Every finding on record at Mjm Health Agency, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 11/22/24. Standard level deficiencies cited.

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: Based on the review of the Agency's Emergency Preparedness Plan and Staff interview, it was determined that since 2021, the Agency failed to update the communication plan. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed 11/19/24 at 12:30 PM. The Emergency Preparedness Plan lacked a communication plan that includes the current administrative staff. 2. The above finding, regarding the lack of a current communication plan was confirmed during an interview with the Assistant Administrator on 11/20/24 at 11:00 AM.

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 Plan and staff interview, it was determined that the Agency failed to conduct / participate in testing of the Emergency Preparedness to ensure the effectiveness of the Agency's Plan. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 11/19/24 at 12:30 PM. The Emergency Preparedness Plan did not contain documentation indicating that the Agency implemented /conducted any testing exercise or drill since 2021. 2. During an interview with the Assistant Administrator and Nurse Manager on 11/20/24 at 11:00 AM, the Assistant Administrator confirmed that the Agency failed to conduct / participate in testing or drills since 2021.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 11/22/24. Standard level deficiencies cited. Abbreviations: # = number % = percent AM = morning SN = Skilled Nurse POC / PsOC = Plan of care / Plans of care SOC = Start of care MD = Medical Doctor RN = Registered Nurse LPN = Licensed Practical Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist OASIS = Outcome and Assessment Information Set

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 review of the Error Summary report and Staff interview, it was determined that in 182 of 357 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 11/01/23 to 10/31/24 (12 months), was reviewed on 11/20/24. The report included a warning for Error # -3330. The Error included 182 (50.98%) of 357 assessments that were submitted late. The submission date was more than 30 days after the assessment was completed. 2. During an interview with the Assistant Administrator and Nurse Manager on 11/20/24 at 12:00 PM, the Nurse Manager stated that the timeframe for submission of OASIS assessments is within 30 days after completion. During the same interview, the Nurse Manager confirmed the above findings.

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 a review of clinical records and Staff interviews, it was determined that in 7 of 7 (Pts. 1, 2, 3, 4, ,5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. Findings include: 1. The following clinical records were reviewed from 11/19/24 to 11/20/24: Pt. #1 SOC 08/06/24. Pt. #2 SOC 02/05/24. Pt. #3 SOC 04/04/23. Pt. #4 SOC 08/03/24. Pt. #5 SOC 09/16/24. Pt. #6 SOC 02/16/24. Pt. #7 SOC 04/08/23. The clinical records contained the “Service Agreement” form and included the “Anticipated frequency”, requiring the SN that completes the SOC to write the proposed frequency for each discipline in the space provided, this section was left blank for the Pts. indicated above. 2. During an interview with the Assistant Administrator and Nurse Manager on 11/20/24 at 1:30 PM, the Nurse Manager confirmed the Agency failed to ensure Pts. were informed in writing of the discipline(s) to provide service, and the frequency of visits provided by each discipline.

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: Based on clinical records review and Staff interview, it was determined that in 3 of 7 (Pts. # 2, 4 and 7) clinical records reviewed the Agency failed to ensure that the PsOC contained patient specific interventions and treatments. Findings include: 1. Pt.# 2 was admitted to home health services on 02/05/24 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 11/19/24. The clinical record contained weekly SN visit notes for certification period 10/02/24 to 11/30/24. The SN weekly notes contain documentation of SN conducting Oxygen saturation assessments. The POC for the certification period 10/02/24 to 11/30/24, lacked orders for Oxygen saturation assessments and patient specific parameters. 2. Pt.# 4 was admitted to home health services on 08/03/24 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 11/19/24. The clinical record contained weekly SN visit notes for certification period 08/03/24 to 10/01/24. The SN weekly notes contain documentation of SN conducting Oxygen saturation assessments. The POC for the certification 08/03/24 to 10/01/24 period, lacked orders for Oxygen saturation assessments and patient specific parameters. 3. Pt. # 7 was admitted to Home Health Services on 04/08/23/23 with the Diagnoses of Heart failure and Hyperglycemia. The clinical record was reviewed on 11/19/24. The PsOC for the certification periods of 12/04/23 to 02/01/24 and 02/02/24 to 04/01/24, included: “Teach glucose monitoring….Blood sugar will be within acceptable range for patient….” The PsOC lacked orders for blood sugar monitoring and patient specific parameters. 4. During interviews with the Assistant Administrator and Nurse Manager on 11/20/24 between 11:00 AM to 1:30 PM, the above findings were confirmed.

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: Based on a review of the Agency's Pt. admission folder and Staff interview, it was determined that the Agency failed to provide information regarding the Nurse Manager. Findings include: 1. The Pt. admission folder was reviewed on 11/18/24. The folder lacked the name and information to contact the Nurse Manager. 2. The following home visits were conducted on 11/18/24 and 11/19/24: Pt. #1. SOC 08/06/24. Pt. #2. SOC 02/05/24. Pt. #3. SOC 04/04/23. During the home visits of Pts. #___ and 2, the Pt. admission folders were observed, and lacked the name and contact details of the Nurse Manager. During the interviews, the Pts./Pt. representatives were not aware of the Nurse Manager's name and contact information. During the home visit with Pt. #3, the Pt. and patient’s representative was unable to locate the admission folder. 3. The following clinical records were reviewed on 11/19/24 to _________: Pt. #1. SOC 08/06/24. Pt. #2. SOC 02/05/24. Pt. #3. SOC 04/04/23. Pt. #4. SOC ________. Pt. #5. SOC ________. Pt. #6. SOC ________. Pt. #7. SOC ________. The clinical records reviewed lacked the name and contact details of the Nurse Manager. 4. During an interview with the Assistant Administrator on 11/19/24 at 11:00 AM, the Assistant Administrator confirmed the Agency failed to provide information regarding the Nurse Manager. .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record reviews and Staff interview, it was determined that in 4 of 7 (Pts. #1, 7, 2 and 4) clinical record reviews, the Agency failed to ensure that services are provided as ordered in the POC. Findings include: 1. Pt. #1 was admitted to Home Health Services on 08/06/24 with the Diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 11/19/24. The clinical record contained a POC for certification period 10/05/24 to 12/03/24, that required: “SN:….Assess Vital signs, notify MD….”. The SN note dated 10/30/24, lack vital sign assessments by the SN as ordered in the POC. 2. Pt. # 7 was admitted to Home Health Services on 04/08/23 with the Diagnosis of Heart failure. The clinical record was reviewed on 11/19/24. The clinical record contained a POC for the certification periods of 12/04/23 to 02/01/24 and 02/02/24 to 04/01/24 that required: “SN:…Weigh every visit….” The SN assessments dated 12/20/23, 01/06/24, 01/09/24, 01/15/24 and 01/25/24 lacked weight assessments by the SN as ordered in the POC. 3. Pt.# 2 was admitted to home health services on 02/05/24 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 11/19/24. The clinical record contained a POC for certification period 10/02/24 to 11/30/24 that required PT to evaluate patient. As of 11/19/24 the clinical record lacked evidence of PT conducting PT evaluation assessment. 4. Pt.# 4 was admitted to home health services on 08/03/24 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 11/19/24. The clinical record contained a POC for certification 10/02/24 to 11/3024 that required PT to evaluate patient. As of 11/19/24 the clinical record lacked evidence of PT conducting PT evaluation assessment. 5. Findings of the Agency staff not providing services as ordered by the physician was confirmed during interviews with the Assistant Administrator and Nurse Manager on 1/20/24 between 11:00 AM and 1:00 PM.

Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This STANDARD is not met as evidenced by: Based on Agency document reviews, clinical record reviews and Staff interview, it was determined that the Agency failed to disclose consistent legal address for the Agency to the State survey Agency. Findings include: 1.The licensure renewal application for Home Health Agency license Number 1010594, dated 02/28/24 and current Agency’s IDPH license expiring 04/30/25 were reviewed on 11/19/24 and included the current Agency address “1S311 Summit Ave, Oakbrook Terrace, IL 60181”. 2. The Admission folder was presented and reviewed on 11/19/24 and included the following documents listed with the address “211 N Hammes Ave #2C, Joliet, IL 60435”: Vaccination inquiry Form, Notice of Medicare Provider Non-Coverage, Multiple Agencies Duplication of Service, Request for Transfer of Home Health Services, Consent for Photographs, Notice of Privacy Practices and Agency brochure. These documents lacked the current address for the Home Health Agency. 3. The PsOC for Pts. #1 through 7 were reviewed from 11/19/24 to 11/20/24 and included, the address “211 N Hammes Ave #2C, Joliet, IL 60435”. The PsOC lacked the current address for the Home Health Agency. 4. During an interview with the Assistant Administrator and Nurse Manager on 11/20/24 at 1:30 PM, the Assistant Administrator stated that the current legal address for the Home Health Agency is the Oakbrook Terrace location. During the same interview, the Assistant Administrated confirmed the findings that Agency did not disclose a consistent legal address for the Home Health Agency.

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 interviews, it was determined that in 2 of 2 (Pts. # 6 and 7) discharge records, the Agency failed to send a discharge summary to the primary care practitioner or other health care professional, within five (5) business days of discharge. 2. Pt. # 7 was admitted to Home Health Services on 04/08/23 with the Diagnoses of Heart failure and Hyperglycemia. The clinical record was reviewed on 11/19/24. The clinical record contained a discharge summary completed by the SN and indicated that Pt. #7 was discharged on 02/16/24 from Agency. The discharge summary dated 02/26/24 contained a “Faxed stamp dated 02/26/24”. 3. During interviews with the Assistant Administrator and Nurse Manager on 11/20/24 from 11:30 AM to 1:00 PM, the Nurse Manager confirmed that the faxed stamp date is the date that discharge summary was sent out to the Physician. During the same interview, the Nurse Manager confimred the above findings. Findings include: 1. Pt.# 6 was admitted to home health services on 02/16/2024 with Diagnosis of Hypertension. The clinical record was reviewed on 11/19/2024 at 11:30 AM. The clinical record contained a SN discharge assessment dated 07/18/2024. The clinical record lacked evidence a discharge summary was sent to the Physician.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical records review and Staff interview, it was determined that in 7 of 7 (Pts #1, 2, 3, 4, 5, 6, and7) the Agency failed to ensure clinical notes were properly authenticated to include the title of staff completing clinical note. Findings include: 1. The Agency staff list was reviewed on 11/19/2024. The Agency staff list included RN’s and LPN. 2. The following clinical records were reviewed between 11/19/2024 and 11/20/24. The clinical records contained SN visit notes that lack the title of discipline completing the SN clinical note. Pt. #1 SOC 08/06/24. Pt. #2 SOC 02/05/24. Pt. #3 SOC 04/04/23 Pt. #4 SOC 08/03/24. Pt. #5 SOC 09/16/24. Pt. #6 SOC 02/16/2024. Pt. #7 SOC 04/08/23. 3. The findings, regarding lack of authentication of SN visit note entries, were confirmed during interviews with the Assistant Administrator and Nurse Manager on 11/20/21 between 11:00 AM and 1:30 PM. .

Recertification survey completed. Standard level deficiencies cited. Abbreviations: SOC = Start of care POC = Plan of Care PT= Physical Therapy PM = afternoon/evening Pt. = Patient x = times

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide Physical Therapy services as ordered by the Physician in the POC, and to notify the Physician of missed visits, as per the Agency’s policy. This was found in 2 of 4 (Pts. #4, and 3) Pts. who received Physical Therapy. Findings include: 1. Pt. #4. SOC 6/3/21. Primary Diagnosis: Cervical Disc Disorder with Radiculopathy, Cervicothoracic Region. The clinical record was reviewed on 10/5/21 at 12:30 PM. The record contained the POC effective 8/2/21 to 9/30/21, which contained the Physician’s order “PT 2 x week x 8 weeks.” The record included documentation the Pt. received only one Physical Therapy visit for the week of 8/29/21 to 9/4/21, and the week of 9/5/21 to 9/11/21. The record lacked documentation the Pt. received any Physical Therapy visits for the week of 9/12/21 to 9/18/21, and 9/19/21 to 9/25/21. The record also lacked documentation the Physician was notified of the missed Physical Therapy visits. 2. The Agency policy titled “Clinical Documentation” was reviewed on 10/5/21 at 2:15 PM. The policy required: “…Services not provided and the reason for the missed visits will be documented and reported to the Physician…” 3. During an interview with the Administrator on 10/7/21 at 1:30 PM, the Administrator confirmed the above findings. 2. Pt. #3. SOC 8/26/21. Primary Diagnosis: Encounter for screening of Osteoporosis. The clinical record was reviewed on 10/5/21at 2:30 PM. The record included the POC effective 8/26/21, which documented the Physician’s order “PT 2 x week x 8 weeks.” The record lacked documentation the Pt. received any Physical Therapy visits for the week of 8/29/21 to 9/4/21, and only one visit for the week of 9/19/21 to 9/25/21. The record lacked documentation the Physician was notified of the missed Physical Therapy visits.