Every finding on record at Home Healthcare Renewal Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/22/2026. The Home Health Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/22/2026. The Home Health Agency was not in compliance with the Condition 42 CFR 484.65, Quality Assessment and Performance Improvement (QAPI), as evidenced by:

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on an interview it was determined the Home Health Agency failed to provide documentation of the development, implementation, evaluation, and maintenance of an effective, ongoing, HHA-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program since January 19, 2019. Therefore, the Condition of Participation, 42 CFR 484.65, Quality Assessment and Performance Improvement was not met, as evidenced by: Findings include: The Agency failed to ensure measurable indicators were developed and were analyzed and tracked to identify trends in patient care. See G-642 Agency failed to ensure quality indicators data was utilized to measure effectiveness and identify opportunities for improvement. See G-644 The Agency failed to ensure performance improvement focused on high risk safety indicators, identify opportunities for immediate improvement and monitor the success of the interventions implemented. See G-646 The Agency failed to track adverse patient events, analyze their causes, and implement preventative actions. See G-654 The Agency failed to take actions aimed at performance improvement, implement those actions, measure its success, and track performance to ensure the improvements are sustained See G-656 6. The Agency failed to ensure performance improvement projects were identified and implemented annually. See G-658 7. The Agency failed to ensure a quality improvement and patient safety program was implemented and maintained. See G-660 The cumulative effect of these practices resulted in the Agency's inability to determine effectiveness of Agency programs.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview, it was determined the Agency failed to ensure measurable indicators were developed, analyzed and tracked to identify trends in patient care. Findings include: 1. During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they "have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.”

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the Agency failed to ensure quality indicators were utilized to measure the effectiveness of the safety of services, the quality of care provided and identified opportunities for improvement. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they "have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.”

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the Agency failed to ensure performance improvement focused on high risk safety indicators, identified opportunities for immediate improvement and monitored the success of the interventions implemented. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they "have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.”

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on an interview it was determined the Home Health Agency failed to track all adverse patient events, to determine through subsequent analysis whether they were the result of errors that should have been preventable, to reduce the likelihood of such events in the future. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they "have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.”

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on an interview it was determined the Home Health Agency failed to measure its success and track performance to ensure that improvements are sustained. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they "have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the Agency failed to ensure performance improvement projects were identified and implemented annually. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they "have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.”

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the Governing Board failed to ensure a quality improvement and patient safety program was implemented and maintained. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they "have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.”

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: Based on document review and interview, the Agency failed to ensure a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases is in place and is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. Findings include: 1. The Infection Control Plan and infection tracking logs were requested by the Agency on 5/19/2026. A document titled “Infection Control Plan” (no effective date indicated) was provided. A review of the Infection Control Plan indicates this document is not specific to the Agency, as it refers to responsibilities of the “Director of Clinical Services” and “Quality Improvement Coordinator.” which are not roles/titles the Agency uses. Additionally, the document states “SURVEILLANCE…The activities related to the Infection Control Surveillance Plan shall be based on an assessment of the of the population served by the agency, JCAHO, CHAP, and ACHC indicators, high risk and high volume indicators, CDC definition of infections, and assessed agency needs based on data collection. 2. An interview with the Agency Supervisor/Owner (E #2) was completed on 5/22/2026 at approximately 10:00 AM. During discussion, E #2 noted they do enter infections in their Electronic Medical Records system, as well as follow-up to those infections, but infections are not officially tracked and reviewed in a QAPI program, as they do not currently have one. Additionally, E #2 noted the Agency does not have anyone with the titles of “Director of Clinical Services” or “Quality Improvement Coordinator.” Further, E #2 agreed they are not currently following what is listed under the “Surveillance” section of the “Infection Control Plan” document.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on document review and interview it was determined the Home Health Agency failed to set forth, in writing, its organizational structure, including lines of authority since February, 2026, as evidenced by: The agency failed to ensure the administrator was appointed by and reports to the governing body. See G-946 2. The agency failed to ensure the administrator was responsible for all day-to-day operations of the HHA. See G-948 3. The agency failed to ensure when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. See G-954

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on document review and staff interview, the Facility failed to ensure the administrator was appointed by the governing body. Findings include: 1. A review of the Governing Board meeting minutes dated 12/20/2025 noted (initials D.W.) was appointed as Administrator by the Governing Board. However, upon entrance to the survey, the Administrator was identified as (initials J.C.). There was no documentation of a Governing Board meeting since 12/20/2025. 2. The policy titled “Home Health Agency Governance Board Charter”, (No effective date provided) states: “3. Roles & Responsibilities…CEO/Administrator Oversight: Appoint, evaluate, and determine the compensation of the Agency Administrator/CEO.” 3. An interview was conducted on 5/20/2026 at approximately 3:00 PM, with the Agency Supervisor/Owner (E #2). During discussion, E #2 noted (initials D.W.), the Administrator that was appointed by the Governing Board on 12/20/2025, unexpectedly passed away in February, 2026. E #2 stated, “I wanted to make sure I had someone qualified, so I made (initials J.C.) the Administrator. I verified (initials J.C.)’s qualifications with the State (Illinois Department of Public Health)”, further stating, "She hasn't been appointed by the Governing Board yet, because we haven’t had our Governing Board meeting for this year.”

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to ensure outdated biologicals were not available for patient use. Findings include: On 5/19/26 at approximately 1:30 pm, an observational tour of the office was conducted. The following was observed in a supply closet: a. 12 Heparin Lock Flushes made by Excelsior Medical. Expired on 8-1-20248 Heparin Flushes made by Excelsior Medical. Expired 8-1-2024 (Found in bag stating, “Caution Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed”. No patient name on bag) b. 6 Clave Neutral Connectors made by ICU Medical, Inc. Expired 4-1-2025 c. 10 Ultrasite Injection Sites made by B. Braun Medical Inc. Expired 4-30-2025 d. 18 SwabCaps. No manufacturer listed on product. Expired 11-1-2024 e. 1 Universal Securement Device made by Tidi Products, LLC. Expired 03-2021 f. 1 Universal Securement Device made by Tidi Products, LLC. Expired 11-2023 g. 2 Universal Securement Devices made by Tidi Products, LLC. Expired 12-2023 h. 3 Universal Securement Devices made by Tidi Products, LLC. Expired 07-2025 i. 2 Universal Securement Devices made by Tidi Products, LLC. Expired 08-2025 j. 2 Medium Universal Securement with Wide Silicone Adhesive Area made by Tidi Products, LLC. Expired 05-2025 k. 57 Tegaderm Films made by 3M Health Care. Expired 8-1-2024 l. 20 Port Access Infusion Sets made by SB-Kawasumi Laboratories, Inc. Expired 8-31-2024 m. 1 Smallbore Ext Set, Clamp, Rotating Luer made by ICU Medical, Inc. Expired 6-1-2024 n. 2 Smallbore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 4-1-2025 0. 1 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 5-1-2025 p. 3 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 7-1-2025 q. 1 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 10-1-2025 r. 4 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 12-1-2025 s. 2 10ml Syringe Luer-Lok Tip with BD Precision Glide Needle made by BD. Expired 8-31-25 t. 1 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 4-29-2025 u. 7 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 7-5-2025 v. 3 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 9-9-2025 w. 1 24G ViaValve Safety IV Catheter-Radiopaque made by Smiths Medical ASD, Inc. Expired 9-15-2024 x. 9 eSwabs made by Copan Italia SpA. Expired 6-30-23 y. 1 eSwabs made by Copan Italia SpA. Expired 7-31-23 z. 20 eSwabs made by Copan Italia SpA. Expired 7-24-24 aa. 6 BBL Culture eSwabs made by Copan Italia SpA. Expired 10-31-2024 bb. 1 Box of 50 23G BD Vacutainer Safety Lok Blood Collection Sets made by Becton, Dickinson, and Company. Expired 7-31-2024 cc. 7 25G BD Vacutainer Safety-Lok Blood Collection Sets made by Becton, Dickinson, and Company. Expired 6-30-24 dd. 2 25G Safety Needle made by BH supplies. Expired 4-17-26 ee.1 22G Safety Needle made by Becton, Dickson, and Company. Expired 2-29-24 ff. 1 22G Safety Needle made by Becton, Dickson, and Company. Expired 7-31-24 gg. 19 22G Safety Needle made by Becton, Dickson, and Company. Expired 7-31-25 hh. 4 Multi Drawing Needle made by Greiner Bio-one. Expired 04-21 ii. 25 21G Safety Needle made by Becton, Dickson, and Company. Expired 8-31-2025 jj. 128 10ml Disposable Syringe made by BH supplies. Expired 11-27-25 kk. 5 boxes of 200 Sterile Alcohol Prep Pads. Expired 9-25-25 ll. 1 Adhesive Island Dressing made by Covidien. Expired 5-1-25 mm.9 Unna-Z Zinc Paste Bandage made by Medline. Expired 10-2025 nn. 27 Elastic Barrier Strip made by Coloplast. Expired 5-18-24 oo. 16 Elastic Barrier Strip made by Coloplast. Expired 5-31-24 pp. 1 box of 30 Elastic Barrier Strip XL made by Coloplast. Expired 5-18-24 qq. 2 boxes of 10 Adapt CeraRings made by Hollister ULC. Expired 09-25 rr. 1 box of 10 Adapt CeraRings made by Hollister ULC. Expired 11-25 ss. 1 box of 10 Adapt CeraRings made by Hollister ULC. Expired 1-26 tt. 2 boxes of 10 Urostomy Pouches made by Hollister Inc. Expired 3-26 uu. 2 boxes of 10 Urostomy Pouches made by Hollister Inc. Expired 4-25 vv. 1 box of 10 Urostomy Pouches made by Hollister Inc. Expired 6-25 ww. 1 box of 5 Skin Barrier-Floating Flange and Tape made by Hollister. Expired 3-24 xx. 1 box of 2 Piece Ostomy Skin Barrier, Tape made by Hollister. Expired 9-1-23 yy. 1 box of 30 Silicone Self-Adhesive Catheters made by Hollister. Expired 5-28-25 zz. 2 boxes of 60 Closed Pouches with filters made by Hollister. Expired 2-24 2. During an interview with the Agency Supervisor(E#2) on 5/19/26 at approximately 1:30 p.m., E#2 stated, “That the expired supplies noted in the supply closet should have been removed on expiration.”

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on document review and interview, the Agency failed to ensure a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, was provided in writing, as authorized by the administrator and governing body. Findings include: 1. A review of the Governing Board meeting minutes dated 12/20/2025 noted E #2 as being appointed as the pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available. There was no documentation of the approval by the previous Administrator of E #2 being the pre-designated person. 2. An interview was conducted on 5/20/2026 at approximately 3:00 PM, with the Agency Supervisor/Owner (E #2). During discussion, E #2 noted the previous Administrator passed away unexpectedly earlier in the year, and a new Administrator is in place, but has not been appointed by the Governing Board, stating, "She hasn't been appointed by the Governing Board yet, because we haven’t had our Governing Board meeting for this year.” 3. A follow-up interview was conducted on 5/22/2026 at approximately 10:30 AM, with the Agency Supervisor/Owner (E #2). During discussion, E #2 noted the new Administrator has not approved in writing, E #2 as the pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available. Additionally, as there has not been a Governing Board meeting since the new Administrator was put in place, the new Administrator has not been appointed by the Governing Board, and pre-designated person has not been appointed under the new Administrator, by the Governing Board.

An investigation was conducted on 09/14/2023 for Complaint # 2311180/101022. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484 as evidence by:

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, it was determined the Agency failed to obtain an informed consent prior to the start of care for 1 of 3 (Patient #3) clinical records reviewed. Findings include: Patient #3 was admitted to home health services on 05/21/2023 with a diagnosis of Urinary Tract Infection. The clinical record was reviewed on 09/14/2023. The clinical record included Start of Care assessment, a plan of care signed by the physician, skilled nurse, physical therapy and occupational therapy visit notes and a discharge assessment. The clinical record lacked consents for services and treatment. 2. During an interview with the Administrator on 09/14/2023 at 1:30 PM, the above findings were confirmed. She stated she also looked in the paper chart and could not find the consent for patient #3.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on staff interview, policy review and document review it was determined the Agency failed to ensure the Administrator was responsible for day-to-day operations. This has the potential to affect all patients served. Findings include: 1. During the entrance interview with the Administrator on 09/14/2023 at 09:50 AM a request for Governing Body minutes for the past 12 months and the annual operating budget was made. The Administrator stated, she does not have an annual operating budget. During an interview with the Administrator at 11:20 AM, Governing Body minutes from 06/30/2020 was presented as the only minutes available. She stated they did not have any governing body minutes for the past 12 months. 2. A policy titled “Agency Budget Planning” was reviewed on 09/14/2023. The policy included, “...5. Annual Review of Plan and Budget a. The overall plan and budget will be reviewed and updated at least annually by the Governing Body…which would include members of the Agency Administrative Staff…” 3. The Administrator's signed job description was reviewed on 09/14/2023. The job description included, "...administer budgets for staff, equipment and service delivery...establish budgets and guidelines for expenditures..." 4. During an interview with the Administrator on 09/14/2023 at 11:30 AM, the above findings were confirmed. She stated she does not have a current or past budget.

Primary HHA is responsible for patient care CFR(s): 484.105(e)(3) The primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients. This ELEMENT is not met as evidenced by: Based on contract review and staff interview, it was determined the Agency failed to ensure patient care provided by staff under arrangement was supervised. This has the potential to affect all patients served receiving services under arrangement. Findings include: The Contract for Staffing of Home Health Therapy and MSW (Medical Social Worker) Services was reviewed on 09/14/2023. The contract was signed by the Agency and the contracted provider on 02/13/2019. The contract lacked documentation on how the Agency will supervise contracted employees. 2. During an interview with the Administrator at 2:15 PM, the above findings were confirmed.

Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This STANDARD is not met as evidenced by: Based on staff interview and policy review it was determined the Agency failed to prepare and plan an annual budget. This has the ability to affect all patients served. Findings include: 1. During the entrance interview with the Administrator on 09/14/2023 at 09:50 AM a request for Governing Body minutes for the past 12 months and the annual operating budget was made. The Administrator stated, she does not have an annual operating budget. 2. A policy title, "Governing Body" was reviewed on 09/14/2023. The policy included, "...5. Adopt and periodically review and approve the… annual operating budget, and capital expenditure plan. 6. Oversee the management and fiscal affairs of the agency. This shall include budget preparation, and reviewing/monitoring financial information and organizational operations…” During an interview with the Administrator at 11:20 AM, Governing Body minutes from 06/30/2020 was presented as the only minutes available. She stated they did not have any governing body minutes for the past 12 months. 3. A policy titled, "Agency Budget Planning" was reviewed on 09/14/2023. The policy included, "...Agency, under the direction of the governing body, shall prepare an overall plan and budget. This will include and annual operating budget and a long-term capital expenditure plan… 5. Annual Review of Plan and Budget a. The overall plan and budget will be reviewed and updated at least annually by the Governing Body…which would include members of the Agency Administrative Staff…” 4. During an interview with the Administrator at 11:30 AM, the above findings were confirmed. She stated she does not have a current or past budget.

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 records review, policy review and staff interview it was determined, the Agency failed to include all required items in the clinical record for 2 of 3 (Patients # 1 and 2) clinical records reviewed. Findings include: Patient #1 was admitted to home health services on 08/23/2023 with a diagnosis of Acute and Chronic Respiratory Failure. The clinical record was reviewed on 09/14/2023. The clinical record included a plan of care signed by the physician with a skilled nurse frequency order of one week one, two week two, one week six. The clinical record lacked skilled nurse clinical notes for the weeks of 08/27/2023 and 09/03/2023. 2. Patient #2 was admitted to home health services on 12/31/2022 with a diagnosis of Pressure Ulcer of Sacral Region Stage 3. The clinical record was reviewed on 09/14/2023. The clinical record included a plan of care signed by the physician with a skilled nurse frequency order of one time a week for eight weeks. The clinical record lacked skilled nurse clinical notes for the weeks of 08/20/2023 and 08/27/2023. 3. A policy titled, "Clinical Documentation" was reviewed. The policy documented, "...5. Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record within seven (7) days after the care has been provided." 4. During an interview with the Administrator on 09/14/2023 at 2:00 PM the above findings were confirmed. She verified the visits were complete for Patient #1 and #2. She stated the nurse has not yet submitted the documentation for the visits.

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: A. Based on a review of the Agency's Emergency Operation Plan and staff interview, it was determined the Agency failed to ensure the Emergency Operation Plan was reviewed biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operation Plan was reviewed on 1/9/23 at 10:20 AM. The Plan contained the document titled: “Authorization" which included, "Effective: 02/01/2019...I hereby certify that the ...Emergency Operations Plan is the official and authorized plan of this organization." The document was signed by the Administrator on "02/01/2019". The Agency failed to review and revised the Emergency Operation Plan every 2 years. The Plan contained a document titled: "Table I-1 Primary and Affiliate Facilities" which included the address of the Agency. The Agency's address recorded on this document was inaccurate. 2. During an interview with the Administrator on 1/9/23 at 11:20 AM, the Administrator stated the Agency relocated about a year and half ago. 3. During an interview with the Administrator and Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the Agency failed to review and revise the Emergency Operation Plan every 2 years.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(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 Hospices at §418.113(a):] 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. *[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. 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):] 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. This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Operation Plan, Agency policy, and staff interview, it was determined the Agency failed to complete a risk assessment. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operation Plan was reviewed on 1/9/23 at 10:20 AM. As of 1/9/23, the Plan lacked a facility and community-based risk assessment. 2. The Agency's policy titled, "Hazard Vulnerability Assessment" was reviewed on 1/9/23 at 11:09 AM, the policy required: "The HVA shall be conducted during the risk assessment phase of developing the EOP and annually thereafter..." 3. During an interview with the Administrator and Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the Agency failed to complete a risk assessment.

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: A. Based on a review of the Agency's Emergency Operation Plan and staff interview, it was determined the Agency failed to review and revise the Plan's policies and procedures biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operation Plan was reviewed on 1/9/23 at 10:20 AM. The Plan contained the document titled: "Overview - Table of Contents" which included the Emergency Operation Plan's policies and procedures. The document included an effective date of 2/01/2019. There was a section to enter the date the Plan's policies and procedures were reviewed and revised, this section was left blank. The Agency failed to review and revise the Emergency Operation Plan policies and procedures every 2 years 3. During an interview with the Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the Agency failed to review and revise the Emergency Operation Plan policies and procedures every 2 years.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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 facilities]. This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Operation Plan and staff interview, it was determined the Agency failed to ensure the communication plan was reviewed biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operation Plan was reviewed on 1/9/23 at 10:20 AM. The Plan contained the policy titled: “Communication Systems" which included, "Effective: 02/01/2019". There was a section to enter the date the communication plan was reviewed and revised; this section was left blank. The Agency failed to review and revise the communication plan every 2 years. 2. During an interview with the Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the Agency failed to review and revise the communication plan every 2 years.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(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 facilities]. 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 a review of the Agency's Emergency Operation Plan and staff interview, it was determined the Agency failed to ensure the communication plan contained all the required components. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operation Plan was reviewed on 1/9/23 at 10:20 AM. The communication plan lacked the names and contact information of the direct staff, contract staff and the patients' physicians. 2. During an interview with the Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the Agency communication plan was incomplete.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Operation Plan, staff trainings/in-services, personnel files, and staff interview, it was determined the Agency failed to ensure staff received initial and ongoing training of the Emergency Operation Plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operation Plan was reviewed on 1/9/23 at 10:20 AM and lacked documentation of education and/or in-service training pertaining to the Agency's Emergency Operation Plan. 2. The Agency's education and/or in-service training for 2020, 2021, and 2022 was reviewed on 1/10/23 at 11:30 AM, and lacked documentation of staff education and/or in-service training pertaining to the Emergency Operation Plan. 3. The following personnel files were reviewed on 1/9/23 at 2:40 PM and lacked any initial and/or ongoing training of the Agency's Emergency Operation Plan: Employee #1. Date of hire 1/8/20. Employee #2. Date of hire 11/30/22. Employee #3. Date of hire 9/28/22. Employee #4. Date of hire 12/27/22. Employee #5. Date of hire 2/12/19. 4. During an interview with the Administrator and Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the Agency failed to provide staff any education and/or in-service training of the Emergency Operation Plan.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times # = number WK = week lbs = pounds AM = morning PM = afternoon, evening > = greater than , = less than SN = Skilled Nurse POC = Plan of care SOC = Start of care RN = Registered Nurse SN = Skilled Nurse Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist IVP = intravenous push cm = centimeters cc = cubic centimeters DC = discharge/discontinue Resp = respirations HVA = hazard vulnerability EOP = Emergency Operation Plan JCAHO = Joint Commission for Accreditation of Healthcare Organizations

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on review of clinical records, observation, and staff interviews, it was determined the Agency failed to ensure Pts. were informed and/or participated in the disciplines to provide care/service and the frequency of visits provided by each discipline. This was found in 13 of 13 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 1/9/23 at 1:45 PM to 1/11/23 at 9:30 AM: Pt. #1. SOC 12/23/22. Pt. received SN service.Pt. #2. SOC 01/05/23. Pt. received PT and PT services.Pt. #3. SOC 12/27/22. Pt. received SN, PT services. Pt. #4. SOC 12/15/22. Pt. received SN, PT and OT services.Pt. #5. SOC 01/03/23. Pt. received SN service.Pt. #6. SOC 12/02/22. Pt. received SN, PT and OT services.Pt. #7. SOC 12/12/22. Pt. received SN, PT, OT and ST services.Pt. #8. SOC 09/13/21. Pt. received SN service. Pt. #9. SOC 12/06/22. Pt. received SN, PT services.Pt. #10. SOC 05/05/22. Pt. received SN, PT, OT, MSW, and Home Health Aide services. Pt. #11. SOC 05/10/22. Pt. received SN service.Pt. #12. SOC 04/23/22. Pt. received SN, PT, OT and MSW services.Pt. #13. SOC 04/15/22. Pt. received SN and Home Health Aide services. 2. The records lacked documentation that at the SOC, the Pt./patient's representative participated or was notified of the discipline(s) to provide care/service and the frequency of those visits, prior to providing Pt. care/services. 3. The following home visits were conducted on 1/9/23 to 1/11/22 from 12:30 PM to 2:00 PM: Pt. #1. SOC 12/23/22. Pt. received SN service.Pt. #2. SOC 01/05/23. Pt. received PT and PT services.Pt. #3. SOC 12/27/22. Pt. received SN, PT services. Pt. #4. SOC 12/15/22. Pt. received SN, PT and OT services.Pt. #5. SOC 01/03/23. Pt. received SN service.During the home visits, the patient's admission home folder was observed and lacked documentation of the disciplines to provide care/service and frequency of visits for each discipline. 4. During a meeting on 1/10/23 at 1:45 PM and 1/11/23 from 11:10 AM to 12:30 PM, with Administrator and Agency Supervisor, the Administrator confirmed the above findings.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). 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 Pts. were informed of their financial responsibility (if any) for payment of Agency care/services. This was found in 5 of 13 Pts. (Pts. #1, 7, 8, 10, and 11) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 1/9/23 at 1:15 PM to 1/11/23 at 9:30 AM: Pt. #1. SOC 12/23/22. Pt. #7. SOC 12/12/22. Pt. #8. SOC 9/13/21. Pt. #10. SOC 5/5/22. Pt. #11. SOC 5/10/22. The above records lacked documentation the Pts. were informed of their financial responsibility (if any) for payment of Agency care/services. 2. During interviews with the Owner/Administrator and Agency Supervisor on 1/10/23 at 1:37 PM, and on 1/11/23 at 11:10 AM to 12:30 PM, the above findings were confirmed.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: A. Based on review of the Agency's Pt. admission folder, observation during home visits, and staff interviews, it was determined the Agency failed to ensure complete information regarding the State Telephone Hotline was provided to Pts. This was found in 13 of 13 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11,12 and 13) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 1/9/23 at 10:15 AM. The folder included a section titled, "JCAHO or The State Hotline" with information pertaining to the IDPH telephone number. This section lacked the correct number to call in a complaint with the Illinois Department of Public Health State Hot Line. 2. The following clinical records were reviewed from 1/9/23 at 1:45 PM to 1/11/23 at 9:30 AM and lacked the correct telephone number to call in a complaint to the Illinois Department of Public Health: Pt. #1. SOC 12/23/22. Pt. #2. SOC 01/05/23. Pt. #3. SOC 12/27/22. Pt. #4. SOC 12/15/22. Pt. #5. SOC 01/03/23 Pt. #6. SOC 12/02/22. Pt. #7. SOC 12/12/22. Pt. #8. SOC 09/13/21. Pt. #9. SOC 12/06/22. Pt. #10. SOC 05/05/22. Pt. #11. SOC 05/10/22 Pt. #12. SOC 04/23/22. Pt. #13. SOC 04/15/22. 3. The following home visits were conducted on 1/9/23 to 1/11/23 from 12:30 PM to 1/11/23 2:00 PM: Pt. #1. SOC 12/23/22.Pt. #2. SOC 01/05/23.Pt. #3. SOC 12/27/22. Pt. #4. SOC 12/15/22.Pt. #5. SOC 01/03/23. During the home visits, the above Patients' admission folders were observed, and lacked the correct telephone number for which the Pt./patient's representative may call in a complaint to the State Hotline. 4. During interviews with the Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM, and 1/11/23 at 11:10 AM to 12:30 PM, the above findings were confirmed.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: A. Based on review of a clinical record and staff interview, it was determined the Agency failed to ensure the SN updated the comprehensive assessment due to a significant change in the patient's condition. This was found in 1 of 1 (Pt. #8) clinical records reviewed, wherein a Pt. was transferred to an inpatient facility. Findings include: 1. Pt. #8. SOC 9/23/21. Primary Diagnosis: Pressure Ulcer of Left Buttock. The clinical record was reviewed on 1/9/23 at 2:00 PM. The record contained the SN visit note dated 12/21/22 which included: "...after foley change no urine was flowing for a while...new foley inserted with same outcome and then SN took foley out and started to see many clots and more bleeding - it was at that time 911 was called 13:45." 2. During an interview with the Administrator and Agency Supervisor on 1/9/23 at 3:20 PM, the Administrator stated the Pt. was transferred to an inpatient facility. As of 1/9/23, the record lacked documentation the comprehensive assessment was updated. 3. During an interview with the Administrator and Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the SN failed to update the comprehensive assessment after the Pt. experienced a significant change in condition.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: A. Based on review of a clinical record and staff interview, it was determined the Agency failed to ensure staff update and revise the comprehensive assessment, within the last 5 days of the 60-Day certification period. This was found in 1 of 1 (Pt. #8) clinical record reviewed, wherein the Pt. received care beyond the initial 60-Day episode. Findings include: 1. Pt. #8. SOC 9/23/21. Primary Diagnosis: Pressure Ulcer of Left Buttock. The clinical record was reviewed on 1/9/23 at 2:00 PM. The record contained PsOC for the certification periods of 9/18/22 to 11/16/22 and effective 11/17/22, requiring for the SN to provide service. The recertification comprehensive assessment was conducted on 11/23/22 (7 days after the previous certification period ended). The record lacked documentation the SN updated and revised the comprehensive assessment within the last 5 days of the previous 60-Day certification period. 2. During an interview with the Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM, the Administrator confirmed the SN failed to staff update and revise the comprehensive assessment within the last 5 days of the 60-Day certification period.

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/treatment, as ordered by the Physician and indicated in the POC. This was found in 5 of 13 (Pts. #4, 8, 13, 6 and 12) clinical records reviewed. 4. Pt. #6. SOC 4/23/22. Primary Diagnosis: Encounter for Orthopedic Aftercare Following Surgical Amputation. The clinical record was reviewed on 1/9/23 at 1:15 PM. The record included the initial comprehensive assessment, completed by the RN on 12/2/22. This assessment included documentation Pt. #6 had a surgical incision to the right 4th toe area amputation site, measuring 5.7 cm long x 1.2 cm wide x 0.1 cm deep. Pt. #6’s POC effective 12/2/22 included the Physician’s order: “…SN to measure and record wound(s) weekly and as needed for significant change to wound and/or decline in wound status. SN to measure/record length, width, depth, and any tunneling/undermining if applicable…” The record lacked documentation the SN measured Pt. #6’s wound on SN visits completed 12/7/22, 12/9/22, 12/13/22, 12/16/22, and 12/30/22. 5. Pt. #12. SOC 4/23/22. Primary Diagnosis: Encounter for Other Orthopedic Aftercare. The clinical record was reviewed on 1/9/23 at 2:40 PM. The record contained the POC effective 4/23/22 to 6/21/22, which included the Physician’s order: “…Notify Physician of: Fasting blood sugar greater than (>) 175 or less than ( Random blood sugar greater than (>) 250 or less than ( The record lacked documentation of the Patient’s blood sugar level for the SN visit conducted on 5/26/22. 6. During interviews with the Owner/Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM and on 1/11/23 at 11:10 AM, the above findings were confirmed. Findings include: 1. Pt. #4. SOC 12/15/22. Diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Long-Term use of Insulin. The clinical record was reviewed on 1/10/23 at 10:15 AM. The record contained the POC effective 12/15/22 that required: "SN to assess and teach pt how to perform a blood sugar via finger stick...including logging blood sugar readings..." The record included weekly SN visit notes from 12/20/22 to 1/4/23, each visit note lacked documentation the SN taught the Pt. on performing "a blood sugar via finger stick prior to insulin administration including logging blood sugar readings" 2. Pt. #8. SOC 9/23/21. Primary Diagnosis: Pressure Ulcer of Left Buttock. The clinical record was reviewed on 1/9/23 at 2:00 PM. The record contained the POC effective 11/17/22 that required: "Notify physician of...Respirations greater than (>) 26 or less than () 175 or less than () 250 or less () 175 or less than () 250 or less () 2 lbs or less than (<) 5 lbs." The weekly SN visit notes dated 6/15/22 to 8/5/22 lacked the patient's weight and blood sugar. As of 1/9/23, it cannot be determined whether the patient's weight and blood sugar results were within the above parameters.

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 contained the required interventions. This was found in 2 of 13 (Pts. #8 and 1) clinical records reviewed. 2. Pt. #1. SOC 12/23/22. Primary Diagnosis: Infection and Inflammatory Reaction Due to Internal Left Hip Prosthesis, Initial Encounter. The clinical record was reviewed on 1/11/23 at 9:30 AM. A home visit was conducted on 1/10/23 at 2:00 PM, along with E #2. During this home visit, E #2 flushed Pt. #1’s right arm PICC with normal saline, administered Ancef 2 grams IVP to the PICC, flushed the PICC again with normal saline after the Ancef infusion, and then changed Pt. #1’s right PICC dressing. E #2 stated she does this for Pt. #1 weekly, along with assessing the PICC insertion site for redness and other signs of infection. Pt. #1’s clinical record includes the POC effective 12/23/22, which lacks Physician orders for PICC line assessment, flushing, or dressing changes. 3. During interviews with the Owner/Administrator and the Agency Supervisor on 1/10/23 at 1:45 PM and on 1/11/23 at 11:10 AM, the above findings were confirmed. Findings include: 1. Pt. #8. SOC 9/23/21. Primary Diagnosis: Pressure Ulcer of Left Buttock. The clinical record was reviewed on 1/9/23 at 2:00 PM. The record contained the POC effective 11/17/22 that required: "Notify physician of...Weight greater than (>) 2 lbs or less than (<) 5 lbs." The same POC included a secondary diagnosis of "Functional quadriplegia." The most recent recertification comprehensive assessment completed by the SN and dated 11/23/22 contained documentation that the Pt. is confined to a bed. The record lacked documentation the Pt. had a bed scale. The POC effective 11/17/22 was inaccurate, requiring the SN to notify physician of a weight greater than 2 lbs or less than 5 lbs." The recertification comprehensive assessment dated 11/23/22 included, "Catheter: Foley Last Changed 11/22/2022 16 Fr 10 cc... flushed per order". The SN visit note dated 11/30/22 included, "Catheter Last Changed 11/23/2022 16 Fr 10 cc". The SN visit note dated 12/7/22 included, "Catheter: Last Changed on 11/24/2022 size 14 FR 10 cc" and that the SN performed "Foley flush x2". The SN visit notes dated 12/7/22 and 12/15/22 included "Catheter: Foley Last Changed:11/24/2022 14 Fr 10 cc". The SN visit note dated 12/21/2022 included "Catheter: Foley Last Changed: 11/24/2022 16 Fr 10 cc". The SN visit note dated 12/21/22 contained: "after foley change no urine was flowing for a while...SN then flush foley but was not able to pull back - tried to pull back several times then blood was seen coming into foley tubing - foley was taken out and new foley inserted with same outcome and then SN took foley out and started to see many clots and more bleeding - it was at that time 911 was called 13:45". The POC effective 11/17/22 lacked instructions for Foley care and maintenance, and as of 1/9/23 the POC was not updated to include Foley catheter care and maintenance.

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 a review of clinical records and staff interviews, it was determined the Agency failed to ensure the Agency assessed the need for Pneumococcal Pneumonia and/or Influenza vaccines. This was found in 10 of 13 (Pts. # 2, 3, 4, 6, 7, 8. 9, 10, 12, and 13) clinical records reviewed. 1. The following clinical records were reviewed from 1/9/23 at 1:45 PM to 1/11/23 at 9:30 AM: Pt. # 2. SOC 01/05/23. Lacked Pneumonia and Influenza vaccination status. Pt. # 3. SOC 12/27/22. Lacked Pneumonia and Influenza vaccination status. Pt. # 4. SOC 12/15/22. Lacked Pneumonia and Influenza vaccination status. Pt. # 6. SOC 12/02/22. Lacked Pneumonia and Influenza vaccination status. Pt. # 7. SOC 12/12/22. Lacked Pneumonia and Influenza vaccination status. Pt. #8. SOC 09/13/21. Lacked Pneumonia and Influenza vaccination status. Pt. #9. SOC 12/06/22. Lacked Pneumonia and Influenza vaccination status. Pt. #10. SOC 05/05/22. Lacked Pneumonia and Influenza vaccination status. Pt. #12. SOC 04/23/22. Lacked Pneumonia and Influenza vaccination status. Pt. #13. SOC 04/15/22. Lacked Pneumonia and Influenza vaccination status. 2. During the Entrance interview on 1/9/23 at 9:15 AM the Agency Supervisor stated the RN is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information should be documented in SOC comprehensive assessment. 3. During meetings with the Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM, and on 1/11/23 from 11:10 AM to 12:30 PM, the Administrator confirmed the above findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, interview during a home visit, Agency policy and staff interview, it was determined staff failed to notify the Physican regarding falls. This was found in 1 of 4 (Pt. #4) home visits conducted. Findings include: 1. Pt. #4. SOC 12/15/22. Diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Long-Term use of Insulin. The clinical record was reviewed on 1/10/23 at 10:15 AM. The record contained the PT visit note dated 12/22/22 which included: "Patient...reports falling twice overnight when getting up to go to bathroom...Notified RN manager, and RN...plans to make visit today to assess..." The PT and SN visit notes dated 12/22/22 lacked documentation the patient's Physician was informed about the fall. A home visit was conducted on 1/11/23 at 9:40 AM with Employee #6. During the home visit an interview was conducted with the Pt. that stated: "I fell... and hit my head, I'm still having a headache. I have an appointment with the Doctor on tomorrow." 2. The Agency policy titled; "Incident Reporting" was reviewed on 1/11/23 at 12:45 PM. The policy required: "...1. Agency will document and report all incidents that deviate from routine agency operations and will or could result in injury or potential harm to a client/caregiver...3..."An Incident Report form shall be completed in its entirety by the person involved or the first person to become aware of the incident..." 3. During an interview with the Administrator and Agency Supervisor on 1/10/23 at 1:45 PM, the Administrator stated the SN or PT was required to complete a fall/ and/or incident report, notify the Physician regarding the fall, and follow-up with any additional Physician orders received. 4. During an interview with the Administrator and the Agency Supervisor on 1/10/23 at 1:37 PM, both confirmed that staff failed to complete the fall/incident report and notify the Physician of the patient's fall.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. 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 discharge summaries were completed within 5 days and sent to the Physician. This was found in 4 of 13 (Pt. #6, 13, 10, and 11) clinical records reviewed. 3. Pt. #10. SOC 1/29/21. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/30/21 at 2:20 PM. The record included the POC effective 1/29/21, which contained the Physician's order "OT 2WK3, 1W5." The record included OT visit notes beginning 2/1/21 through 3/26/21, which documented the OT provided service. The record also contained a Physician's order dated 3/26/21 to discharge Pt. #16 from Agency services. The record lacked an Occupational Therapy discharge summary. 4. Pt. #11. SOC 1/11/21. Primary Diagnosis: Encounter for Other Orthopedic Aftercare. The clinical record was reviewed on 3/30/21 at 2:40 PM. The record included the POC effective 1/11/21, which contained the Physician's order "SN 1WK9." The record included weekly SN visit notes beginning 1/12/21 through 2/10/21, which documented the SN provided service. The record also contained a Physician's order dated 2/11/21 to discharge Pt. #17 from Agency services. The record lacked a SN discharge summary. 5. The Agency policy titled "Discharge Summary" was reviewed on 1/11/23 at 1:30 PM. The policy required: "...Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged...A copy of the discharge summary will be provided to the Patient's primary care practitioner...after discharge from the organization within five (5) business days of the Patient's discharge..." 6. During a meeting on 1/10/23 at 1:37 PM and 1/11/23 from 11:10 AM to 12:30 PM, with the Administrator and Agency Supervisor, the Administrator confirmed the above findings. Findings include: 1. Pt. #6. SOC 4/23/22. Primary Diagnosis: Encounter for Other Orthopedic Aftercare. The clinical record was reviewed on 1/9/23 at 1:15 PM. The record included the PT Evaluation dated 12/2/22, which contained the frequency and duration of visits: “1w1, 2w3, 1w4.” This evaluation was signed by the Physician. The record also included the 12/10/22 Physician’s order: “DC PT services due to no answer to door following previously scheduled visits.” The record lacked documentation the PT completed a discharge summary and sent it to the Physician within 5 days of discharge from PT. 2. Pt. #13. SOC 4/15/22. Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The closed clinical record was reviewed on 1/9/23 at 3:00 PM. The record contained the Discharge comprehensive assessment and Discharge Summary forms, both dated 8/10/22 indicating Pt. #13 was discharged from the Agency. As of 1/9/23, the record/Agency lacked documentation that a copy of the Agency's Discharge Summary was sent to the Physician.