Every finding on record at Illinois Home Health Services, LLC

. Recertification survey was conducted. Standard level deficiencies cited. Focused Infection Control Survey was conducted. Standard level deficiencies cited. Abbreviations: Pt./ Pts. = Patient/Patients AM = Morning PM = Afternoon/Evening SOC= Start of Care

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: . A. Based on review of the Agency's Pt. admission folder, and staff interview, it was determined the Agency failed to ensure, at time of admission, a copy of the Agency's transfer and discharge policy would be given to Pts. and their families. This has the potential to affect all Pts. admitted to the Agency. Findings include: 1. The Agency Pt. admission folder provided by the Agency was reviewed on 5/10/21 at 1:00 PM. The folder lacked a copy of the Agency's transfer and discharge policy. 2. During an interview with the Director of Nursing on 5/11/21 at 2:30 PM, the Director of Nursing indicated the same admission folder is given to all Patients and, confirmed the admission folder did not contain a copy of the Agency's transfer and discharge policy. The Director of Nursing also confirmed not being aware that the transfer and discharge policies should be provided to the Pt./Pt. Caregivers.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: . A. Based on Pt. admission packet review and staff interview, it was determined the Agency failed to ensure, at time of admission, a copy of the name and contact information of the Administrator would be given to Pts. and their families. This has the potential to affect all Pts. admitted to the Agency. Findings include: 1. During the Agency entrance interview on 5/10/21 at 10:05 AM, the Director of Nursing confirmed the Administrator's name and contact information. 2. The Agency Pt. admission folder was reviewed on 5/10/21 at 1:00 PM. The folder lacked information identifying the Administrator's name and contact information. 3. During an interview with the Administrator and Director of Nursing on 5/11/21 at 3:00 PM, the Director of Nursing indicated the same admission folder is given to all Patients. The administrative staff confirmed the Administrator's name is not indicated in Agency's admission packet.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: . A. Based on a review of the Agency's Pt. admission folder and staff interview, it was determined the Agency failed to ensure the Agency admission folder included information regarding the Clinical Manager (Director of Nursing), and their contact information. This has the potential to affect all Pts. admitted to the Agency. Findings include: 1. The Agency Pt. admission folder was reviewed on 5/10/21 at 1:00 PM. The folder lacked information identifying the Director of Nursing's name and contact information. 2. During an interview with the Administrator and Director of Nursing on 5/11/21 at 3:00 PM, the Director of Nursing indicated the same admission folder is given to all Patients. During the same interview, the administrative staff also confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on review of the Agency Policy, Infection Log binders and staff interview, it was determined the Agency failed to maintain and implement a surveillance program to identify, prevent, control, monitor and track staff and patients. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. The Agency Policy, Surveillance and COVID-19 binders were reviewed on 5/11/21 at 10:00 AM. The Infection Log binder last document was dated 2/13/20. No updates or any other data related to infection control surveillance was in the binder. 2. The "Policy and Procedure Manual" binder contained the "Infection Control Surveillance" policy which included: "Agency will establish a continuous data monitoring collecting system to detect infections or identify changes in infection trends. The three types of surveillance that may be used are: -. Total surveillance - all infections identified in client and employees. -. Targeted surveillance- specific infections, populations, or procedures. -. Outbreak surveillance - specific infections or infection clusters with multiple individuals at the same time. The Agency will implement a process of identifying all infections in the client and/or employee population and evaluate effectiveness of current control measures or identify and action plan to improve incidence of infections. Special Instructions -. "The Agency will perform targeted infection control surveillance ....." -. "Employee infections are to be reported if an employee develops or has a known exposure ...." 1 ."The Agency staff will attempt to identify the source of infection ...." 3. "A community acquired infection would be monitored through outbreak surveillance ..." 5. "The Agency will closely monitor and investigate employee's occupational exposure ....." 6. "An infection control log will be maintained ....." 2. During an interview with the Director of Nursing (DON) on 5/11/21 at 2:30 PM, the above findings were confirmed.