Optimum Healthcare Services, Inc. of Il

“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, the Agency failed to submit timely reports for 88 of 655 reports submitted for the last 12 months. Finding include: 1. The Agency’s Error Summary report for 07/01/2024 thru 06/30/2025 was reviewed on 07/30/25 at 10:10 AM. The report included 45 of 407 (11.06%) of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed during an interview with the Acting Administrator and Director of Nursing on 08/01/25 between 9:30 AM and 11:30 AM.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, and staff interview, for 7 of 7 of clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6 and 7), the Agency failed to provide information regarding the Agency’s transfer and discharge policy. Findings include: 1. The Agency Pt. admission folder was reviewed on 07/28/25. The folder lacked the Agency’s transfer and discharge policy. 2. The following home visits were conducted from 07/30/25 to 07/31/25: Pt. #1. SOC 04/29/25. Pt. #2. SOC 12/21/24. Pt. #3. SOC 06/17/25. During the home visits, the Pt. admission folders were observed and lacked the Agency’s policy on transfer and discharge. 3. During an interview with the Director of Nursing and the Acting Administrator on 08/01/25 at 10:00 AM, it was confirmed this was the admission folder used for all admissions, including the 7 of 7 clinical records reviewed . During the same interview, the above finding was confirmed.”

“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 review and staff interviews, the Agency failed to provide the services and treatments as ordered by the physician in the POC. This was identified in 3 of 7 clinical records reviewed (Pts # 4, 6 and 7). 3. Pt. #7 was admitted to the Home Health Services on 09/01/24 with the diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Atrial Fibrillation. The clinical record was reviewed on 07/31/25. The clinical record included a POC dated 09/01/24, that required the SN to assess the patient’s heart rate 1 time a week for 9 weeks. The SN failed to include the heart rate on 09/23/24. 4. The above findings were confirmed, during the interviews with the Acting Administrator and Clinical Manager, on 07/31/25 at 11:00 AM and on 08/01/25 between 9:30 AM and 10:30 AM. 2. Pt. #6 was admitted to the Home Health Services on 10/16/24 with the diagnosis of Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 07/31/25. The clinical record included Physician order for Resumption of Care dated 10/24/24, that required “Physical Therapy for Evaluation and management of functional deficits related to ambulation, musculoskeletal status and disease condition.” The record lacked documentation of a PT evaluation or visit. Findings include: 1. Pt. # 4 was admitted to Home Health Services on 09/05/24 with diagnosis of Pressure Ulcer of Sacral Region, Stage 2. The clinical record was reviewed on 07/31/25, the POC beginning 05/03/25 to 07/01/25 included orders to notify physician of vital sign parameters out of rage: “Fasting blood sugar: greater than (>) 200 less ( Random blood sugar: greater than (>) 250 less than ( The weekly SN visit notes for the certification period lacked assessment of blood sugar levels.”

“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 the clinical record reviews and staff interview, in 2 of 7 (Pts. #5 and 7) records reviewed, the Agency failed to ensure the clinical records were complete. Findings include: 1. Pt. #5 was admitted to the Home Health Services on 07/03/24 with the diagnosis of Pressure Ulcer Left Buttocks, Stage 4. The clinical record was reviewed on 07/30/25. The clinical record included a POC dated 06/28/25, that required the SN services 1 time a week for 9 weeks. The clinical record lacked the SN visit notes after 07/08/25. On 07/31/25 at 11:00 AM, during the interview with the Acting Administrator and Clinical Manager, it was stated the SN visit were conducted and the SN notes were not yet completed. 2.Pt. #7 was admitted to the Home Health Services on 09/01/24 with the diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Atrial Fibrillation. The clinical record was reviewed on 07/31/25. The clinical record included a POC dated 09/01/24, that required the SN services 1 time a week for 9 weeks. The clinical record lacked the RN supervisory visit notes for the LPN. On 07/31/25 at 11:00 AM, during the interview with the Acting Administrator and Clinical Manager, it was stated the LPN supervision was conducted during the recertification visit and the notes were not completed. 3.The above findings were confirmed, during the interview with the Acting Administrator and Clinical Manager, on 07/31/25 between 11:00 AM and 11:30 AM.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, and staff interview, for 7 of 7 clinical records reviewed (Pts #1, 2, 3, 4, 5, 6, and 7), the Agency failed to provide information regarding the Administrator and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 07/28/25. The folder lacked documentation identifying the Agency Administrator’s name, their address and phone number to file a complaint and/or grievance. 2. The following home visits were conducted from 07/30/25 to 07/31/25: Pt. #1. SOC 04/29/25. Pt. #2. SOC 12/21/24. Pt. #3. SOC 06/17/25. During the home visits, the Pt. admission folders were observed and lacked the Agency’s Administrator, their address and phone number to file a complaint and/or grievance. 3. During an interview with the Director of Nursing and the Acting Administrator on 08/01/25 at 10:00 AM, it was confirmed this was the admission folder used for all admissions, including the 7 of 7 clinical records reviewed, and that the folder lacked contact information for the Administrator.”

“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 the clinical record reviews, home visit observations and staff interview, in 3 of 7 (Pts. #1, 2 and 6) clinical records reviewed, the Agency failed to ensure the Plans of Care included orders for the services provided. 3. Pt. #6 was admitted to Home Health Services on 10/16/24 with the diagnosis of Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 07/31/25. The record included Skilled Nursing notes dated 10/30/24 and 11/30/24 which included the documentation, “ Genitourinary...Suprapubic catheter changes managed by: Home Health Agency.” The clinical record included a POC for the certification period of 10/16/24 to 12/14/24. The POC lacked documentation of interventions and caregiver education for the care of the Urinary Device. The POC also lacked documentation of supplies, treatment, and procedure for the care of the skin surrounding the insertion site. 4. During interviews with the Director of Nursing and Alternate Administrator on 07/31/25 at 11:30 AM and on 08/01/25 from 9:40 AM to 10:30 AM, it was stated that the POC should include all the requirements. During the same interviews, the above findings were confirmed. 2. Pt. #2 was admitted to Home Health Services on 12/21/24 with diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. The clinical record was reviewed on 07/31/25 and included a POC for certification period 04/20/25 to 06/18/25, The POC for this period lacked physician orders for Home Health Aide services, no additional orders were found. The clinical record included weekly Home Health Aide visits for this certification period. 1. Pt. #1 was admitted to the Home Health Services on 04/29/25 with the diagnosis of Essential Hypertension. The clinical record was reviewed on 07/30/25. A home visit was conducted on 07/30/25 with the Physical Therapist. The POC dated 06/28/25, lacked the orders for the Physical therapy services.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review, and staff interviews, the Agency failed to ensure that concerns are communicated/coordinated with the Physician to ensure Pt. needs were identified and addressed for 1 of 2 (Pt. #6) closed/discharged record reviewed. Findings include: 1. Pt. # 6 was admitted to Home Health Services on 10/16/25 with the diagnosis of Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 07/31/25. The clinical record included an SN visit dated 11/06/24 that included the documentation, “SN received patient in bed sleeping and responsive to verbal and tactile stimuli…Per patient’s caregiver (daughter-in-law), patient has been in bed for past two days and not eating or drinking. Only had one meal the previous day with less than 15% eaten. Has not eaten anything as of this time. Blood pressure 90/50. SN left a message at the Physician’s office regarding patient’s present condition. Awaiting response. Meanwhile, SN advised family to send patient to the hospital to the emergency room for further evaluation and treatment. Per daughter-in-law, Patient’s Son does not want patient to be send to the Hospital as patient is DNR. She also said that at the last patient’s hospital stay, the son was informed about Hospice care for his father (patient), but he declined. Caregiver said son prefers his father to be provided comfort care at this home. Nurse manager at the office of this.” The clinical record lacked a follow up conversation/communication with the Physician regarding Pt. status. 2. During an interview with the Acting Administrator and Director of Nursing on 08/01/25, the above finding was 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 a review of the Agency’s Pt. admission folder, observation during home visits, and staff interview, for 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6 and 7), the Agency failed to provide information regarding the Clinical Director (Director of Nursing) and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 07/28/25. The folder lacked documentation identifying the Clinical Manager’s name, their address and phone number. 2. The following home visits were conducted from 07/30/25 to 07/31/25: Pt. #1. SOC 04/29/25. Pt. #2. SOC 12/21/24. Pt. #3. SOC 06/17/25. During the home visits, the Pt. admission folders were observed and lacked the Clinical Manager’s name, their address and phone number. 3. During an interview with the Director of Nursing and the Acting Administrator on 08/01/25 at 10:00 AM, it was confirmed this was the admission folder used for all admissions, including the 7 of 7 clinical records reviewed, and that the folder lacked contact information for the Clinical Manager.”

“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 the clinical record review and staff interview, the Agency failed in 1 of 2 (Pts. #7) clinical records reviewed with Aide services to conduct the Aide supervision in the home. Findings include: 1. Pt. #7 was admitted to the Home Health Services on 09/01/24 with the diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Atrial Fibrillation. The clinical record was reviewed on 07/31/25. The clinical record included a POC dated 09/01/24, that required the Aide services 1 time a week for 9 weeks. On 07/31/24 at 11:00 AM, during the interview with the Acting Administrator, she stated the Aide supervision was conducted over the telephone. The RN failed to conduct the supervisory visits in the patient’s home every 14 days. 2. The above findings were confirmed, during the interview with the Acting Administrator and Clinical Manager, on 07/31/25 between 11:00 AM and 11:30 AM.”