Every finding on record at New Haven Home Health Care, Inc

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: SOC = Start of Care Pt./Pts. = Patient/Patients RN = Registered Nurse SN = Skilled Nurse AM = morning PM = afternoon HHA = Home Health Aide

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 2 of 7 (Pts. #5 and 7) clinical records reviewed. Findings include: 1. Pt. #5 was admitted for skilled home health on 2/13/23 with a primary diagnosis of Alzheimer’s Disease. The clinical record was reviewed on 1/17/24. The record contained a “Face to Face” document sent from the physician’s office dated 2/9/23. The SOC initial assessment was conducted by the RN on 2/13/23. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 2. Pt. #7 was admitted for skilled home health on 12/8/23 with a primary diagnosis of Bilateral osteoarthritis of knee. The clinical record was reviewed on 1/17/24. The record contained a “Face to Face” document sent from the physician’s office dated 12/1/22. The SOC initial assessment was conducted by the RN on 12/8/23. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 3. During an interview with the Administrator and Director of Nursing on 1/17/24 at 2:00 PM it was stated that the initial assessment should be conducted within 48 hours of the referral date, the date documented on the Face-to-Face physician form or on a specified physician ordered date. During the same interview, the above findings were confirmed.

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: Based on clinical record and staff interviews, it was determined the Agency failed to obtain a physician order for a wound treatment. This was found in 1 of 7 (Pt. #6) clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 4/6/23 with primary diagnosis of Alzheimer’s disease, unspecified. The clinical record was reviewed on 1/17/24. The record contained "Skilled Nurse Visit" notes dated 5/11/23, 5/18/23 and 5/25/23. The notes included the documentation: “Wound 1 – Location: Right hip pressure ulcer…Treatment: …cleansed wound with normal saline solution…covered with hydrocolloid dressing…” The record lacked documentation of a physician order for the wound treatment. 2. On 1/17/24 at 1:45 PM, during an interview conducted with the Administrator and Director of Nursing, it was stated that a physician order is needed for wound treatment. During the same interview, the above finding was confirmed.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, it was determined the Agency failed to ensure that Pt. changes in condition, assessment or concerns were communicated to the healthcare team, and with the physician to ensure Pt. needs were identified and addressed. This was found in 2 of 7 (Pts. #1 and 5) clinical records reviewed. Findings include: 1. Pt. #1 was admitted for skilled home health services on 10/11/23 with the primary diagnosis of Other postherpetic nervous system involvement. The clinical record was reviewed on 1/17/24. The record contained “Skilled Nurse Visit” notes which include documentation for the following dates: 11/15/23, blood pressure = 110/56 and 12/4/23, blood pressure = 120/56. The record also contained “HHA Visit” notes which include documentation for the following dates: 12/11/23, blood pressure = 111/56; 12/18/23, blood pressure = 111/58; 12/18/23, blood pressure = 119/52; 12/22/23, blood pressure = 117/52. The above-mentioned notes also included documentation of the Home Health Aide, “Noted with low diastolic (blood pressure). Nurse and office notified.” The clinical record lacked documentation that Pt. #1’s diastolic blood pressure, which was not within the parameters specified in the plan of care, was communicated to the physician. 2. Pt. #5 was admitted for skilled home health services on 4/6/23 with the primary diagnosis of Alzheimer’s Disease, unspecified. The clinical record was reviewed on 1/17/24. The clinical record included a “Skilled Nurse Visit” note which included documentation by the Licensed Practical Nurse that on 5/11/23, “Noted pressure related alteration of intact skin on the right hip which is warm to touch with firm tissue consistency. The pressure ulcer appears with persistent red skin which is categorized as stage 1. SN performed wound care…” The "Skilled Nurse Visit” notes dated 5/18/23 and 5/25/23 also included documentation and measurements of Pt. #5’s pressure ulcer on the right hip. The clinical record contained “HHA Visit” notes for the dates 5/15/23, 5/17/23, 5/23/23, 5/24/23, 5/29/23 and 5/31/23; and the above-mentioned HHA notes included documentation that Pt. #5’s “Skin is intact.” The clinical record lacked documentation that the onset of the pressure ulcer was communicated to the physician, RN and the HHA. 3. During an interview conducted with the Administrator and Director of Nursing on 1/17/24 at 1:30 PM, it was stated as of the time of the interview that any changes in condition/assessment of the Pt. should be communicated and coordinated with the physician, the RN and the HHA. During the same interview, the above finding was 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 review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 4/6/23 with a primary diagnosis of Alzheimer’s disease, unspecified. The record contained Physician Order dated 6/1/23, indicating that Pt. #6 was discharged from the Agency. As of the date of the clinical record review on 1/17/24, the record lacked documentation that a copy of the Pt. #6’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 4/7/23 with a primary diagnosis of Hemiplegia following cerebral infarction affecting left non-dominant side. The record contained Physician Order dated 6/5/23, indicating that Pt. #7 was discharged from the Agency. As of the date of the clinical record review on 1/17/24, the record lacked documentation that a copy of the Pt. #7’s discharge summary was sent to the Physician. 3. During an interview with the Administrator and the Director of Nursing on 1/19/24 at 1:45 PM, the above findings were confirmed.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined 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 Plan was reviewed on 02/17/21 at 2:00 PM. The plan lacked a facility and community based risk assessment. 2. During an interview with the Administrator on 02/19/21 at 11:00 AM, the Administrator confirmed the above finding.

Names and Contact Information CFR(s): 484.102(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).] 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 the review of the Agency's Emergency Preparedness Plan, policy review, and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/17/21 at 2:00 PM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement, Patients' Physicians, and Volunteers. 2. The Agency policy titled, "Emergency Management Policy" was reviewed on 02/17/21 at 2:15 PM. The policy required: ..."Special Instructions...4... A listing of all staff members and telephone numbers will be included in the Agency's on-call book. If there were actual or impending disaster, the triage system would be initiated to insure patient needs are met." 3. During an interview with the Administrator on 2/19/21 at 11:00 AM, the Administrator confirmed the above finding.

Recertification and FIC survey scheduled 1/25/21. Survey team arrived at listed Agency address at 9:00 AM. No agency staff present. Agency name, office days and hours listed on the office door. Listed and alternate phone number called multiple times from 9:10 AM to 10:15 AM. No response. Voice messages left to contact HFSN Supervisor. COOS contacted. No changes with Address or phone numbers. Agency Illinois License expires 7/31/21. IQIES/OASIS reports reviewed from 1/1/20 to 1/25/21. 59 patients noted. Last report submitted by agency was on 10/30/20. Survey team left the Agency location at 10:30 AM. Recertification survey conducted from 2/16/21 - 2/19/21. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 02/19/2021. New Haven Home Health Care was in compliance with the requirements for Infection Control for COVID-19. Identification of abbreviations: DON = Director of Nursing SOC = Start of care POC = Plan of care SN = Skilled nurse

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 orders; This ELEMENT is not met as evidenced by: . A. Based on clinical records review and staff interview, it was determined that the Agency failed to ensure clinical records and assessments were complete and incorporated into clinical records. This was found in 4 of 7 clincial records reviewed (Pts.# 6, 3, 2 and 4). Findings include: 1. Pt.#6 SOC 10/14/2020 Diagnoses: Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus Without Complications. The clinical record was reviewed on 02/17/2021 at 12:30 PM. The clincial record contained a POC for certification period 12/13/2020 to 02/10/2021 that required SN services 1 times a week for 9 weeks. The clinical record fail to contain SN visits notes for week 6 to week 9 of certification period. During an interview with the Administrator and the DON on 02/19/2021 at 11:00 AM the Administrator stated that SN made the visits and not incorporated the notes in the clinical record. 2. Pt.#3 SOC 10/30/20 Diagnoses: Essential (primary) Hypertension, Generalized Osteoarthritis. The clinical record was reviewed on 02/17/20 at 7:30 AM. The record included a POC for certification period for 12/29/20 to 02/26/21. The POC orders for Discipline and Treatment documented under frequency: SN Frequency: 1w9 (1x9weeks) Effective: 12/29/20. The pt. was re-certified on 12/24/20 and seen by SN on 01/02/21, 01/04/21 and 02/17/21 for a home visit with surveyor. The Agency failed to deliver services as ordered by the Physician in the POC. 3. Pt.#2 SOC 10/26/20 Diagnosis: Hypertension. The clinical record was reviewed on 2/17/21 at 1:00 PM. The record contained POC with certification period 12/25/20 to 2/22/21 which required: " ...SN frequency of 1 week 9 ..." The record lacked current SN visit notes for week of 1/24-30 and 1/31-2/6 (weeks 6 and 7). 4. Pt.#4 SOC 02/01/21 Diagnosis: Hypertension. The clinical record was reviewed on 2/17/21 at 10:00 AM. The record contained POC for certification period 2/1/21 to 4/1/21. The POC lacked documentation of SN frequency, list of current medications and vital sign parameters to notify physician. During an interview with the Administrator and DON on 2/19/21 on 10:00 AM, the Administrator stated the required documentation are to be submitted within a week and confirmed that visits were conducted for Pt. #2 but notes were not completed. During interviews with the Administrator and DON on 2/19/21 at 10:00 AM and 11:00 AM, the Administrator confirmed the above findings.