Every finding on record at Wellbound Illinois LLC

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Comprehensive Emergency Management Plan, Agency policy and staff interview, it was determined the Agency failed to ensure the Emergency Management Plan was updated to include all events. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Comprehensive Emergency Management Plan last “reviewed and approved by the Board of Directors, Administrator and Alternate Administrator on 6/5/20” was reviewed on 11/1/21 at 2:30 PM with the Administrator. The Plan lacked documentation the Agency activated its Emergency Management Plan during the first quarter of 2020, due to a global pandemic (COVID-19). 2. The Agency’s policy titled “Emergency Management Policy” was included in the “Comprehensive Emergency Management Plan” reviewed on 11/1/21 at 2:30 PM (as indicated above). The policy required: “…17… All administrative emergency or disaster activities will be documented by the Director of Clinical Services and/or the Administrator…” 3. During an interview with the Administrator on 11/2/21 at 1:15 PM, the Administrator stated the Agency activated the Agency’s Comprehensive Emergency Management Plan on 3/15/20 due to the public announcement of COVID-19. 4. During an interview with the Administrator on 11/1/21 at 3:45 PM, 11/3/21 at 1:15 PM, and the Director of Nursing on 11/3/21 at 10:40 AM, both confirmed the above findings.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(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 Hospices at §418.113(a):] 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. *[For LTC facilities at §483.73(a):] 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):] 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. This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Comprehensive Emergency Management Plan, Agency policy and staff interview, it was determined the Agency failed to revise the Emergency Management Plan’s risk assessment to include infectious diseases. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Comprehensive Emergency Management Plan last “reviewed and approved" on 6/5/20 was reviewed on 11/1/21 at 2:30 PM with the Administrator. The Plan’s all-hazard vulnerability risk assessment last updated on 6/28/19 lacked documentation the Agency updated the assessment to include emerging infectious diseases. 2. The Agency’s policy titled “Hazard Vulnerability Analysis (HVA) was included in the “Comprehensive Emergency Management Plan” reviewed on 11/1/21 at 2:30 PM (as indicated above). The policy required: “…The Hazard Vulnerability Analysis (HVA) shall be revised annually by the Administration, and whenever a new threat emerges. Changes to the Hazard Vulnerability Analysis (HVA) shall be updated in the Emergency Operations Plan…” 3. During an interview with the Administrator on 11/1/21 at 3:45 PM, the Administrator stated the Agency activated the Comprehensive Emergency Management Plan in March 2020, because of the announcement of COVID-19. 4. During an interview with the Administrator on 11/1/21 at 3:45 PM and the Director of Nursing on 11/3/21 at 10:40 AM, both confirmed the above findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Comprehensive Emergency Management Plan and staff interview, it was determined the Agency failed to include volunteers in its Emergency Management Plan, and establish a policy for the use of volunteers. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The Comprehensive Emergency Management Plan last “reviewed and approved" on 6/5/20 was reviewed on 11/1/21 at 2:30 PM with the Administrator. The Plan lacked the name and contact information of volunteers, and a policy regarding the duties and responsibilities of volunteers. 2. During an interview with the Administrator on 11/1/21 at 3:45 PM and the Director of Nursing on 11/3/21 at 10:40 AM, both confirmed the Agency’s Comprehensive Emergency Management Plan lacked any volunteers, and a policy for the use of volunteers.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: SOC = Start of Care OASIS = Outcome and Assessment Information Set SN = Skilled Nurse HHA's = Home Health Agencies Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon, Evening O2 = Oxygen lts = liters lbs = pounds # = Number HVA = Hazard Vulnerability Analysis RE = regarding COVID -19 = Corona Virus Disease 2019 RN = Registered Nurse

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the SOC assessment was conducted in a timely manner. This was found in 4 of 7 (Pts. #1, 3, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/24/21. Diagnoses: Essential (Primary) Hypertension, Primary Generalized (Osteo) Arthritis and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11/1/21 at 1:30 PM. The record contained the “Documentation of Face-To-Face Encounter” form dated 6/11/21, signed by the Physician and faxed to the Agency on “2021-06-14”. The SOC visit was conducted by the RN on 6/24/21 (10 days after receipt of the referral). The record lacked documentation of a Physician ordered SOC date or that the Pt. was discharged from an inpatient facility. As of 11/1/21, the record lacked documentation the Agency started service within the required time frame. 2. Pt. #3. SOC 7/9/21. Diagnoses: Hypertensive Heart Disease without Heart Failure and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 11/3/21 at 9:20 AM. The record contained the “Face-To-Face Encounter” form dated 7/10/21 and signed by the Physician. The record included documentation the form was faxed to the Agency on “07/15/2021”. The SOC visit was conducted by the RN on 7/9/21. The record lacked documentation of a Physician ordered SOC date or that the Pt. was discharged from an inpatient facility. As of 11/3/21, the record lacked a referral or Physician’s order to initiate service for the 7/9/21 SOC, until 7/15/21. 3. Pt. #6. SOC 3/25/21. Diagnoses: Unspecified Chronic Obstructive Pulmonary Disease and Unspecified Dementia without Behavioral Disturbance. The closed clinical record was reviewed on 11/1/21 at 11:50 AM. The record contained the “Patient Referral” signed by the Physician and dated 3/22/21. The referral was also faxed to the Agency on “3/22/21”. The SOC visit was conducted by the RN on 3/25/21 (3 days after receipt of the referral). The record lacked documentation of a Physician ordered SOC date or that the Pt. was discharged from an inpatient facility. As of 11/1/21, the record lacked documentation the Agency started service within the required time frame. 4. Pt. #7. SOC 4/7/21. Diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Chronic Pain. The closed clinical record was reviewed on 11/1/21 at 12:40 PM. The record contained the “Physician Face To Face Encounter” form signed by the Physician and dated 3/8/21. The form was faxed to the Agency on “3/19/2021”. The SOC visit was conducted by the RN on 4/7/21 (19 days after receipt of the referral). The record lacked documentation of a Physician ordered SOC date or that the Pt. was discharged from an inpatient facility. As of 11/1/21, the record lacked documentation the Agency started service within the required time frame. 5. During an interview with the Director of Nursing on 11/3/21 at 11:00 AM, the Director of Nursing confirmed the SOC assessment was not conducted within 48 hours of receiving the referral.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure service was provided, as required by the Health Care Professional. This was found in 1 of 1 (Pt. #6) clinical records reviewed, wherein the Pt. required MSW services. Findings include: 1. Pt. #6. SOC 3/25/21. Diagnoses: Unspecified Chronic Obstructive Pulmonary Disease and Unspecified Dementia without Behavioral Disturbance. The closed clinical record was reviewed on 11/1/21 at 11:50 AM. The record contained the “Referral Order” dated 7/20/21 and signed by the Nurse Practitioner, requesting “Social Worker Referral”. The record lacked documentation the Agency provided Social Worker services on or after 7/20/21. The Agency discharged the Pt. on 9/20/21. 2. During an interview with the Director of Nursing on 11/3/21 at 11:00 AM, the Director of Nursing confirmed the Agency failed to ensure Social Worker services were provided, as ordered.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on a review of clinical records, Agency policy, and staff interview, it was determined that the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. service; and ensure staff comply with the Agency's infection control policies. This was found in 4 of 7 (Pts. #5, 1, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #5 SOC 8/30/21. Diagnosis: Pressure-induced deep tissue damage of other site. The clinical record was reviewed on 11/02/21 at 2:00 PM. The record included documentation the HHA provided service on 9/4/21, 9/11/21, 9/18/21. 9/25/21, 10/2/21, 10/9/21, 10/16/21, 10/23/21, and 10/27/21. The record/agency lacked documentation that the Pt. was screened for COVID-19, prior to the visits indicated above. __. Pt. #1. SOC 6/24/21. Diagnoses: Essential (Primary) Hypertension, Primary Generalized (Osteo) Arthritis and Hypertensive Heart Disease with Heart Failure. A home visit was conducted with Employee #6 on 11/2/21 at 1:00 PM. During the home visit, observed Employee #6 enter into the therapy bag without performing hand hygiene, and removed a blood pressure cuff, stethoscope, gait belt and pulse oximeter from the bag, and used this equipment on the Pt. Employee #6 stated, “I thought I had alcohol with me to clean my equipment, but I don’t…” Employee #6 asked the Pt. for alcohol wipes and proceeded to clean the blood pressure cuff and stethoscope with the alcohol wipes, and returned these items into the therapy bag. Employee #6 did not clean the gait belt and pulse oximeter after using them on the Pt., and returned these items into the therapy bag. Employee #6 failed to perform hand hygiene before entering the therapy bag and removing the reusable equipment, and the clean the equipment after Pt. use as required by the Agency. __. Pt. #6. SOC 3/25/21. Diagnoses: Unspecified Chronic Obstructive Pulmonary Disease and Unspecified Dementia without Behavioral Disturbance. The closed clinical record was reviewed on 11/1/21 at 11:50 AM. The record contained the weekly SN visit notes dated 8/6/21, 8/10/21 and from 8/25/21 to 9/14/21. The record lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. __. Pt. #7. SOC 4/7/21. Diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Chronic Pain. The closed clinical record was reviewed on 11/1/21 at 12:40 PM. The record contained the SN visit notes dated 8/11/21, 8/18/21, 9/29/21 and the Agency’s discharge comprehensive assessment dated 10/3/21. The record lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. __. The Agency policy titled, “Instructions to Read RE: COVID-19” was reviewed on 11/1/21 at 12:00 PM. The policy required: “How should HHA’s screen patients for COVID-19? When making a home visit, HHA’s should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following: 1. International travel within the last 14 days… 2. Signs or symptoms of a respiratory infection… 3. In the last 14 days, has had contact with someone or under investigation for COVID-19… 4. Residing in a community where… spread of COVID-19 is occurring…” __. The Agency policy titled, “Hand Hygiene” was reviewed on 11/3/21 at 2:00 PM. The policy required: “…3. Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients… C. After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient)…” __. The Agency policy titled, “Bag Technique” was reviewed on 11/3/21 at 2:10 PM. The policy required: “…2. Prior to administering care, alcohol-based hand rub or soap and paper towels will be removed, and hands will be washed… Hand washing will always be completed before opening the bag. 3. After hand washing, the supplies and/or equipment needed for the visit will be removed from the bag… 5. When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. __. During an interview on 11/3/21 at 11:00 AM, the Director of Nursing stated staff are required to call the Pt. before the visit and ask the COVID screening questions, and this information is entered in the clinical record.

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 a review of clinical records and staff interview, it was determined the Agency failed to ensure the staff provide care and/or service, as specified on the POC. This was found in 2 of 7 (Pts. #1 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/24/21. Diagnoses: Essential (Primary) Hypertension, Primary Generalized (Osteo) Arthritis and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11/1/21 at 1:30 PM. The record contained the POC for the certification period of 8/23/21 to 10/21/21 requiring: “SN to assess for… pain with movement of the joint…” The SN visit note dated 9/23/21 lacked documentation the SN assessed for pain. 2. Pt. #7. SOC 4/7/21. Diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Chronic Pain. The closed clinical record was reviewed on 11/1/21 at 12:40 PM. The record contained the POC for the certification period of 8/5/21 to 10/3/21 requiring: “SN… properly assess, manage and mitigate BLE pain…” The SN visit note dated 4/7/21 lacked documentation the SN assessed for BLE pain. The POC effective 8/5/21 required: “SN to obtain blood glucose level every SN visit unless obtained by patient (Report to MD fasting blood glucose below 60 mg/dl or above 160 mg/dl or non-fasting blood sugar below 70 mg/dl or above 250 mg/dl)…” The SN visit note dated 9/29/21 lacked documentation the SN or Pt. had assessed the blood glucose level. 3. During an interview with the Director of Nursing on 11/3/21 at 11:00 AM, the Director of Nursing confirmed staff failed to provide care and/or service, as specified on the POC.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, interview and observation during home visits, review of Agency policy and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete. This was found in 2 of 7 (Pts. #1 and 3) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/24/21. Diagnoses: Essential (Primary) Hypertension, Primary Generalized (Osteo) Arthritis and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11/1/21 at 1:30 PM. The record contained the “Medication Profile” form completed by the RN and effective 10/22/21 which lacked the medication “O2”. A home visit was conducted on 11/2/21 at 11:00 AM with E #6. During the home visit, the “Medication Profile” form located in the patient’s home folder was observed and included an entry written by the SN: “O2 1 lts via nasal cannula as needed”. During an interview with Pt. #1, the Pt. confirmed O2 is used as needed. The “Medication Profile” form in the clinical record was incomplete. 2. Pt. #3. SOC 7/9/21. Diagnoses: Hypertensive Heart Disease without Heart Failure and Unspecified Chronic Obstructive Pulmonary Disease. On 11/1/21, the Agency presented a copy of the “Medication Profile” form effective 7/9/21, completed by the RN and retrieved from the medical record. A home visit was conducted on 11/2/21 at 1:00 PM with the Administrator. During the home visit, an interview was conducted with the Pt. that presented the medications: “Ferrous Sulfate 325 MG Take 1 Tablet by mouth daily” and “Vitamin D3 50 MCG tablet Take 1 tablet by mouth daily”. Both medication containers included the date 9/24/21. The Pt. stated the Physician prescribed those medications a few months ago, and that the RN was aware of the new medications. As of 11/1/21, the Medication Profile form in the clinical record was incomplete. 3. The Agency's policy titled, “Policies and Procedures Responsibilities: Staff Members” was reviewed on 11/3/21 at 2:40 PM. The policy required: “Documentation…viii. Medication profile updated monthly/and or new orders received…” 4. During an interview with the Director of Nursing on 11/3/21 at 11:00 AM, the Director of Nursing confirmed the Agency failed to ensure the Medication Profiles in the clinical record were complete.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure that documentation of forms were complete and accurate. This was found in 7 of 7 (Pts. #2, 4, 5, 1, 3, 6, and 7) clinical records reviewed. __. Pt. #1. SOC 6/24/21. Diagnoses: Essential (Primary) Hypertension, Primary Generalized (Osteo) Arthritis and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11/1/21 at 1:30 PM. The record contained the “Admission and Consent Form” completed by the RN, signed by the Pt. and dated 6/24/21. The form lacked documentation indicating whether the Pt. had Advance Directives, as required by the Agency’s form. The “Beneficiary Elected Transfer” form signed by the Pt., RN and dated 6/24/21 lacked the name of the previous agency the Pt. received services, and the effective date of the agency transfer, as required by the Agency. __. Pt. #3. SOC 7/9/21. Diagnoses: Hypertensive Heart Disease without Heart Failure and Unspecified Chronic Obstructive Pulmonary Disease. The record contained the “Admission and Consent Form” completed by the RN, signed by the Pt. lacked the date the form was signed and documentation indicating whether the Pt. had Advance Directives. The “Beneficiary Elected Transfer” form signed by the Pt. and RN lacked the date the form was signed, the name of the previous agency the Pt. received services, and the effective date of the agency transfer, as required by the Agency’s form. The “Notice of Medicare Non-Coverage” form, signed by the Pt. lacked the effective date coverage of the patient’s current services would end, date the form was signed, facts used to make that decision, an explanation why the services are no longer covered, rationale for this decision, as required by the CMS form. The “Patient/Patient’s Representative Responsibility” form lacked the date the Pt. and RN signed the form. The “…Patient Satisfaction Survey” form was signed by the Pt. The form lacked the date the Pt. signed the form, and the satisfaction survey questions were left blank. The undated “Patient Classification / Prioritization for Emergency Disaster Planning Protocol” from included the patient’s name. No other information was entered on the form identifying the patient’s risk level in the event of an emergency, as required by the Agency’s form. The “Home Safety Checklist” form lacked the date the form was completed, and lacked a “Yes” or “No” response to the following questions: “Are exits and pathways clear? Floorings (rugs, tiles, boards) in good repair? Door sills are low?” as required by the Agency’s form. __. Pt. #6. SOC 3/25/21. Diagnoses: Unspecified Chronic Obstructive Pulmonary Disease and Unspecified Dementia without Behavioral Disturbance. The closed clinical record was reviewed on 11/1/21 at 11:50 AM. The record contained “Admission and Consent Form” completed by the RN, signed by the Pt. and dated 3/25/21. The form lacked documentation indicating whether the Pt. had Advance Directives. The “Beneficiary Elected Transfer” form dated 3/25/21, signed by the Pt. and RN lacked the date the form was signed, name of the previous agency the Pt. received services, and the effective date of the agency transfer. __. Pt. #7. SOC 4/7/21. Diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Chronic Pain. The closed clinical record was reviewed on 11/1/21 at 12:40 PM. The record contained the “Notice of Medicare Non-Coverage (HHABN)” form signed by the Pt., authorized representative and dated 4/7/21. The form is intended to provide notice to a Pt. of any services not covered by their payer source. The form included blank spaces requiring the admitting RN to complete, indicating exactly what the payer source will not reimburse, date the service will end, and reason(s) for the service to end. The form included documentation that SN services will be reduced. As of 11/1/21, the form lacked the reason for the reduction of SN services, estimated cost of the service, and available options for the Pt. to choose, as required by the CMS form. The “Notice of Medicare Non-Coverage” form, signed by the Pt. and dated 4/7/21 lacked the effective date coverage of the patient’s current services would end, facts used to make that decision, an explanation why the services are no longer covered, rationale for this decision. The “Change of Agency Form” signed by the Pt., RN and dated 4/7/21 was left blank. The form lacked the name of the previous agency that provided service and the effective last date of service from the previous Agency, as required by the Agency’s form. __. During an interview with the Director of Nursing on 11/2/21 at 3:30 PM and 11/3/21 at 11:00 AM, the Director of Nursing stated all of the forms indicated above are included in the Agency’s admission packet that the RN is required to complete during the SOC visit. The RN is required to complete all applicable forms before submitting the admission packet to the Agency. During the same interview, the Director of Nursing confirmed the documents/forms indicated above were incomplete, and/or not authenticated by the RN. Findings include: 1. Pt. #2. SOC: 10/12/21. Principal Diagnosis: Hyperkalemia. The clinical record was reviewed on 11/1/21 at 3:30 PM. The record included a form titled: “Admission and Consent Form” which was signed on 10/12/21 by Pt. #2, lacked documentation of entries on the section Patient Legal Representative, Name, Phone, Relationship, or None, Patient opt out to have Legal Representative. “Beneficiary Elected Transfer Form”, signed by Pt. #2 and RN on 10/12/21, the rest of the forma was left blank. “Notice of Medicare Non-Coverage” was signed by Pt. #2 on 10/12/21, lacked documentation when the current services will end. “Interpreter/Translator Service”, was signed by Pt. #2 on 10/12/21. Patient’s primary language, I have limited sight, hearing or other medical condition or other mental status due to… was left blank. 2. Pt. #4. SOC 9/16/21. Principal Diagnosis: Cerebral Aneurism, non-ruptured. The clinical record was reviewed on 11/2/21 at 1:00 PM. The record included a form titled: “Admission and Consent Form” which was signed on 10/12/21 by Pt. #4, lacked documentation of entries on the section Patient Legal Representative, Name, Phone, Relationship, or None, Patient opt out to have Legal Representative. “I Have Limited English Proficiency”, was signed by Pt#4, not dated and the primary language information was left blank. 3. Pt. #5. SOC: 8/30/21. Principal Diagnosis: Pressure-induced deep tissue damage of other site. The clinical record was reviewed on 11/2/21 at 2:00 PM. The record included a form titled: “Patient, Conduct, Responsibilities and Rights” which was signed by (POA) and RN and lacked date. “Home Health Advance Beneficiary Note (HHABN) was signed by POA, not dated and the rest of the form was not completed. The “Change of Agency Form” was signed by POA and RN, not dated and the rest of the form was left blank.