Chicago Health, 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 review of the Error Summary report for the last 12 months and staff interview, the Agency failed to submit 70 of 631 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 06/16/25 to 06/16/26, was reviewed on 06/16/26. The report documented 70 of 631 (11.09 %) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator / Alternate Clinical Manager on 06/17/26 at 1:30 PM, the Administrator confirmed the above findings.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on Agency’s admission folder review, clinical records review and staff interview, the Agency failed to provide patients a copy of the Agency’s transfer and discharge policy on admission. 1. The Agency’s patient admission folder was reviewed on 06/17/26. The admission folder lacked written information of the Agency’s transfer and discharge policy. 2. The following clinical records were reviewed between 06/15/26 and 06/17/26 - Pt. #1 SOC 05/21/26 Pt. #2 SOC 04/14/26 Pt. #3 SOC 03/05/26 Pt. #4 SOC 04/15/26 Pt. #5 SOC 04/17/26 Pt. #6 SOC 02/05/26 Pt. #7 SOC 01/28/26 The clinical records lacked evidence that a copy of the Agency’s transfer and discharge policy was provided to the patients/patient representative on admission. 3. During interviews with the Administrator and alternate Clinical Manager on 06/17/26 between 11:45 AM an 2:15 PM, the above finding was confirmed.”

“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, for 2 of 7 clinical record reviews, (Pts. #1 and 5), the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. Findings include: 1. Pt. #1 was admitted to home health on 05/21/26 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 06/16/26 and included the document “Encounter – Home Visit Date of Service: 05/01/26 (Pt. #1)”, which was faxed to the Agency on 05/07/26. The initial comprehensive assessment was conducted by the RN on 05/21/26. The record lacked a specific Physician ordered SOC date. The record lacked documentation the Agency initiated services within 48 hours of the referral date. 2. Pt. #5 was admitted to home health on 04/17/26 with the diagnosis of Paraplegia. The clinical record was reviewed on 06/16/26 and included the document “Encounter – Home Visit Date of Service: 03/31/26 (Pt. #5)”, which was faxed to the Agency on 04/02/26. The initial comprehensive assessment was conducted by the RN on 04/17/26. The record lacked a specific Physician ordered SOC date. The record lacked documentation the Agency initiated services within 48 hours of the referral date. 3. During an interview with the Administrator and Alternate Clinical Manager on 06/17/26 at 11:30 AM, 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 observation and interviews during home visits, clinical records review and staff interviews, for 3 of 7 Pts. (Pts. #1, 2 and 7), the Agency failed to ensure that the Plans of Care included all the requirements. 3. Pt. # 7 was admitted to home health services on 01/28/26 with Diagnoses: Low back pain and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 06/16/26, the clinical record included weekly SN visit notes for certification period 03/29/26 to 05/27/26 that include documented blood sugar assessments. The POC for same certification period lacked blood sugar parameters for patient and SN to follow. 4. During interviews on 06/17/26 between 11:45 AM and 1:30 PM with the Administrator and alternate Clinical Manager the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health on 05/21/26 with the diagnosis of Hypertensive Heart Disease with Heart Failure. A home visit was conducted with an RN on 06/15/26 and during the visit, the RN had asked Pt.’s family member if there was special footwear to support Pt. #1’s right foot due which had a fracture. Pt.#1’s family presented an orthotic shoe that was prescribed for Pt. #1 but stated that they were not using it because the straps were too long. The clinical record was reviewed on 06/16/26 and included a POC effective 05/21/26. The POC lacked documentation of the description of the footwear, its care and instructions for use. 2. Pt. #2 was admitted to home health on 04/14/26 with the diagnosis of Other Seizures. A home visit was conducted with the Home Health Aide (HHA) on 06/16/26 and during the visit, the HHA assisted Pt. #2 with a shower, and while in the bathroom, the HHA described the medical equipment Pt. #2 uses. Pt. #2’s bathroom was observed to have grab bars, a commode over the toilet and Pt. #2 was sitting on the shower bench. The clinical record was reviewed on 06/16/26 and included a POC effective 04/14/26. The POC lacked documentation of the above-mentioned DME (Durable Medical Equipment).”

“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 reviews and staff interviews, for 3 of 7 clinical records reviewed (Pts. #1, 2 and 5), the Agency failed to ensure physician orders were followed. Findings include: 1. Pt. #1 was admitted to home health on 05/21/26 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 06/16/26 and included a physician order: “Assessment: …the following services are medically necessary home health services: Skilled Nursing…Physical Therapy…MSW (Medical Social Worker) …” The record lacked documentation that any Physical Therapy (PT) visits or MSW services were provided. 2. Pt. #2 was admitted to home health on 04/14/26 with the diagnosis of Other seizures. The clinical record was reviewed on 06/16/26 and included a physician order: “Home Health PT/OT/RN.” The record lacked documentation that any Occupational Therapy (OT) services were provided. 3. Pt. #5 was admitted to home health on 04/17/26 with the diagnosis of Paraplegia. The clinical record was reviewed on 06/16/26 and included a physician order: “Qualifying services: Skilled Nursing…Physical Therapy…Occupational Therapy…MSW…The record lacked documentation that any OT or MSW services were provided. 4. During an interview with the Administrator and Alternate Clinical Manager on 06/17/26 at 11:30 AM, 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 Agency’s admission folder review and staff interview, the Agency failed to provide the name and contact information of the Clinical Manager to the patients on Admission. Findings include: 1. The Agency’s patient admission folder was reviewed on 06/16/26, the admission folder did not include the name and contact information of the Agency Clinical Manager, to whom the patients can contact with any questions about their services. 2. During an interview with the Administrator and Alternate Clinical Manager on 06/17/26 at 1:45 PM, the above finding was confirmed.”