in 1 of 5 (Pt. #6) clinical records reviewed, wherein wound care was required. Findings include: 1. Pt. #6. SOC 7/17/21. Primary Diagnosis: Dislocation of Internal Left Hip Prosthesis, Subsequent Encounter. The clinical record was reviewed on 8/31/21 at 8:30 AM. The record contained the SOC comprehensive assessment dated 7/17/21 which included: “Surgical Wound left hip… SN to perform/instruct wound care as follows: cleanse wound with normal saline, pat dry, cover with border dressing”. The POC effective 7/17/21 lacked wound care instructions for the left hip wound. 2. During an interview with the Administrator, DON and the Business Development Director on 9/1/21 at 10:33 AM, the DON and Business Development Director confirmed the Agency failed to ensure the POC included wound care interventions for Pt. #6.

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 a review of the Agency’s Infection Control and Surveillance Program, Agency policy, State of Illinois - Illinois Department of Public Health guidance, Agency policy and staff interview, it was determined the Agency failed to ensure Infection Surveillance was conducted on 1 of 1 (E #3) employee that tested COVID-19 positive. This also have the potential to affect staff within the Agency. Findings include: 1. The Agency’s Infection Control and Surveillance Program included the “State of Illinois COVID-19 Workplace Health and Safety Guidance” dated 9/29/20 which included: “If you have been a close contact to a COVID-19 case, you must self-quarantine at home …from the date of last exposure to the case… What should I do if I had close contact with someone with COVID-19, but I am not sick, and I am a health care worker? If possible, you should stay home for 14 days after you were last exposed to this person and monitor for symptoms. If it is not feasible due to staffing needs and if you are asymptomatic, you can return to work. Your workplace must meet specific criteria to determine there is a staffing crisis. If you do work, you should monitor your temperature and for signs of respiratory illness before starting work and for every four hours during your shift…” 2. The Agency policy titled, “Infection Control Plan” was reviewed on 8/30/21 8/30/21 at 3:31 PM and included: “Refers staff who are exposed to or who potentially have an infectious disease to physicians for… testing…” 3. During an interview with E #3 on 8/30/21 at 2:40 PM, E #3 stated the exposure to COVID-19 was on “7/12/21 while traveling from… I returned to work on 7/13/21 in the office, I worked from July 13th to July 16th and became symptomatic in the afternoon of July 16th, while I was at work I started coughing, weak, like I didn’t feel well... I went home on July 16th..." and had notified the Administrator and the Business Development Director. E #3 stated, "I remained home until I tested for COVID on 7/19/21, the test was positive... I self-quarantined from July 16th to July 28th" (12 days)... I was cleared to return to work from ...(Administrator), ...(Business Development Director) and the Illinois Department of Public Health." E #3 presented an email from the Illinois Department of Public Health dated 7/21/21 which stated: “To Whom It May Concern, Please excuse … from work or school. Per guidance from the Centers for Disease Control and Prevention, a person who has COVID-19 should isolate away from others and not attend work or school for a minimum of 10 days after symptom onset…” 4. The Agency’s “Infection Control Log (EMPLOYEE)” was reviewed on 8/30/21 at 3:20 PM. The Log contained quarterly reports of staff reported infections for 2019, 2020 and 1st quarter of 2021. The Log lacked documentation E #3 was referred for COVID-19 testing after exhibiting symptoms in the workplace; surveillance of E #3 COVID-19 exposure, testing, self-quarantine; and surveillance of staff that entered and worked in the office from 7/13/21 to 7/16/21. 5. During an interview with the Administrator, DON and the Business Development Director on 9/1/21 at 10:33 AM (Administrative Staff), the Administrative Staff confirmed the Agency failed to conduct Infection Surveillance of E #3 and office staff that worked from 7/13/21 to 7/16/21.