Every finding on record at Nightengale of Chicago Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 03/07/25. Standard level deficiencies cited. Abbreviations: COVID 19 = Coronavirus disease of 2019

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. 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 establish policies and procedures based on the Agency’s identified risk assessment. Findings include: 1. The Agency’s Emergency Preparedness Plan last updated on 05/13/24 was reviewed on 03/06/25. The Plan included the “Hazard Vulnerability Analysis (risk assessment) form that contained different types of potential emergencies as identified by the Agency, including hurricane, flood, tornado, blackouts, snow, drought, ice and COVID-19. As of 03/06/25, the Emergency Preparedness Plan lacked policies and procedures based on potential emergencies identified by the Agency. 2. During an interview with the Administrator on 03/06/25 at 10:30 AM, the Administrator confirmed the above findings.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of Agency’s Emergency Preparedness Plan, staff in-services binder and staff interview, it was determined that the Agency failed to conduct and document staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan and staff in-services binder were reviewed on 03/06/25 and lacked documentation that the Agency conducted Emergency Preparedness training in 2022, 2023 and 2024. 2. During an interview with the Administrator on 03/06/25 at 10:30 AM, the Administrator confirmed the above findings.

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 review of Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to ensure that the Emergency Preparedness plan was tested and /or activated and documented, as required. Findings include: 1. The Emergency Preparedness Plan was reviewed on 03/06/25. The Emergency Preparedness Plan included documentation of an Emergency Preparedness drill on 05/16/22, 05/15/23 and 05/13/24, with participants including the Administrator, Director of Nursing, Employee #6 (Licensed Practical Nurse) and a contracted Physical Therapist. The documentation lacked the details/description of the type of exercise/emergency scenario of the Emergency Plan testing conducted. The Agency lacked documentation that the Agency participated in full scale, facility/community-based exercise or an actual activation of Emergency Preparedness plan, and that other employees participated in any exercises from 2022. 2. During an interview with the Administrator on 03/06/25 at 10:30 AM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 03/07/25. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care POC = Plan of Care SN = Skilled Nurse AM = morning PM = afternoon HHA= Home Health Aide PT = Physical Therapy RN = Registered Nurse LPN = Licensed Practical Nurse % = Percent w = week mg = milligram dL = deciliter

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 of 64 of 73 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 02/01/24 to 02/25/25 (12 months), was reviewed on 03/03/25. The report included a warning for Error # -3330. The Error included 64 (87.67 %) of 73 assessments that were submitted late. 2. During staff interviews with the Administrator and Director of Nursing, on 03/05/25 at 1:30 PM, the administrative team confirmed the above findings.

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: Based on review of the Agency's Pt. admission folder, observations during home visits, clinical record reviews, 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 provide the Pt./patient's representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 03/03/25 and lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 03/03/25 and 03/04/25: Patient #1. SOC 08/06/24. Patient #3. SOC 05/23/24. During the home visits of Pts. #1, and #3, the patient's admission folder was observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed on 03/04/25 and 03/05/25: Pt. #1. SOC 08/06/24. Pt. #2. SOC 03/07/24. Pt. #3. SOC 05/23/24. Pt. #4. SOC 05/09/24. Pt. #5. SOC 02/07/24. Pt. #6. SOC 06/03/24. Pt. #7. SOC 07/22/24. The clinical records lacked documentation that the Pt./Pt.'s representative was provided the name and contact information of the Administrator to file a complaint or grievance. 4. During staff interviews with the Administrator and Director of Nursing on 03/05/25 at 1:30 PM, the administrative team confirmed the above findings.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide 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 to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record review and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7), clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. Findings include: 1.The Agency’s Pt. admission folder was reviewed on 03/03/25. The folder lacked documentation of the Agency's transfer and discharge policies. 2. The following home visits were conducted on 03/03/25 and 03/04/25: Patient #1. SOC 08/06/24. Patient #3. SOC 05/23/24. During the home visits, the Pt. admission folders were observed, and lacked documentation of the Agency's transfer and discharge policies. 3. The following clinical records were reviewed on 03/04/25 and 03/05/25: Pt. #2. SOC 03/07/24. Pt. #4. SOC 05/09/24. Pt. #5. SOC 02/07/24. Pt. #6. SOC 06/03/24. Pt. #7. SOC 07/22/24. The records lacked documentation the Agency provided Pts. information, regarding the Agency's policies pertaining to transfer and discharge. 4. During interview with the Administrator and Director of Nursing, on 03/05/24 at 1:30 PM, it was confirmed the Pt. admission folder reviewed is used for all Pts. admitted to this Agency, and that the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies.

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 review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical record review, 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 the Pt./representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 03/03/25. The folder included the “Consent for Medical Treatment” the form did not include the frequency of visits and disciplines who will provide care. 2. The following clinical records were reviewed from 03/04/25 and 03/05/25: Pt. #1. SOC 08/06/24. Pt. received SN and PT services. Pt. #2. SOC 03/07/24. Pt. received SN services. Pt. #3. SOC 05/23/24. Pt. received SN services. Pt. #4. SOC 05/09/24. Pt. received SN services. Pt. #5. SOC 02/07/24. Pt. received SN services. Pt. #6. SOC 06/03/24. Pt. received SN and PT services. Pt. #7. SOC 07/22/24. Pt. received SN services. The clinical records included the “Consent for Medical Treatment” form signed by the Pt./representative. The consent forms lacked documentation of the service(s) to be provided and visit frequencies. 3. The following home visits were conducted on 03/03/25 and 03/04/25: Patient #1. SOC 08/06/24. Patient #3. SOC 05/23/24. During the home visits of Pts. #1 and 3, the Pt. admission folders were observed and lacked documentation indicating the Pt./representative was notified of the discipline(s) to provide service, and frequency of visits in writing. 4. During staff interviews with the Administrator and Director of Nursing, on 03/05/25 at 1:30 PM, the administrative team confirmed the above findings.

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 review of clinical records, and staff interviews, it was determined in 4 of 7 (Pts. #4, 5, 2,and 7) clinical records reviewed, the Agency failed to ensure the initial assessment was done within 48 hours upon receipt of a referral. 3. Pt. #2 was admitted to home health services on 03/07/24 with the diagnosis of Type 2 Diabetes Mellitus with other specified complication. The record included a Physician’s office fax referral for home health services dated 02/12/24. The record included the initial SOC assessment, dated 03/07/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 03/06/25, the record lacked documentation the Agency initiated service within the required time frame. 4. Pt. #7 was admitted to home health services on 07/22/24 with the diagnosis of Alzheimer’s disease with early onset. The record included a Physician referral fax for home health services dated 07/18/24. The record included the initial SOC assessment, dated 07/22/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 03/06/25, the record lacked documentation the Agency initiated service within the required time frame. 5. During interview with the Administrator and Director of Nursing, on 03/05/25 at 1:30 PM and 2:30 PM, the above findings were confirmed. Findings include: 1. Pt. #4 was admitted to home health services on 05/09/24 with the diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 03/04/25. The record included a Physician's office fax referral dated 04/25/24. The record included the initial SOC assessment, dated 05/09/24 and lacked documentation of an inpatient stay or physician ordered SOC date. As of 03/06/25, the record lacked documentation the Agency initiaited service within the required timeframe. 2. Pt. #5 was admitted to home health services on 02/07/24 with the diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 03/04/25. The record included a Physician's office fax referral dated 01/08/24. The record included the initial SOC assessment dated 02/07/24 and lacked documentation of an inpatient stay or physician ordered SOC date. As of 03/06/25, the record lacked documentation the Agency initiated servcie within the required timeframe.

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 reviews and staff interviews, it was determined that in 3 of 7 (Pts. #4, 5 and 6) clinical records reviewed, the Agency failed to ensure that services were provided as ordered in the POC. Findings include: 1. Pt. #4 was admitted to home health services on 05/09/24 with the diagnoses of Chronic Systolic (Congestive) Heart Failure and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 03/04/25. The clinical record included a POC for the certification period 01/04/25 to 03/24/25, required: “Orders for Discipline and Treatment: Notify Physician of vital sign parameters out of range:…. Fasting Blood Sugar: greater than (>)250 mg/dl. Less than ()250 mg/dL less than (to report to Physician if falling outside established parameters as ordered. 2. Pt. #5 was admitted to home health services on 02/07/24 with the diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 03/04/25. The clinical record included a POC for the certification period of 12/03/24 to 01/31/25, required: “…. Physical Therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence….” As of 03/04/25, the record lacked a Physical Therapy assessment as ordered in the POC. The POC for the certification period of 12/03/24 to 01/31/25, required SN, “Notify Physician of vital sign parameters out of range:…. Fasting Blood Sugar: greater than (>)250 mg/dl. Less than ()250 mg/dL less than ( The SN notes dated 12/06/24, 12/27/24 and 01/10/25, lacked blood sugar assessments to report of Physician if falling outside established parameters as ordered. The same POC for the certification period of 12/03/24 to 01/31/25, required: “SN frequency: 1w9….” The clinical record lacked SN services for the week of 01/19/25 to 01/25/25, as ordered in the POC. 3. Pt. #6 was admitted to home health services on 06/03/24 with the diagnosis of Other Polyosteoarthritis. The clinical record was reviewed on 03/05/25. The clinical record contained a POC for certification period 06/03/24 to 08/01/24: “Occupational Therapy to assess functional status….” As of 03/25/25, the record lacked an Occupational Therapy assessment, as ordered in the POC. 4. During an interview with the Administrator and Director of Nursing on 03/05/25 at 2:30 PM, the administrative team confirmed the above findings.

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 review of clinical records and staff interviews, it was determined that in 6 of 7 (Pts. #1, 2, 3, 4, 5 and 6) clinical records reviewed, the Agency failed to assess the need for Pneumonia and/or Influenza vaccines of Pts. Findings include: 1. The following clinical records were reviewed on 03/03/25 and 03/04/25: Pt. #1. SOC 08/06/24. Lacked inquiry for Pneumonia and Influenza vaccines. Pt. #2. SOC 03/07/24. Lacked inquiry for Pneumonia and Influenza vaccines. Pt. #3. SOC 05/23/24. Lacked inquiry for Pneumonia and Influenza vaccines. Pt. #4. SOC 05/09/24. Lacked inquiry for Pneumonia and Influenza vaccines. Pt. #5. SOC 02/07/24. Lacked an inquiry for the Pneumonia vaccine. Pt. #6. SOC 06/03/24. Lacked inquiry for Pneumonia and Influenza vaccines. 2. During staff interviews with the Administrator and Director of Nursing on 03/05/25 at 1:30 PM and XXX the administrative team confirmed the above findings. .

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 review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews, 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 provide the Pt./patient's representative information regarding the Agency Supervisor/Director of Nursing. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 03/03/25. The folder lacked the name and information to contact the Agency Supervisor/Director of Nursing. 2. The following home visits were conducted on 03/03/25 and 03/04/25: Patient #1. SOC 08/06/24. Patient #3. SOC 05/23/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Agency Supervisor/Director of Nursing. 3. The following clinical records were reviewed on 03/04/25 and 03/05/25: Pt. #1. SOC 08/06/24. Pt. #2. SOC 03/07/24. Pt. #3. SOC 05/23/24. Pt. #4. SOC 05/09/24. Pt. #5. SOC 02/07/24. Pt. #6. SOC 06/03/24. Pt. #7. SOC 07/22/24. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Agency Supervisor/Director of Nursing. 4. During staff interviews with the Administrator and Director of Nursing on 03/05/25 at 1:30 PM, both confirmed the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor/Director of Nursing. .

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 interviews, it was determined that in 3 of 3 (Pts. #5, 6, and 7) closed/discharged clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the discharge summary. Findings include: 1. Pt. #5 was admitted to home health services on 02/07/24 with the diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 03/04/25. The discharge assessment, indicated Pt. #5 was discharged from the Agency on 01/31/25. The record contained a discharge summary, signed by the RN on 03/03/25 and lacked documentation that it was sent to the Physician. 2. Pt. #6 was admitted to home health services on 06/03/24 with the diagnosis of Other Polyosteoarthritis. The clinical record was reviewed on 03/05/25. The transfer discharge assessment indicated Pt. #6 was transferred to an inpatient facility (patient discharged from Agency) on 07/22/24. The record contained a transfer summary, signed by the RN on 10/31/24 and lacked documentation that it was sent to the Physician. 3. Pt. #7 was admitted to home care services on 07/22/24 with diagnosis of Alzheimer’s disease with early onset. The clinical record was reviewed on 03/04/25. The discharge date was 09/17/24. As of 03/06/25, the clinical record lacked evidence that a discharge summary was sent to the physician. 4. During interview with the Administrator and Director of Nursing, on 03/05/25 at 1:30 PM 2:30 PM, the above findings were confirmed.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care POC = Plan of Care PsOC = Plans of Care SN = Skilled Nurse PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist AM = Morning PM = Afternoon, Evening wk/w = week & = and

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: A. Based on review of clinical records and staff interviews, it was determined that the Agency failed to ensure informed consents contained the disciplines that will furnish care and the frequency of visits. This was found in 7 of 7 clinical records reviewed. (Pts. # 1,2,3,4,5,6 and 7) Findings Include: 1. The following clinical records were reviewed between 12/20/2021 and 12/21/2021. Pt. #1 SOC: 08/23/2021 Pt. #2 SOC: 06/24/2021 Pt. #3 SOC: 01/18/2021 Pt. #4 SOC: 10/18/2021 Pt. #5 SOC: 11/29/2021 Pt. #6 SOC: 06/25/2021 Pt. #7 SOC: 02/18/2021 The records lacked documentation of patient consenting to the disciplines that will furnish care and frequency of visits. 2. During an interview with the Administrator 12/23/2021 at 10:30AM it was confirmed that the records lacked documentation of patients consent to services to be provided and the frequency of visits prior to SOC.

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 clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide SN, PT, and OT services as ordered by the Physician. This was found in 3 of 7 (Pts. #1, 6, and 7) clinical records reviewed. Findings include: 1. Pt. #1 SOC 8/23/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/21/21 at 10:30 AM. The record included the PT re-evaluation dated 10/21/21, which included the order “Frequency: 2wk1 & 1wk7.” This re-evaluation was signed by the Physician. The record lacked documentation the PT provided service for the week of 11/28/21 to 12/4/21, and for the week of 12/5/21 to 12/11/21, or that the Physician was notified of these missed visits. 2. Pt. #6. SOC 6/25/21. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 12/20/21 a 1:35 PM. The record contained the PT Care Plan dated 6/30/21. This care plan contained the order “Frequency 1wk1, 2wk4.” This PT care plan was signed by the Physician. The record lacked documentation the Pt. received a second PT visit for the week of 7/18/21 to 7/24/21, or that the Physician was notified of the missed visit. 3. Pt. #7. SOC 2/18/21. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 12/20/21 at 3:00 PM. The record contained the POC for the certification period beginning 2/18/21. This POC included the order “SN Frequency: 1w1, 2w2, 1w6.” This POC was signed by the Physician. The record lacked documentation the Pt. received a second SN visit on the week of 2/21/21 to 2/27/21, or that the Physician was notified of the missed visit. The record also contained the OT care plan dated 3/9/21, which contained the order “Visit Frequency: 1wk6.” The record lacked documentation the Pt. received an OT visit on the week of 3/28/21 to 4/3/21, or that the Physician was notified of the missed visit. 4. The Agency policy titled “Informed Consent/Refusal of Treatment” was reviewed on 12/21/21 at 1:45 PM. The policy required: “…The Patient will be informed of the expected consequences whenever any treatment/care is refused. Documentation of such refusal and Physician notification will be made part of the clinical record, and includes…Date and time of Physician contact…” 5. During an interview with the Administrator on 12/22/21 at 12:30 PM, the Administrator stated if missed visits cannot be made up within the current treatment week, the Physician should be notified, and this should be documented in the Patient's clinical record.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. 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 the PsOC were signed by the Physician or allowed practitioner within 60 days. This was found in 4 of 7 (Pts. #2, 3, 6 and 7) clinical records reviewed. Pt. # 2 SOC 06/24/2021 Diagnosis: Orthostatic Hypotension. The clinical record was reviewed on 12/21/2021 at 11:00AM. The clinical record contained a POC for certification period of 10/22/2021 to 12/20/2021 that as of 12/21/2021 the POC lacked physician or allowed practitioner signature indicating the POC was reviewed. Pt. # 3 SOC 01/18/2021 Diagnosis: Unspecified Chronic Bronchitis. The clinical record was reviewed on 12/21/2021 at 11:40AM. The clinical record contained a POC for certification period of 09/15/2021 to 11/13/2021 that as of 12/21/2021 the POC lacked physician or allowed practitioner signature indicating the POC was reviewed. Findings include: 1. Pt. #6. SOC 6/25/21. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 12/20/21 a 1:35 PM. The record included the POC for the certification period beginning 6/25/21. This POC was signed by the Physician on 9/13/21, 80 days after the SOC. 2. Pt. #7. SOC 2/18/21. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 12/20/21 at 3:00 PM. The record included the POC for the certification period beginning 2/18/21. This POC was signed by the Physician on 7/1/21, 132 days after the SOC. The record also contained the POC for the recertification period beginning 4/19/21. This POC was signed by the Physician on 7/1/21, 73 days after the SOC. 3. The Agency policy titled “Verification of Physician Orders” was reviewed on 12/21/21 at 1:45 PM. The policy required: “…Signed orders will be placed in the clinical record within 30 days of initiation of the order…” 4. The Agency policy titled “Reassessments/Recertification” was reviewed on 12/21/21 at 1:55 PM. The policy required: “…The updated plan of care will be prepared and sent to the Physician for review and signature in a timely manner…” 5. During interviews with the Administrator on 12/21/21 at 12:30 PM and on 12/23/21 at 11:00 AM, the Administrator confirmed the above findings.