Illinois Home Health Care of Naperville

“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 observation and interviews during home visits, clinical records reviewed and staff interviews, for 8 of 13 Pts. (Pts. #1, 10, 3, 4, 5, 11, 12 and 13), the Agency failed to ensure that the PsOC included all the requirements. Findings include: 1. Pt. #1 was admitted to home health on 04/07/26 with a diagnosis of hypertensive heart disease and chronic kidney disease with heart failure. During a home visit conducted with a physical therapist (PT) on 07/27/26, it was observed that the PT took measurements of Pt. #1’s ankle and stated that ankle measurements were required at every visit. The clinical record was reviewed on 07/28/26 and included PT and occupational therapy (OT) documentation of ankle measurements. The record also included a plan of care (POC) effective 06/06/26, which lacked documentation specifying the parameters of the ankle measurements that were to be reported to the physician. 2. Pt. #10 was admitted to home health on 02/25/26 with a diagnosis of Alzheimer’s Disease. The clinical record was reviewed on 07/29/26 and included PT documentation of ankle measurements. The record also included a plan of care (POC) for the certification period of 03/03/26 to 05/01/26, which lacked documentation specifying the parameters of the ankle measurements that were to be reported to the physician. 3. Pt. # 3 was admitted to Home Health Services on 06/24/26 with Diagnosis of other pneumonia, unspecified organism. The clinical record was reviewed on 07/29/26. The clinical record included weekly PT and OT visits beginning week of 06/24/26, the weekly therapy visits included bilateral ankle measurements. The POC for Pt #3 for certification period 06/24/26 to 08/22/26 lacked patient-specific interventions / parameters to follow for the ankle measurements. 4. Pt. #4 was admitted to Home Health Services on 07/06/26 with Diagnosis that included not limited to Parkinson’s Disease without Dyskinesia. The clinical record was reviewed on 07/29/26. The clinical record included weekly SN visits beginning week of 07/06/26, the weekly SN visits included bilateral ankle measurements. The POC for Pt #4 for certification period 07/06/26 to 09/03/26 lacked patient-specific interventions / parameters to follow for the ankle measurements. 5. Pt. #5 was admitted to Home Health Services on 09/30/25 with Diagnosis of but not limited to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinic record was reviewed on 07/28/26. The clinical record included weekly SN, PT and OT visits with documentation of ankle measurements. The record included PsOC effective 05/28/26 to 07/26/26 and 07/27/26 to 09/24/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 6. Pt. # 11 was admitted to Home Health Services on 07/30/26 with Diagnosis of but not limited to Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 07/30/26. The clinical record included weekly PT and OT visits with documentation of ankle measurements. The record included POC effective 02/25/26 to 04/25/26 which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 7. Pt. #12 was admitted to Home Health Services on 01/30/26 with Diagnosis of but not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 07/30/26. The clinical record included weekly SN, PT and OT visits with documentation of ankle measurements. The record included POC effective 01/30/26 to 03/3/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 8. Pt. #13 was admitted to Home Health Services on 10/27/25 with Diagnosis of but not limited to Chronic Atrial Fibrillation. The clinical record was reviewed on 07/30/26. The clinical record included weekly SN, PT and OT visits with documentation of ankle measurements. The record included POC effective 10/27/25 to 12/25/25, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 9. During staff interviews with the Executive Director and Patient Care Manager on 07/30/26 between 12:30 PM to 3:30 PM, the Administrative staff confirmed the above findings. Findings include: 1. Pt. #1 was admitted to home health on 04/07/26 with a Diagnosis of Hypertensive Heart Disease and Chronic Kidney disease with Heart Failure. During a home visit conducted with a physical therapist (PT) on 07/27/26, it was observed that the PT took measurements of Pt. #1’s ankle and stated that ankle measurements were required at every visit. The clinical record was reviewed on 07/28/26 and included PT and occupational therapy (OT) documentation of ankle measurements. The record also included a plan of care (POC) effective 06/06/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 2. Pt. #10 was admitted to Home Health Services on 02/25/26 with a Diagnosis of Alzheimer’s Disease. The clinical record was reviewed on 07/29/26 and included PT documentation of ankle measurements. The record also included a plan of care (POC) for the certification period of 03/03/26 to 05/01/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 3. Pt. # 3 was admitted to Home Health Services on 06/24/26 with Diagnosis of other pneumonia, unspecified organism. The clinical record was reviewed on 07/29/26. The clinical record included weekly PT and OT visits beginning week of 06/24/26, the weekly therapy visits included bilateral ankle measurements. The POC for Pt #3 for certification period 06/24/26 to 08/22/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 4. Pt. #4 was admitted to Home Health Services on 07/06/26 with Diagnosis that included not limited to Parkinson’s Disease without Dyskinesia. The clinical record was reviewed on 07/29/26. The clinical record included weekly SN visits beginning week of 07/06/26, the weekly SN visits included bilateral ankle measurements. The POC for Pt #4 for certification period 07/06/26 to 09/03/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 5. Pt. #5 was admitted to Home Health Services on 09/30/25 with Diagnosis of but not limited to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinic record was reviewed on 07/28/26. The clinical record included weekly SN, PT and OT visits with documentation of ankle measurements. The record included PsOC effective 05/28/26 to 07/26/26 and 07/27/26 to 09/24/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 6. Pt. # 11 was admitted to Home Health Services on 07/30/26 with Diagnosis of but not limited to Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 07/30/26. The clinical record included weekly PT and OT visits with documentation of ankle measurements. The record included POC effective 02/25/26 to 04/25/26 which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 7. Pt. #12 was admitted to Home Health Services on 01/30/26 with Diagnosis of but not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 07/30/26. The clinical record included weekly SN, PT and OT visits with documentation of ankle measurements. The record included POC effective 01/30/26 to 03/3/26, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 8. Pt. #13 was admitted to Home Health Services on 10/27/25 with Diagnosis of but not limited to Chronic Atrial Fibrillation. The clinical record was reviewed on 07/30/26. The clinical record included weekly SN, PT and OT visits with documentation of ankle measurements. The record included POC effective 10/27/25 to 12/25/25, which lacked patient specific interventions / parameters of ankle measurements to be reported to the Physician. 9. During staff interviews with the Executive Director and Patient Care Manager on 07/30/26 between 12:30 PM to 3:30 PM, the Administrative staff confirmed the above findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical records reviewed, Agency policy review and staff interviews, for 1 of 7 (Pt. #6) the Agency failed to ensure that treatment provided was ordered by the Physician. Findings include: 1. Pt. #6 was admitted to Home Health Services on 12/04/25 with the Diagnosis of Venous Insufficiency. The clinical record was reviewed on 07/28/26. The SN notes included the following documentation: 07/01/26, included: “….Pt has new open wound, images and measurements obtained, waiting for wound orders, placed foam dressing for now….” 07/09/26, included: “….Wound care completed….” The clinical record lacked physician orders for the above wound treatment used by the SN. 2. The Agency policy titled: Wound Assessment, Documentation, and Photography effective date 04/15/99 was reviewed on 07/30/26 and required: “….Procedure:….2. Perform wound care according to….physician orders….3. Document the following in the medical record:….i. exact wound care performed, following physician orders….” 3. During an interview with the Executive Director and Patient Care Manager on 07/30/26 at 3:00 PM, the Administrative Staff confirmed the above findings.”