Interim Healthcare Services of Joliet Inc.

“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 the review of the Agency’s Error Summary report and Staff interview, it was determined in 8 of 27 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 09/01/24 thru 08/22/25, was reviewed on 09/2/25 at 12:00 PM. The report included error # -3330 for submissions. 29.63% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator, on 09/02/25 at 12:15 PM.”

“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 records reviewed and staff interview, for 2 of 7 (Pts. #5 and 7) clinical records reviewed, the Agency failed to ensure patient care was provided as ordered in the plan of care. Findings include: 1. Pt. #5 was admitted to the Home Health Services on 05/09/25 with the diagnosis of Unilateral Primary Osteoarthritis. The clinical record was reviewed on 09/03/25. The clinical record included a POC dated 05/09/25, that required the PT services 1 time a week for 1 week and 3 times a week for 3 weeks. The PT did not provide the 3rd visit, during the week of 05/17/25 to 05/23/25 (week #3). 2. Pt. #7 was admitted to the Home Health Services on 06/21/25 with the diagnosis of Unspecified Intracranial Injury. The clinical record was reviewed on 09/03/25. The clinical record included a POC dated 06/21/25, that was modified on 08/04/25 to include the Aide services 2 times a week for 3 weeks. The Aide did not provide the 2nd visit, during the week of 08/03/25 to 08/09/25, week #7. 3. The above findings were confirmed, during the interview with the Director of Health Care Services, on 09/03/25 between 1:00 PM and 1:30 PM.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on a review of clinical records, Agency policy, and Staff interviews, in 3 of 7 (Pts. #2, 4, and 7) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. 2. Pt. #4 was admitted to the Home Health Services on 04/16/24 with the diagnosis of Wedge Compression Fracture. The clinical record was reviewed on 09/02/25. The clinical record included SN discharge visit notes the lacked documentation of the patient’s vital signs. 3. Pt. #7 was admitted to the Home Health Services on 06/21/25 with the diagnosis of Unspecified Intracranial Injury. The clinical record was reviewed on 09/03/25. The clinical record included orders for the Aide services and lacked the Aide visit notes. During the interview with the Director of Health Care Services, the Aide notes were presented as a late incorporation, for the discharge record. 4. The Agency’s policy titled “Pain Management” was reviewed on 09/03/25 at 2 :00 PM and included “....Procedure ... II Pain assessment, including levels of pain... will be documented in clinician’s notes, including but not limited to... A... 4. Intensity using pain scale, ...” 5. The above findings were confirmed, during interviews with the Administrator and Director of Healthcare Services, on 08/13/25 from 11:46 AM to 1:30 PM. Findings include: 1. Pt. #2 was admitted to Home Health Services on 07/24/25 with the diagnosis of Displaced Fracture of Head of Right Radius, Subsequent Encounter for Open Fracture Type 1 or II with Routine Healing. The clinical record was reviewed on 09/03/25. The clinical record included Certified Occupational Therapist Assistant (COTA) and Physical Therapy (PT) visit notes that required the COTA and PT to assess and document Pt. #2’s pain intensity, using a pain rating scale of 0 to 10 (0 equal no pain, 10 equal severe pain). The COTA visit notes dated 08/06/25, 08/12/25, and the PT visit note dated 08/12/25 contained documentation the Pt. experienced pain to the both wrists and/or knee. The COTA and PT visit notes lacked Pt. #2’s pain intensity rating.”

“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 clinical record reviews and staff interview, the Agency failed to ensure discharge summaries for 3 of 5 (Pts. #3, 5 and 6) clinical records reviewed were sent to the physician. 3. Pt. #6 was admitted to Home Health Services on 06/20/25 with the diagnosis of Complete Rotator Cuff Tear or Rupture of Left Shoulder, not Specified as Traumatic. The clinical record was reviewed on 09/03/25. The clinical record included the Agency’s “Physician Discharge Summary” completed by the RN and dated 06/27/25. The record lacked documentation that a copy of the summary was sent to the Physician. 4. During interviews with the Administrator and Director of Healthcare Services on 09/03/25 from 11:46 AM to 1:30 PM, both confirmed the Agency failed to send a copy of the Discharge Summary to the Physician. Findings include: 1.Pt. #3 was admitted to the Home Health Services on 07/17/25 with the diagnosis of Unilateral Primary Osteoarthritis. The clinical record was reviewed on 09/02/25. The clinical record included a discharge summary dated 07/31/25, that lacked documentation that the discharge summary was sent to the physician. 2. Pt. #5 was admitted to the Home Health Services on 5/09/25 with the diagnosis of Unilateral Primary Osteoarthritis. The clinical record was reviewed on 09/03/25. The clinical record included a discharge summary dated 05/31/25, that lacked documentation that the discharge summary was sent to the physician.”