Dependable Nursing Home Health Services, Inc.

“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), §485.542(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: Based on a review of the Agency’s Emergency Operations Plan and staff interview, it was determined the Agency failed to review and update its Emergency Operations Plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan was reviewed on 9/16/24. The Plan contained an “Emergency Operations Plan Signature Page” signed by the Administrator, Director of Nursing and dated 3/1/22, indicating when the plan was last reviewed and updated. 2. During an interview with the Administrator and the Alternate Director of Nursing on 9/18/24 at 2:05 PM, the Administrator confirmed the Agency failed to review and update the Emergency Preparedness plan biennially.”

“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 Operations Plan and staff interview, it was determined the Agency failed to review and update the Emergency Operations policies and procedures as required, and develop a risk assessment. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan was reviewed on 9/16/24. The Plan contained the Emergency Operations policies and procedures which lacked a date, indicating when the policies and procedures were last reviewed and updated. 2. As of 9/16/24, the Emergency Operations Plan lacked a risk assessment. 3. During an interview with the Administrator and the Alternate Director of Nursing on 9/18/24 at 2:05 PM, the Administrator confirmed the Agency failed to review and update the Emergency Operations policies and procedures as required, and develop a risk assessment..”

“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 interviews, it was determined that in 536 of 654 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 6/2023 to 5/2024, was reviewed on 9/16/24. The report included error # -3330 for 536 of 654 late submissions, which was 81.96 % of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Administrator on 9/19/24 at 10:30 AM, the administrator confirmed that the error occurred.”

“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 a review of the Agency’s Pt. admission folder, clinical records, and staff interviews, it was determined that in 6 of 7 (Pts. #1, 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 provided by each discipline. Findings include: 1. The patient’s admission folder was reviewed on 9/16/24 and contained a form titled, “Clinician Visit Schedule”. The Agency required the SN to complete the form during the SOC visit, the RN indicates the service(s) to be provided and enter the frequency of the visits. 2. The following clinical records were reviewed from 9/16/24 to 9/18/24: Pt. #1. SOC 10/7/23. Pt. #3. SOC 8/21/24. Pt. #4. SOC 4/11/24. Pt. #5. SOC 8/24/24. Pt. #6. SOC 6/24/24. Pt. #7. SOC 11/7/23. The clinical records lacked a completed “Clinician Visit Schedule” form, or other documentation indicating the Pt./representative was notified of the service(s) to be provided, and the frequency of visits in writing. 3. Home visits were conducted on the following Pts. from 9/16/24 to 9/28/24: Pt. #1. SOC 10/7/23. Pt. #3. SOC 8/21/24. During the home visits, the patient’s admission folder was observed and lacked documentation indicating the Pt./representative was notified of the service(s) to be provided, and the frequency of visits in writing. Pt. #1 was unable to locate the Pt. admission folder. 4. During interviews with the Administrator and Alternate Director of Nursing on 9/18/24 at 2:05 PM and 3:45 PM, both confirmed the Agency failed to ensure the Pt./representative was informed in writing of the services to be provided, and the frequency of visits.”

“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 Agency’s Pt. admission folder, observation during home visits and staff interviews, it was determined the Agency failed to provide an accurate address to file a complaint with the Illinois Department of Public Health. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) pts. reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 9/16/24 at 11:30 AM. The folder included an inaccurate address for which a Pt./patient’s representative may submit a complaint to the State Hotline in writing. 2. The following home visits were conducted from 9/17/24 to 9/18/24: Pt. #2. SOC 4/9/24. Pt. #3. SOC 8/21/24. During the home visits, the Pt. admission folders were observed and the address for which a Pt./patient’s representative may file a complaint in writing to the Illinois Department of Public Health was inaccurate. 3. During an interview with the Administrator and Alternate Director of Nursing on 9/18/24 at 2:05 PM they confirmed the Pt. admission folder had an inaccurate address for a Pt./patient representative to file a complaint in writing.”

“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 a review of clinical records, and staff interview, it was determined in 5 of 7 (Pts. #1, 2, 7, 3, and 6) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service. Findings include: 1. Pt. #1 was admitted to home health services on 10/7/23 with the diagnosis of Organ-Limited Amyloidosis. The clinical record was reviewed on 9/16/24. The clinical record contained the SOC comprehensive assessment completed by the SN and dated 10/7/23. As of 9/16/24, the record lacked a referral on or before 10/7/23 to initiate service. 2. Pt. #2 was admitted to home health services on 4/9/24 with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). The clinical record was reviewed on 9/16/24. The clinical record contained the SOC comprehensive assessment completed by the SN and dated 4/9/24. As of 9/16/24, the record lacked a referral on or before 4/9/24 to initiate service. 3. Pt. #7 was admitted to home health services on 4/1/24 with the diagnosis of Pressure Ulcer of Left Heel, Stage 3. The clinical record was reviewed on 9/18/24. The clinical record contained the SOC comprehensive assessment completed by the SN and dated 4/1/24. As of 9/18/24, the record lacked a referral on or before 4/1/24 to initiate service. Findings include: 1. Pt. #1 was admitted to home health services on 10/7/23 with the diagnosis of Organ-Limited Amyloidosis. The clinical record was reviewed on 9/16/24. The clinical record contained the SOC comprehensive assessment completed by the SN and dated 10/7/23. As of 9/16/24, the record lacked a referral on or before 10/7/23 to initiate service. 2. Pt. #2 was admitted to home health services on 4/9/24 with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). The clinical record was reviewed on 9/16/24. The clinical record contained the SOC comprehensive assessment completed by the SN and dated 4/9/24. As of 9/16/24, the record lacked a referral on or before 4/9/24 to initiate service. 3. Pt. #7 was admitted to home health services on 4/1/24 with the diagnosis of Pressure Ulcer of Left Heel, Stage 3. The clinical record was reviewed on 9/18/24. The clinical record contained the SOC comprehensive assessment completed by the SN and dated 4/1/24. As of 9/18/24, the record lacked a referral on or before 4/1/24 to initiate service. 4. Pt. #3. Was admitted to home health services on 8/21/24 with the diagnosis of Pressure Ulcer Sacral Region Unstageable. The clinical record was reviewed on 9/17/24. The record included a Physician referral for home health services dated 8/14/24. The record included the initial SOC assessment, dated 8/21/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 9/19/24, the record lacked documentation the Agency initiated service within the required time frame. 5. Pt. #6. Was admitted to home health services on 6/24/24 with the diagnosis of Complete Trauma Amputation at Level Between Knee and Ankle, Left Lower Leg. The clinical record was reviewed on 9/18/24. The record included a Physician referral for home health services dated 8/14/24. The record included the initial SOC assessment, dated 6/21/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 9/19/24, the record lacked documentation the Agency initiated service within the required time frame. 6. During an interview with the Administrator and Alternate Director of Nursing on 9/18/24 at 2:05 PM and 3:45 PM, the Administrative team confirm 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 a review of clinical records and staff interviews, it was determined that in 4 of 7 (Pts. #2, 3, 5, and 6) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and/or Influenza vaccines, as required by the Agency. 2. Pt. #3. Was admitted to home health services on 8/21/24 with the diagnosis of Pressure Ulcer Sacral Region Unstageable. The clinical record was reviewed on 9/17/24. The record lacked documentation Pt. was assessed for Influenza and Pneumococcal vaccines at the SOC. 3. Pt. #5. Was admitted to home health services on 8/24/24 with the diagnosis of Hemiplegia following Cerebral Infarction Affecting Left Non-Dominant Site. The clinical record was reviewed on 9/18/24. The record lacked documentation Pt. was assessed for Influenza and Pneumococcal vaccines at the SOC. 4. Pt. #6. Was admitted to home health services on 6/24/24 with the diagnosis of Complete Trauma Amputation at Level Between Knee and Ankle, Left Lower Leg. The clinical record was reviewed on 9/18/24. The record lacked documentation Pt. was assessed for Influenza and Pneumococcal vaccines at the SOC. 5. The Agency’s policy titled, “Vaccinations” was reviewed on 9/19/22 at 10:08 AM and included: “...6) The following shall be documentation approaches…. A) Individual client/patient record entries identifying the assessment for the need of vaccination; date of referral; client/patient response; administration, contraindication, or refusal and any follow up activities. B) Standardized check off form recording client/patient specific information, including the assessment for the need of the vaccination…….”4) A home health agency should document in each client’s/patient’s medical record that a vaccination against pneumococcal pneumonia was offered and was administered, arranged, refused, or medically contraindicated or that the client is not a member of a vaccination priority population”. 6. During the Entrance Conference on 9/16/24 at 10:25 AM, the Administrator stated, the RN is required to assess the patient’s Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information is documented in SOC comprehensive assessment. During an interview with the Administrator and Alternate Director of Nursing on 9/18/24 at 2:05 PM and 3:45 PM, the administrative team confirm the above findings. Findings include: 1. Pt. #2 was admitted to home health services on 4/9/24 with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). The clinical record was reviewed on 9/16/24. The clinical record lacked documentation the Agency had assessed the patient’s need for the Pneumococcal Pneumonia vaccine, during the SOC visit as required by the Agency.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation and interview during a home visit, clinical record review, Agency policy review, and staff interview, it was determined that in 1 of 7 (Pt. #2) clinical records reviewed, the Agency failed to ensure there was coordination of care between care providers to ensure Pt. needs are met. Findings include: 1. Pt. #2 was admitted to home health services on 4/9/24 with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). A home visit was conducted on 9/18/24 with the Alternate Director of Nursing. During the home visit, observed that Pt. #2 had a cough, and was taking medication for the cough. During an interview, Pt. #2 stated a physician had ordered a chest x-ray in June 2024, and that Pt. #2 informed the SN. As of 9/18/24, Pt. #2 stated she had not received a chest x-ray. The clinical record was reviewed on 9/16/24, and lacked a physician order or other documentation regarding the need for a chest x-ray. The record lacked care coordination between the ordering physician, primary physician, and the Director of Nursing. 2. The Agency’s policy titled; “Coordination of Patient Services” was reviewed on 9/18/24 at 3:30 PM. The policy required, “...All personnel furnishing services shall maintain a liaison to assure that their efforts are coordinated effectively... To establish effective interchange, reporting, and coordination of patient care does occur...” 3. During an interview with the Administrator and Alternate Director of Nursing on 9/18/24 at 2:05 PM, both confirmed the SN failed to effectively coordinate services.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, wherein the Pt. received home health aide services, the Agency failed to ensure the RN conduct home health aide supervision every 14 days. Findings include: 1. Pt. #1 was admitted to home health services on 10/7/23 with the diagnosis of Organ-Limited Amyloidosis. The clinical record was reviewed on 9/16/24. The clinical record contained the home health aide supervisory note dated 7/25/24. The home health aide provided services 1 to 2 times a week from 7/30/24 to 8/15/24. The RN then supervised the Pt. on 8/15/24 (16 days without home health aide supervision). As of 9/16/24, the record lacked documentation the RN supervised the home health aide every 2 weeks. 2. During an interview with the Administrator on 9/19/24 at 10:20 AM, the Administrator confirmed the RN failed to conduct home health aide supervision every 14 days.”

“If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) The supervisory assessment must be completed onsite (that is, an in person visit), or on the rare occasion by using two-way audio-video telecommunications technology that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed 1 virtual supervisory assessment per patient in a 60-day episode. This Element is not met as evidenced by: Based on a review of clinical records, and staff interview, it was determined that in 1 of 1 (Pt. #1) clinical records reviewed, the Agency failed to ensure the RN conduct onsite supervision of the home health aide. Findings include: 1. Pt. #1 was admitted to home health services on 10/7/23 with the diagnosis of Organ-Limited Amyloidosis. The clinical record was reviewed on 9/16/24. The clinical record contained the home health aide supervisory notes dated 7/25/24, 8/15/24, 8/29/24, and 9/12/24. 2. During an interview with the Administrator on 9/18/24 at 2:05 PM, the Administrator stated the RN completed the home health aide supervisory notes by “calling the Pt. and aide on the phone”. During the same interview, the Administrator confirmed the RN failed to conduct onsite supervision of the home health aide.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on clinical record review, observation and interview during a home visit, Agency policy review, and staff interview, it was determined in 1 of 7 (Pt. #2) clinical records reviewed, the Agency failed to ensure the information contained in the clinical record was accurate. Findings include: 1. Pt. #2 was admitted to home health services on 4/9/24 with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). The clinical record was reviewed on 9/16/24. The clinical record contained weekly SN visit notes from 6/13/24 to 9/4/24 all documenting the Pt. had a stage 1 pressure ulcer wound to the coccyx. The SN documented that during each visit wound care was provided (cleaned area with wound cleanser, patted dry with clean gauze, and applied a barrier cream). A home visit was conducted on 9/18/24 with the Alternate Director of Nursing. During the home visit, the patient’s coccyx area was observed and there was no wound. An interview was conducted with the Pt. that stated, “sometimes not every week” that the SN assess the patient’s coccyx/ backside area. 2. The Agency’s policy titled, “Clinical Documentation” was reviewed on 8/18/24 and included “...Purpose - To ensure that there is an accurate record of the services provided...” 3. During an interview with the Administrator and Alternate Director of Nursing on 9/18/24 at 2:05 PM, the above finding was confirmed, and both stated they were not aware of Pt. #2 having a coccyx wound. The Administrator stated he had not ordered the wound care supplies indicated above, and that the only supplies ordered for Pt. #2 are ileostomy supplies.”