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“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 interview, it was determined that in 15 of 196 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 04/23/23 to 03/24/24 (12 months), was reviewed on 07/16/24. The report included a warning for Error # -3330. The Error included 15 (7.65 %) assessments that were submitted late. 2. During an interview with the Administrator, Director of Nursing and Intake Coordinator on 07/18/24 at 9:45 AM, the Administrator stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrator confirmed the above findings.”

“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 record review and Staff interview, it was determined that in 5 of 7 (Pts. #1, 4, 5, 7 and 3) clinical records reviewed, the Agency failed to ensure that the PsOC contained Patient-specific interventions. 2. Pt. # 3 was admitted to Home Health Services on 05/06/24, with Diagnosis of Unspecified Fracture of Right Femur. The clinical record was reviewed on 07/17/24. The clinical record contained PsOC for certification periods 05/06/24 to 07/04/24 and 07/05/24 to 09/02/24. The PsOC contained SN interventions for blood sugar monitoring and blood sugar level parameters. The patient does not have history of diabetes and is not taking diabetic medication. 3. The findings related to the PsOC not including patient-specific interventions were confirmed during interviews with the Administrator, Director of Nursing and Intake Coordinator on 07/18/24 between 10:30 AM and 12:00PM. Findings include: 1. The following clinical records were reviewed from 07/16/24 to 07/17/24 and PsOC, indicated Orders and Treatments: “….notify MD if systolic BP is higher than 160 mm hg or lower than 90 mm hg….”: Pt. #1 POC effective 05/21/24 to 07/19/24 Pt. #4 POC effective 06/04/24 to 08/02/24 Pt. #5 POC effective 05/22/24 to 07/20/24 Pt. #7 POC effective 04/28/24 to 06/26/24 The PsOC lacked Pt. specific diastolic blood pressure parameters to report to the Physician.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on review of clinical records, Agency policy and Illinois Administrative Code and Staff interview, it was determined that in 1 of 2 (Pt. # 1) clinical records reviewed with PTA services, the Agency failed to ensure services were provided under the supervision of a PT. Findings include: 1. Pt. #1 was admitted to Home Health Services on 01/22/24 with Diagnosis of: Idiopathic Chronic Gout, left knee without tophus. The clinical record was reviewed on 07/16/24. The record included PTA services provided on the following dates: 06/06/24, 06/08/24, 06/11/24, 06/13/24, 06/13/24, 06/18/24, 06/20/24 and 06/27/24. The record lacked documentation that PTA services were supervised by a PT. 2. The Agency’s policy titled: Supervision of Physical Therapy Assistants and Occupational Therapy Assistants was reviewed on 07/18/24. The policy required: “….Services furnished by a Physical Therapy Assistant… will be furnished under the supervision of a qualified Physical or Occupational Therapist. Supervisory visits will occur every 30 days or every twelfth visit or according to that state law, whichever occurs first, by the appropriate therapist....” 3. The Illinois Administrative Code Title 77: Section 245.40 (g) 2 A-B was reviewed on 07/18/24 and requires: “.... 2) Supervision of the physical therapist assistant shall include the following: B) On-site supervision shall take place every four to six visits. The supervisory visits may be made either when the physical therapist assistant is present so that the supervisor may observe and assist, or when the physical therapist assistant is absent so that the supervisor may assess relationships and determine whether goals are being met....” 4. During an interview with the Administrator, Director of Nursing and Intake Coordinator on 07/18/24 at 9:45 AM, the Administrator confirmed the above findings.”