Absolute Home Health LLC

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on an interview it was determined the Home Health Agency failed to provide documentation of the development, implementation, evaluation, and maintenance of an effective, ongoing, HHA-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program since January 19, 2019. Therefore, the Condition of Participation, 42 CFR 484.65, Quality Assessment and Performance Improvement was not met, as evidenced by: Findings include: The Agency failed to ensure measurable indicators were developed and were analyzed and tracked to identify trends in patient care. See G-642 Agency failed to ensure quality indicators data was utilized to measure effectiveness and identify opportunities for improvement. See G-644 The Agency failed to ensure performance improvement focused on high risk safety indicators, identify opportunities for immediate improvement and monitor the success of the interventions implemented. See G-646 The Agency failed to track adverse patient events, analyze their causes, and implement preventative actions. See G-654 The Agency failed to take actions aimed at performance improvement, implement those actions, measure its success, and track performance to ensure the improvements are sustained See G-656 6. The Agency failed to ensure performance improvement projects were identified and implemented annually. See G-658 7. The Agency failed to ensure a quality improvement and patient safety program was implemented and maintained. See G-660 The cumulative effect of these practices resulted in the Agency’s inability to determine effectiveness of Agency programs.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on document review and interview it was determined the Home Health Agency failed to set forth, in writing, its organizational structure, including lines of authority since February, 2026, as evidenced by: The agency failed to ensure the administrator was appointed by and reports to the governing body. See G-946 2. The agency failed to ensure the administrator was responsible for all day-to-day operations of the HHA. See G-948 3. The agency failed to ensure when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. See G-954”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview, it was determined the Agency failed to ensure measurable indicators were developed, analyzed and tracked to identify trends in patient care. Findings include: 1. During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they “have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.””

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on document review and interview, it was determined the Agency failed to ensure quality indicators were utilized to measure the effectiveness of the safety of services, the quality of care provided and identified opportunities for improvement. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they “have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.””

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on document review and interview, it was determined the Agency failed to ensure performance improvement focused on high risk safety indicators, identified opportunities for immediate improvement and monitored the success of the interventions implemented. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they “have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.””

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on an interview it was determined the Home Health Agency failed to track all adverse patient events, to determine through subsequent analysis whether they were the result of errors that should have been preventable, to reduce the likelihood of such events in the future. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they “have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on document review and interview, it was determined the Agency failed to ensure performance improvement projects were identified and implemented annually. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they “have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on document review and interview, it was determined the Governing Board failed to ensure a quality improvement and patient safety program was implemented and maintained. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they “have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on document review and interview, the Agency failed to ensure a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases is in place and is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. Findings include: 1. The Infection Control Plan and infection tracking logs were requested by the Agency on 5/19/2026. A document titled “Infection Control Plan” (no effective date indicated) was provided. A review of the Infection Control Plan indicates this document is not specific to the Agency, as it refers to responsibilities of the “Director of Clinical Services” and “Quality Improvement Coordinator.” which are not roles/titles the Agency uses. Additionally, the document states “SURVEILLANCE…The activities related to the Infection Control Surveillance Plan shall be based on an assessment of the of the population served by the agency, JCAHO, CHAP, and ACHC indicators, high risk and high volume indicators, CDC definition of infections, and assessed agency needs based on data collection. 2. An interview with the Agency Supervisor/Owner (E #2) was completed on 5/22/2026 at approximately 10:00 AM. During discussion, E #2 noted they do enter infections in their Electronic Medical Records system, as well as follow-up to those infections, but infections are not officially tracked and reviewed in a QAPI program, as they do not currently have one. Additionally, E #2 noted the Agency does not have anyone with the titles of “Director of Clinical Services” or “Quality Improvement Coordinator.” Further, E #2 agreed they are not currently following what is listed under the “Surveillance” section of the “Infection Control Plan” document.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on an interview it was determined the Home Health Agency failed to measure its success and track performance to ensure that improvements are sustained. Findings include: During an interview on 05/19/2026 at approximately 1:45 PM, the Agency Supervisor (E #2) verbally agreed that they “have never had an established QAPI program since E #2 and their spouse bought the agency in January 19, 2019.””

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on document review and staff interview, the Facility failed to ensure the administrator was appointed by the governing body. Findings include: 1. A review of the Governing Board meeting minutes dated 12/20/2025 noted (initials D.W.) was appointed as Administrator by the Governing Board. However, upon entrance to the survey, the Administrator was identified as (initials J.C.). There was no documentation of a Governing Board meeting since 12/20/2025. 2. The policy titled “Home Health Agency Governance Board Charter”, (No effective date provided) states: “3. Roles & Responsibilities…CEO/Administrator Oversight: Appoint, evaluate, and determine the compensation of the Agency Administrator/CEO.” 3. An interview was conducted on 5/20/2026 at approximately 3:00 PM, with the Agency Supervisor/Owner (E #2). During discussion, E #2 noted (initials D.W.), the Administrator that was appointed by the Governing Board on 12/20/2025, unexpectedly passed away in February, 2026. E #2 stated, “I wanted to make sure I had someone qualified, so I made (initials J.C.) the Administrator. I verified (initials J.C.)’s qualifications with the State (Illinois Department of Public Health)”, further stating, “She hasn’t been appointed by the Governing Board yet, because we haven’t had our Governing Board meeting for this year.””

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to ensure outdated biologicals were not available for patient use. Findings include: On 5/19/26 at approximately 1:30 pm, an observational tour of the office was conducted. The following was observed in a supply closet: a. 12 Heparin Lock Flushes made by Excelsior Medical. Expired on 8-1-20248 Heparin Flushes made by Excelsior Medical. Expired 8-1-2024 (Found in bag stating, “Caution Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed”. No patient name on bag) b. 6 Clave Neutral Connectors made by ICU Medical, Inc. Expired 4-1-2025 c. 10 Ultrasite Injection Sites made by B. Braun Medical Inc. Expired 4-30-2025 d. 18 SwabCaps. No manufacturer listed on product. Expired 11-1-2024 e. 1 Universal Securement Device made by Tidi Products, LLC. Expired 03-2021 f. 1 Universal Securement Device made by Tidi Products, LLC. Expired 11-2023 g. 2 Universal Securement Devices made by Tidi Products, LLC. Expired 12-2023 h. 3 Universal Securement Devices made by Tidi Products, LLC. Expired 07-2025 i. 2 Universal Securement Devices made by Tidi Products, LLC. Expired 08-2025 j. 2 Medium Universal Securement with Wide Silicone Adhesive Area made by Tidi Products, LLC. Expired 05-2025 k. 57 Tegaderm Films made by 3M Health Care. Expired 8-1-2024 l. 20 Port Access Infusion Sets made by SB-Kawasumi Laboratories, Inc. Expired 8-31-2024 m. 1 Smallbore Ext Set, Clamp, Rotating Luer made by ICU Medical, Inc. Expired 6-1-2024 n. 2 Smallbore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 4-1-2025 0. 1 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 5-1-2025 p. 3 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 7-1-2025 q. 1 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 10-1-2025 r. 4 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 12-1-2025 s. 2 10ml Syringe Luer-Lok Tip with BD Precision Glide Needle made by BD. Expired 8-31-25 t. 1 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 4-29-2025 u. 7 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 7-5-2025 v. 3 Small bore Ext Set, Clamp, Rotating Luers made by ICU Medical, Inc. Expired 9-9-2025 w. 1 24G ViaValve Safety IV Catheter-Radiopaque made by Smiths Medical ASD, Inc. Expired 9-15-2024 x. 9 eSwabs made by Copan Italia SpA. Expired 6-30-23 y. 1 eSwabs made by Copan Italia SpA. Expired 7-31-23 z. 20 eSwabs made by Copan Italia SpA. Expired 7-24-24 aa. 6 BBL Culture eSwabs made by Copan Italia SpA. Expired 10-31-2024 bb. 1 Box of 50 23G BD Vacutainer Safety Lok Blood Collection Sets made by Becton, Dickinson, and Company. Expired 7-31-2024 cc. 7 25G BD Vacutainer Safety-Lok Blood Collection Sets made by Becton, Dickinson, and Company. Expired 6-30-24 dd. 2 25G Safety Needle made by BH supplies. Expired 4-17-26 ee.1 22G Safety Needle made by Becton, Dickson, and Company. Expired 2-29-24 ff. 1 22G Safety Needle made by Becton, Dickson, and Company. Expired 7-31-24 gg. 19 22G Safety Needle made by Becton, Dickson, and Company. Expired 7-31-25 hh. 4 Multi Drawing Needle made by Greiner Bio-one. Expired 04-21 ii. 25 21G Safety Needle made by Becton, Dickson, and Company. Expired 8-31-2025 jj. 128 10ml Disposable Syringe made by BH supplies. Expired 11-27-25 kk. 5 boxes of 200 Sterile Alcohol Prep Pads. Expired 9-25-25 ll. 1 Adhesive Island Dressing made by Covidien. Expired 5-1-25 mm.9 Unna-Z Zinc Paste Bandage made by Medline. Expired 10-2025 nn. 27 Elastic Barrier Strip made by Coloplast. Expired 5-18-24 oo. 16 Elastic Barrier Strip made by Coloplast. Expired 5-31-24 pp. 1 box of 30 Elastic Barrier Strip XL made by Coloplast. Expired 5-18-24 qq. 2 boxes of 10 Adapt CeraRings made by Hollister ULC. Expired 09-25 rr. 1 box of 10 Adapt CeraRings made by Hollister ULC. Expired 11-25 ss. 1 box of 10 Adapt CeraRings made by Hollister ULC. Expired 1-26 tt. 2 boxes of 10 Urostomy Pouches made by Hollister Inc. Expired 3-26 uu. 2 boxes of 10 Urostomy Pouches made by Hollister Inc. Expired 4-25 vv. 1 box of 10 Urostomy Pouches made by Hollister Inc. Expired 6-25 ww. 1 box of 5 Skin Barrier-Floating Flange and Tape made by Hollister. Expired 3-24 xx. 1 box of 2 Piece Ostomy Skin Barrier, Tape made by Hollister. Expired 9-1-23 yy. 1 box of 30 Silicone Self-Adhesive Catheters made by Hollister. Expired 5-28-25 zz. 2 boxes of 60 Closed Pouches with filters made by Hollister. Expired 2-24 2. During an interview with the Agency Supervisor(E#2) on 5/19/26 at approximately 1:30 p.m., E#2 stated, “That the expired supplies noted in the supply closet should have been removed on expiration.””

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on document review and interview, the Agency failed to ensure a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, was provided in writing, as authorized by the administrator and governing body. Findings include: 1. A review of the Governing Board meeting minutes dated 12/20/2025 noted E #2 as being appointed as the pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available. There was no documentation of the approval by the previous Administrator of E #2 being the pre-designated person. 2. An interview was conducted on 5/20/2026 at approximately 3:00 PM, with the Agency Supervisor/Owner (E #2). During discussion, E #2 noted the previous Administrator passed away unexpectedly earlier in the year, and a new Administrator is in place, but has not been appointed by the Governing Board, stating, “She hasn’t been appointed by the Governing Board yet, because we haven’t had our Governing Board meeting for this year.” 3. A follow-up interview was conducted on 5/22/2026 at approximately 10:30 AM, with the Agency Supervisor/Owner (E #2). During discussion, E #2 noted the new Administrator has not approved in writing, E #2 as the pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available. Additionally, as there has not been a Governing Board meeting since the new Administrator was put in place, the new Administrator has not been appointed by the Governing Board, and pre-designated person has not been appointed under the new Administrator, by the Governing Board.”