Every finding on record at Illinois Health Care Services, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/26/25. Standard level deficiencies cited.

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: Based on review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 09/26/25. The plan lacked documentation of Hazard Vulnerability Assessments for the years 2023 and 2024. 2. During an interview with the Administrator and Alternate Director of Nursing on 09/26/25 at 10:00 AM, the above finding was confirmed.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Program and Plan and staff interview, the Agency failed to ensure the Agency conducted the required individual and/or community exercises since 2023 to ensure the effectiveness of the Emergency Preparedness Plan. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 09/26/25. The Plan lacked documentation that full-scale community or individual exercises were conducted by the Agency for the years reviewed, 2023 and 2024. 2. During an interview with the Administrator and Alternate Director of Nursing on 09/26/25 at 10:00 AM, it was confirmed the Agency failed to meet the testing requirements of the Agency’s Emergency Plan.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 09/26/25. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse SOC = Start of Care POC = Plan of Care OASIS = Outcome and Assessment Information Set Pt / Pts = Patient / Patients MSW = Medical Social Worker

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 a review of the Error Summary report and staff interview, in 500 of 945 assessments submitted for the last 12 months, the Agency failed to submit reports timely. Findings include: 1. The Error Summary report for 9/23/24 to 9/23/25, was reviewed on 9/23/25. The report documented for 945 OASIS reports submitted 500 (52.9%) were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator on 9/24/25 at 1:45 PM, the Administrator and alternate Director of Nursing confirmed the above finding.

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 staff interviews, Agency policy review and clinical records reviewed in 7 of 7 (Pts #1,2,3,4,5,6 and 7) the Agency failed to ensure patients were assessed for Pneumococcal vaccination status on admission. Findings include: 1. During an interview with the Administrator and alternate Director of Nursing on 09/24/25 at 1:00 PM, it was stated that patients are assessed for pneumococcal vaccination status on admission and documented on admission form. 2. The Agency policy titled "Policy on Pneumonia Vaccination" was reviewed on 09/24/25. The policy required "Procedure....1...Our clinicians upon Start of Care will obtain patient information regarding pneumonia vaccination status, will document where and when patient obtain their pneumonia vaccination". 3. The following clinical records were reviewed between 09/23/25 to 09/24/25, Pt #1 SOC 09/11/25 Pt #2 SOC 07/16/25 Pt #3 SOC 08/06/25 Pt #4 SOC 06/04/25 Pt #5 SOC 08/22/25 Pt #6 SOC 2/15/25 Pt #7 SOC 05/29/25 The clinical records lacked documentation of Agency staff completing pneumococcal vaccination status assessment. 4. The above findings were confirmed during interviews with the Administrator and alternate Director of Nursing on 09/24/25 at 1:00 PM and on 09/26/25 at 10:00 AM.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, for 1 of 1 (Pt. #5) Pt. wherein MSW services were provided, the Agency failed to ensure that concerns are communicated/coordinated within the healthcare team to ensure Pt. needs were identified and addressed. Findings include: 1.Pt. #5 was admitted for home health services on 08/22/25 with the diagnosis of Aftercare Following Joint Replacement Surgery. The clinical record was reviewed on 09/24/25 at 4:00 PM. The MSW assessment note dated 08/23/25 included the documentation, “Medical Social Services Goals: 1. Patient will have transportation to go to medical appointments within 2 to 4 weeks; 2. Patient will have meal services arranged within 2 to 4 weeks; 3. Patient will have homemaking/ housekeeping arranged for within 2 to 4 weeks. Medical Social Services Interventions: 1. Arrange transportation to medical appointments; 2. Arrange for meal service; 3. Assist with arranging for homemaking/ housekeeping services.” The record lacked documentation that transportation, meal and homemaking services were arranged for the Pt. 2.During an interview with the Administrator and Alternate Director of Nursing on 09/26/25 at 10:00 AM, it was stated that the Agency had no documentation of the follow up with the Agencies involved and/or information on the status the MSW referral for transportation, meal or housekeeping/homemaker services. During the same interview, the above findings were confirmed.

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: Based on a review of clinical records, and staff interview, the Agency failed to send a discharge summary to the primary care practitioner or other health care professional after the patients were discharged from the Agency. This was found in 2 of 2 (Pt. # 6 and 7) discharge records reviewed. Findings include: 1. Pt. #6 was admitted to home health services on 02/15/25 with diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 09/23/25. The clinical record had a discharge from agency SN visit dated 06/14/25. The clinical record lacked documentation indicating agency sent a discharge summary to the primary care practitioner. 2. Pt. #7 was admitted to home health services on 05/29/25 with Unspecified Atrial Fibrillation. The clinical record was reviewed on 09/24/25. The clinical record had a transfer / discharge from agency SN visit dated 08/09/25. The clinical record lacked documentation of a discharge summary was sent to the primary care practitioner. 3. The above findings were confirmed during an interview with the Administrator and Alternate Director of Nursing on 09/24/25 at 1:00PM.

An investigation was conducted on 07/19/24 for Complaint #IL107129 / #242678. The Facility was not in compliance with Standards for Home Health Agencies, at 42 CFR 484:

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, policy review and staff interview, it was determined in 2 of 4 (Pts. #3 and 4) clinical records reviewed, the plan of care was not followed as ordered. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 05/25/24 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/ Unspecified Chronic Kidney. The clinical record was reviewed on 07/19/24. The clinical record included a POC dated 05/25/24, that required the SN to assess the patient 1 time a week for 9 weeks. The clinical record included SN visit notes as ordered for weeks one through five. The record lacked documentation of visits completed for week six, 06/28/24, and week seven, 07/05/24. During the interview with the Administrator, it was stated no visit/assessment notes were available to review and the clinical record included a status of “not yet started” for the visits scheduled on 06/28/24 and 07/05/24. 2. Pt. #4 was admitted to Home Health Services on 03/08/24 with the diagnosis of Other Post procedural Complications of Skin, Sub cutaneous. The clinical record was reviewed on 07/19/24. The clinical record contained PsOC dated 03/08/24 and 05/07/24, that required the SN to assess the patient 1 time a week for 9 weeks. The clinical record included documented missed visits dated 05/10/24 and 05/17/24. The record lacked documentation of rescheduled visits or attempts made to reschedule the missed visits. The record also included two scheduled visits dated 06/28/24 and 07/05/24 that were documented as, "not yet started". The record lack documentation that visits were made on 06/28/24 and 07/05/24. 3. The Agency’s policy titled “Staffing Guidelines/ Missed Visits” was reviewed at 11:55 AM and included : “…2. Missed visits are rescheduled if possible… 4. Home visit staff documents reason for missed visits and informs prescribing care giver…” 4. The findings were confirmed with the during the interview with the Administrator and Director of Nursing on 07/19/24 at 11:40 AM.

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: Based on the clinical record review and Staff interview, it was determined for 1 of 3 discharged records (Pt.# 4) the Agency failed to complete a discharge summary. Findings include: 1. The clinical record for Pt. #4 was reviewed on 07/19/24. The clinical record included a Start of Care assessment on 05/25/24. The record also included a discharge date of 07/05/24. The record lacked a discharge summary. 2. The findings were confirmed, during the interview with the Administrator on 07/19/24 at 1:45 PM.

Rectification survey completed. Standard Level deficiencies cited. Abbreviations: POC = Plan of Care PTA = Physical Therapy Assistant RN = Registered Nurse SOC= Start of Care SN = Skilled Nurse MSW = Medical Social Worker

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), §485.625(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 review of Agency's Emergency Preparedness Binder, Agency's Inservice Binder and Staff interview, it was determined that the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all hazards approach. Findings include: 1. The Agency's Emergency Preparedness Binder and Agency's Inservice Binder were reviewed on 08/24/2022 at 1:30 PM. The plan lacked documentation that a facility/based and/or community based risk assessment was completed. 2. During an interview with Administrator on 08/25/2022 at 11:00 AM, the Administrator confirmed the above findings.

Rectification survey completed. Standard Level deficiencies cited. Abbreviations: POC = Plan of Care PTA = Physical Therapy Assistant RN = Registered Nurse SOC= Start of Care SN = Skilled Nurse MSW = Medical Social Worker

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 home visit observations, clinical records review and staff interview it was determined that the Agency failed to ensure the RN complete a comprehensive assessment within the last 5 days of certification period. This was found in 2 out of 4 clinical records reviewed wherein services were provided after the initial 60 day certification period. (Pts# 1 and 2) Findings include: 1. Pt #1. SOC 06/22/2022 Diagnosis: Pressure ulcer of sacral region, stage 4. The clinical record was reviewed on 08/24/2022 at 11:30 AM, the record contained a 60 day POC ending 08/20/2022. The clinical record lacked evidence that the RN completed a comprehensive assessment withing the last 5 days of the certification period. A home visit was conducted on 08/24/2022 with the PTA at 9:00AM. The home visit confirmed patient continues to receive home care services. 2. Pt #2. SOC 04/20/2022 Diagnosis: Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 08/24/2022 at 12:00PM. The clinical record contained a 60 day certification period ending 08/17/2022. The clinical record lacked evidence of the RN completing a comprehensive assessment within the last 5 days of the certification period. A home visit was conducted on 08/24/2022 at 2:00PM with the SN. The home visit confirmed patient continues to receive home care services. 3. Findings of the RN not completing a comprehensive assessment within the last 5 days of certification period were confirmed during an interview with the Administrator on 08/25/2022 at 10:00AM.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on home visit interviews, clinical record reviews, and staff interviews, it was determinied that Agency staff failed to conform with physician orders. This was found in 2 of 2 clinical records reviewed with physican orders for MSW services. (Pts #1 and #4). Findings include: 1. Pt #. 1 SOC 06/22/2022 Diagnosis: Pressure Ulcer of Sacral Region Stage 4. The clinical record was reviewed on 08/24/2022. The clinical record contained a POC for certification period 06/22/2022 to 08/20/2022. The POC contained a physician order for MSW Evaluation. A home visit was conducted with the PTA on 08/24/2022. During the home visit, the patient stated that no MSW has done an evaluation visit since the beginning of home care services. (The certification period for the MSW physician order ended 08/20/2022). 2. Pt. #4 SOC 06/22/2022 Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/24/2022 at 2:00 PM. The record included a signed POC for recertification period of 06/22/2022 to 08/20/2022, documented orders for discipline and treatment "....Medical Social Worker to assess psychological issues that impact health care....MSW to establish a plan as discussed with Case Manager and approved by physician..." The clinical record did not contian documentation regarding MSW evaluation or services. 3. During interviews with Administrator on 08/25/2022 from 10:00 AM to 11:00 AM, the Administrator confirmed the above findings.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined that the Agency failed to ensure that the clinical records were accurae and complete. This was found in 5 of 7 clinical records reviewed. (Pts. #1, 2, 3, 5, and 7). Findings include: Pt #1 SOC 06/22/2022. Diagnosis Pressure Ulcer Sacral Region, Stage 4. A home visit was conducted on 08/24/2022 at 9:00AM with the PTA. During the home visit interview, the patient stated she takes Tylenol #3 for pain. The patient also stated that she has never taken Norco for pain. The clinical record was reviewed at 08/24/2022 at 11:30AM. The clinical record contained a POC beginning 06/22/2022 that contained Norco 5mg-325mg oral Tablet. The POC did not include Tylenot #3. No modification to the physican orders were in the clinical record. Pt #2 SOC 04/20/2022. Diagnosis Type Diabetes Mellitus without complications. The clinical record contained a POC with inaccurae dates for the certification period. The POC was dated 06/19/2022 to 06/18/2022. The POC did not contain physican orders to modify the POC. Pt #3 SOC 06/28/2022 Diagnosis Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/24/2022 at 9:00AM. The record included a signed POC certification period 06/28/2022 to 8/26/2022 instructing the staff to nofify the physician of vital signs outside of parameters. The SN note dated 07/14/2022 did not include vital sign documentation. The POC required SN 2 times a week for 1 week then 1 time a week for 8 weeks. The clinical record lacked documentation of SN visits for the week of 07/25/2022 (week 5), week of 08/08/2022 (week 7) and 08/15/2022 (week 8). Pt #5 SOC 06/22/2022 Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/23/2022 at 11:00 AM. The clinical record contained a POC certification period of 06/22/2022 to 08/20/2022 which required SN visits 2 times a week for one week then one time a week for 8 weeks. The clinical record did not include SN visits for the week of 07/25/2022 (week 5) through 08/15/2022 (week 9). The record included an incomplete discharge assesment dated 08/17/2022. Pt #7 SOC 03/08/2022 Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/23/2022 at 12:15 PM. The record included a signed POC for certification period of 05/07/2022 to 07/05/2022, required SN frequency 1 time a week for 9 weeks. The record lacked documentation of SN visits for week of 05/30/2022 (week 5) and week of 06/05/2022 (week 6). During and interview with the Administrator at 10:30 AM and 11:00AM, the Administator confirmend that the notes were not in the clinical record.