Every finding on record at Infinity Home Health Care, Inc

Substantial Allegation Survey conducted for complaint # 222599 /IL 70585. Standard level deficiencies cited. Abbreviations: # = number PM = evening E = Employee SN = Skilled Nurse SOC = Start of care RN = Registered Nurse Pt./ Pts. = Patient/Patient

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure that documentation of forms was complete and accurate. This was found in 3 of 3 (Pts. #1, #2 and #3) clinical records reviewed. Findings include: 1. Pt. #1. SOC 4/8/22. Principal Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 5/23/22 at 1:30 PM. The clinical record lacked SN notes for the weeks of 4/10/22 to 4/16/22 and 4/17/22 to 4/23/22. During an interview with E#1 (Administrator) on 5/23/22 at 1:30 PM, SN submitted “Confirmation of Skilled Visit” containing signature of Pt. #1, indicating that visits were conducted on 4/14/22 and 4/21/22, but the SN notes were not yet incorporated in the medical record at the time of the review. 2. Pt. #2. SOC 3/9/22. Principal Diagnosis: Type 2 Diabetes Mellitus without Complication. The clinical record was reviewed on 5/23/22 at 2:00 PM. The clinical record lacked SN notes for the weeks of 4/10/22 to 4/16/22 and 4/17/22 to 4/23/22. During an interview with E#1 on 5/23/22 at 2:00 PM, the SN submitted “Confirmation of Skilled Visit” containing signature of Pt. #2 indicating that visits were conducted on 4/15/22 and 4/22/22 but the SN notes were not yet incorporated in the medical record at the time of the review. 3. Pt. #3. SOC 12/1/21. Principal Diagnosis: Atherosclerosis of Coronary Artery Bypass Graft without Angina Pectoris. The clinical record was reviewed on 5/23/22 at 2:30 PM. The clinical record lacked SN notes for the weeks of 4/3/22 to 4/9/22, 4/10/22 to 4/16/22 and 4/17/22 to 4/23/22. During an interview with E#1 on 5/23/22 at 2:00 PM, it was revealed that the SN conducted skilled visits on 4/6/22, 4/15/22 and 4/20/22 but the SN notes were not yet incorporated in the medical record at the time of the review. 4. During an interview with E#1 and E#3 (RN/ Backup Director of Nursing) on 5/23/22 at 4:00 PM and the above findings were confirmed. E#1 also stated the clinicians should submit clinical notes at least within a week of the visit.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PM = afternoon/evening DON = Director of Nursing Pt./ Pts. = Patient/Patients

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: A. Based on clinical record and staff interviews, it was determined the Agency failed to ensure that the service provided was ordered by the Physician. This was found in 3 of 7 (Pt. #3, #7 and #2) clinical record reviews. Findings include: 3. Pt. #2. SOC: 8/31/21 Diagnosis: Encounter for other Orthopedic Aftercare. The clinical record of Pt. #2 was reviewed on 9/21/21 at 12:30 PM. The record included the POC for the certification period dated 8/31/21 through 10/29/21, which required SN visits 1 time a week for 9 weeks. The record instead documented SN visits for 2 times a week for 2 weeks for 8/31/21, 9/3/21, 9/15/21 and 9/18/21. The record lacked documentation order for additional SN visit during those two weeks. 4. During an interview with the DON on 9/21/21 at 2:30 PM, the DON confirmed that staff failed to update the POC and obtain the Physician’s order for the additional SN visits. 1. Pt. #3. SOC 7/19/21. Primary Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 9/20/21 at 2:00 PM. The POC for the period of 7/19/21 to 9/16/21 requires: Skilled Nursing: Frequency and Duration: 1/wk x 9 weeks. The record contained documentation that 2 SN visits were provided for the week of 7/19/21 to 7/24/21. The record lacked documentation for an additional SN visit order for that week. 2. Pt. #7. SOC 7/15/21. Primary Diagnosis: Primary Osteroarthritis, Left Shoulder. The clinical record was reviewed on 9/20/21 at 2:46 PM. The POC for the period of 7/15/21 to 9/12/21 requires: Skilled Nursing: Frequency and Duration: 1/wk x 9 weeks. The record contained documentation that 2 SN visits were provided for the week of 7/18/21 to 7/24/21. The record lacked documentation for an additional SN visit order for that week.

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 clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure Pts. were assessed for the status of the influenza and/or pneumococcal vaccine at the (SOC) Start of Care per Agency policy. This was found in 3 of 7 (Pts. #2, #5 and #3) clinical records reviewed. Findings include: 4. Pt. #3. SOC 7/19/21. Principal Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 9/20/21 at 2:00 PM. The record included a comprehensive assessment conducted by the RN during the start of care dated 7/19/21 which included documentation “Immunizations: Influenza, Pneumonia.” The form lacked immunization dates and/or comments whether the patient received or refused the immunization. 5. The Agency’s Policy on Pneumococcal Vaccine was reviewed on 9/22/21 at 11:00 AM. The policy requires, “Procedure: All persons upon admission shall be assessed for recent and past vaccinations including Pneumococcal Vaccine.” 6. The Agency’s Policy on Influenza Vaccination was reviewed on 9/22/21 at 11:15 AM. The policy requires, “ Procedure: All persons upon admission shall be assessed for recent and past flu vaccinations.” 7. During the entrance conference interview with the Director of Nursing and the Alternate Administrator on 9/20/21 at 10:30 AM, the Director of Nursing stated that screening for pneumococcal and influenza vaccinations are conducted during the admission of the patient and it is documented in the comprehensive assessment at the start of care. 8. During an interview with the Director of Nursing and Alternate Administrator on 9/21/21 at 2:30 PM, and on 9/22/21 at 1:00 PM, the above findings were confirmed. 1. Pt. #2. SOC: 8/31/21 Diagnosis: Encounter for other Orthopedic Aftercare. The clinical record of Pt. #2 was reviewed on 9/21/21 at 12:30 PM. The record lacked documentation of the Influenza and Pneumococcal vaccination status of the patient upon admission. 2. Pt. #5. SOC: 8/10/21 Diagnosis: Bilateral Osteoarthritis of the Hip. The clinical record of Pt. #3 was reviewed on 9/22/21 at 9:30 AM. The record lacked documentation of the Influenza and Pneumococcal vaccination status upon admission.