Gaffey Home Nursing & Hospice, Inc.

“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 review, Agency policy review and staff interview, for 1 of 1 (Pt. #1) Pt. receiving wound care, the Agency failed to ensure that wound care measurements were conducted, as per Agency policy. Findings include: 1.Pt. #1 was admitted to home health services with diagnoses of Pressure Ulcer, right heel, stage 3. The clinical record was reviewed on 04/21/26. The clinical record included the POC for the certification period of 03/17/26 to 05/15/26 that required 1 time a week for 1 week and 2 times a week for 8 weeks for wound care. The SN visits dated and wound flowsheet dated 04/06/26, 04/10/26, 04/13/26 and 04/17/26, lack wound care measurements. 2. Agency policy titled: “Wound Measurement” was reviewed on 04/22/26 and required: “….g. Documentation of wound measurements is part of the required documentation for all wound care procedures….” 3. During an interview with the Agency Supervisor and Clinical Director on 04/22/26 at 1:45 PM, the Agency Supervisor stated that Nurses should document a wound measurement weekly and document it in the clinical record. During the same interview, the Administrative team confirmed the above findings.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on review of the Patient’s Admission Folder, clinical record review, and staff interview, the Agency failed to ensure Pts. were provided with the correct information to file a concern or complaint with the Illinois Department of Public Health in 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6, and 7). Findings include: 1. The Patient’s Admission folder was reviewed on 04/20/26. The booklet included the following information regarding Complaints: “COMPLAINTS, you have the right: 1) ”To make complaints to the home health agency regarding treatment or care that is (or fails to be) furnished…..” 2) “To be free from any discrimination or reprisal for exercising his or her rights or voicing grievances to the home health….” 3) “To be advised of the state toll free home health telephone hot line, its contact information, its hours of operation…” (See page 1 of this booklet). The folder included under Tablet of Contents: Staff information: Complaints to: __________ Administrator’s Name/Title Phone #: ____________ Agency Address: ____________________________________________ State Hotline: 1800-______________________ (If agency is unable to resolve complaint). The Agency failed to provide the Pts. and/or the patients’ representatives with the State of Illinois’ toll-free home health telephone hotline purpose and its contact information. 2. During an interview with the Agency Supervisor on 04/22/26 at 3:45 PM, the above findings were confirmed.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical records review, Agency policy review and staff interviews, for 7 of 7 (Pts. # 1, 5, 6, 2, 3, 4 and 7) clinical records reviewed, the Agency failed to ensure that the Plans of Care (PsOC) included Pt. specific interventions. 6. Pt. #4 was admitted to home health services on 04/03/26 with the diagnosis of but not limited to Malignant Neoplasm of overlapping sites of the bladder and Type 2 Diabetes mellitus. The clinical record was reviewed on 04/22/26 and included a POC effective 04/03/26. The POC lacked documentation of vital signs and blood glucose parameters to be reported to the Physician. The clinical record indicated that Pt. #4 uses an indwelling pleural drainage catheter but, lacked documentation of the procedure and supplies used for the care of the drainage catheter and the incision site. The POC also lacked documentation of the amount of drainage to be removed and parameters to be reported to the Physician. The clinical record also indicated Pt. #4 has an access port but also lacked documentation of its care and the frequency and the supplies used. 7. Pt. #7 was admitted to home health services on 07/01/25 with the diagnosis of Traumatic subdural hematoma without loss of consciousness. The clinical record was reviewed on 04/22/26 and included a POC for certification period of 07/01/25 to 08/29/25. The POC lacked documentation of vital signs parameters to be reported to the Physician. The POC also lacked individualized interventions and goals addressing the diagnosis/problems identified. 8. The policy titled “Plan of Care” was reviewed on 04/23/26 and required, “Purpose: To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs… To assure that the plan meets state/federal guidelines, and all applicable laws and regulations. Special instructions…1. An individualized Plan of Care signed by a physician/allowed non-physician practitioner (NPP) shall be required for each client receiving home health…The Plan of Care shall be completed to include: m…procedures….n. Medical supplies and equipment required…” 9. During interviews with the Agency Supervisor and Clinical Director on 04/22/26 from 1:45 PM to 3:30 PM, the above findings were confirmed. Findings: 1.Pt. # 1 was admitted to home health services on 11/17/25 with diagnosis of Pressure Ulcer, right heel, stage 3. The clinical record was reviewed on 04/21/26. The clinical record included PsOC for certification periods of 01/16/26 to 03/16/26 and 03/17/26 to 05/15/26 and lacked individualized vital sign parameters to report to Physician. 2. Pt. # 5 was admitted to home health services on 07/15/25 with diagnosis of Type 2 Diabetes Mellitus with Moderate nonproliferative Diabetic retinopathy. The clinical record was reviewed on 04/21/26. The clinical record included PsOC for the certification periods of 01/11/26 to 03/11/26 and 03/12/26 to 05/10/26 and lacked individualized vital sign parameters and blood sugar parameters to report to Physician. 3. Pt. # 6 was admitted to home health services on 11/11/24 with the diagnosis of but not limited to Malignant Neoplasm of Lower Lobe, right bronchus or lung and Type 2 Diabetes Mellitus. The clinical record was reviewed on 04/21/26. The clinical record included PsOC for certification periods of 11/11/24 to 01/09/25 and 01/10/25 to 03/10/25 and lacked individualized vital sign parameters and blood sugar parameters to report to Physician. 4. Pt. #2 was admitted to home health services on 12/23/20 with diagnoses of atherosclerotic heart disease of the native coronary artery with unspecified angina pectoris and Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 04/21/26. The PsOC dated 01/26/26 to 03/26/26 and 03/27/26 to 05/25/26 lacked documentation of vital signs and blood glucose parameters to report to the physician. 5. Pt. #3 was admitted to home health services on 02/05/26 with diagnoses of Pneumonia and Type 2 diabetes mellitus with diabetic polyneuropathy. The clinical record was reviewed on 04/21/26. The POC dated 02/05/26 to 04/05/2026 lacked documentation of vital signs and blood glucose parameters to report to the physician.”

“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 clinical record reviews, policy review, and staff interviews, for 7 of 7 (Pts. #1,2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to conduct complete assessments of patients’ Influenza and Pneumonia vaccination status. Findings include: 1. The following clinical records were reviewed from 04/21/26 to 04/22/26, the records lacked documentation that the Influenza and Pneumonia vaccination was assessed. Pt. #1 SOC 11/17/25 lacked Influenza and Pneumonia vaccination assessment. Pt. #2 SOC 12/22/20 lacked Influenza and Pneumonia vaccination assessment. Pt. #3 SOC 02/05/26 lacked Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 04/03/26 lacked Influenza and Pneumonia vaccination assessment. Pt. #5 SOC 07/15/25 lacked Influenza and Pneumonia vaccination assessment. Pt. #6 SOC 11/11/24 lacked Influenza and Pneumonia vaccination assessment. Pt. #7 SOC 07/01/25, lacked Influenza and Pneumonia vaccination assessment. 2. During staff interviews with the Agency Supervisor and Clinical Director on 04/22/26 from 1:45 PM to 3:45 PM, the above findings were confirmed.”

“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 and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) the Agency failed to provide information regarding the Clinical Manager/Agency Supervisor and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 04/20/26. The folder lacked information identifying the Agency Supervisor’s name and contact information. 2. The clinical records of the following Pts. were reviewed from 04/21/26 to 04/22/26 Pt. #1 SOC 11/17/25. Pt. #2 SOC 12/22/20. Pt. #3 SOC 02/05/26. Pt. #4 SOC 04/03/26. Pt. #5 SOC 07/15/25. Pt. #6 SOC 11/11/24. Pt. #7 SOC 07/01/25. The clinical records reviewed lacked information identifying the Agency Supervisor’s name and contact information. 3. During a staff interview with the Agency Supervisor and Clinical Director on 04/22/26 at 3:45 PM it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.”