Every finding on record at Home Health One, Ltd

An investigation was conducted on exit date for Complaint #IL000115844 /#252669. The Home Health Agency was in substantial compliance with the Medicare requirements at 42 CFR 484 Condition of Participation for Home Health Agencies, with standard level citations. Abbreviations: SN = Skilled Nursing WK, wk = week Labs = laboratory PM = afternoon MD = Medical Doctor CBC = Complete Blood Count CMP = Comprehensive Metabolic Panel Pt./Pts. = Patient/Patients PT = Physical Therapy/Therapist & = and POC = Plan of Care SOC = Start of Care

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 a review of clinical records, and staff interviews, it was determined in 2 of 4 (Pts. # 3 and 4) clinical records reviewed, the Agency failed to ensure services were provided in accordance with Physician orders, as indicated on the POC. Findings include: 1. Pt. #3 was admitted for home health services on 1/6/25 with a diagnosis of, but not limited to, Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. The closed clinical record was reviewed on 6/23/25. The closed clinical record included the POC for the certification period of 1/6/25 to 3/6/25 that required, “Skilled nursing: 2 WK1, 1wk4… 1wk5… Labs: Per MD order… CBC with automated differential, CMP, Vitamin D -25 Hydroxy in 1 month 02/06/2025”. The record contained documentation that after the SOC visit on 1/6/25, the SN provided services weekly from 1/9/25 to 2/17/25. As of 6/23/25, the record lacked documentation the SN obtained the labs: "CBC with automated differential, CMP, Vitamin D -25 Hydroxy" as ordered by the MD. 2. Pt. #4 was admitted for home health services on 4/28/25 with a diagnosis of, but not limited to, Contusion of Left Front Wall of Thorax, Subsequent Encounter. The clinical record was reviewed on 6/23/25. The clinical record included the POC effective 4/28/25 that required, “Referral to: PT for evaluation & treatment…” The PT evaluation was conducted on 5/6/25 and contained “Visit Frequency 1wk6”. As of 6/23/25, the record lacked documentation the PT provided service during the week of 5/18/25 to 5/24/25. 3. During an interview with the Alternate Director of Nursing on 6/23/25 at 12:30 PM, the Alternate Director of Nursing confirmed services were not provided in accordance with Physician orders indicated on the POC.