Quality Life Health Care Serv LLC

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on a review of the Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the Plan was established based on a risk assessment using an all-hazards approach. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/29/23 at 3:00 PM and 11/30/23 at 10:00 AM. The plan included a “Hazard Vulnerability Assessment” form, that required Agency staff to enter a score in each column for the different types of events and rate according to probability, level of vulnerability and preparedness. The form was left blank. 2. During an interview with the Acting Administrator/Agency Manager on 11/30/23 at 11:00 AM, the above findings were confirmed.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined that the Agency failed to ensure the communication plan was complete. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/29/23 at 3:00 PM and 11/30/23 at 10:00 AM. The plan lacked documentation of the names and contact information of Staff, patient’s physicians and contracted providers. 2. During an interview with the Acting Administrator/Agency Manager on 11/30/23 at 11:00 AM, the above findings were confirmed.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on clinical record review, home visit observation and Staff interview, it was determined that the Agency failed to ensure that Staff provided care as ordered by the physician. This was found in 2 of 7 (Pts. # 3 and 4) clinical records reviewed. 2. Patient #4, was admitted to the Home Health Services on 05/11/23 with the Diagnoses: Primary General Osteoarthritis and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 11/28/23. The Physician orders dated 09/12/23 included orders for the SN to notify the physician of blood glucose greater than 250 or less than 70 with the frequency of 1 time a week for 9 weeks. The SN did not assess the patient’s blood glucose for the entire 9 week-certification, as ordered by the physician. 3. The findings were confirmed during the interview with the Acting Administrator / Clinical Manager, on 11/29/23 between 2:00 PM and 3:15 PM. Findings include: 1. Patient #3 was admitted to Home Health Services on 06/22/23 with Diagnoses of Peripheral Vascular Disease, Essential Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/29/23. The signed order effective 08/21/23 and 10/20/23, included orders for Discipline and Treatment to notify physician for “….Pain level….and Blood sugar: fasting…Blood sugar…Random….” The Skilled Nursing note dated 10/05/23, lacked a pain and diabetes assessment. The following Skilled Nursing notes dated 10/26/23, 11/02/23, 11/09/23 and 11/16/23, lacked a diabetes assessment. A home visit was conducted with Employee #3 (Licensed Practical Nurse) on 11/29/23 at 1:00 PM, it was observed, there was no diabetic assessment done.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined the Agency failed to ensure the coordination of care. This was found in 1 of 7 (Pt. #7) clinical records reviewed. Findings include: 1. Patient #7, was admitted to the Home Health Services on 01/24/23 with the Diagnoses of “Primary Hypertension and Type 2 Diabetes.” The clinical record was reviewed on 11/28/23 and lacked the required coordination for the Aide’s last visit to be conducted prior to the Patient’s discharge from the Agency. The record included a discharge visit by the RN dated 09/19/23 that ended at 9:45 AM. The record included an Aide visit note dated 09/19/23 from 10:00 AM to 12:00 PM, (after the Agency’s discharge). 2. The above findings were confirmed during the interview with the Acting Administrator/ Agency Manager on 11/30/23 between11:00 AM and 12:00 PM.”

“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 review of clinical records and Staff interview, it was determined that the Agency failed to ensure that the clinical records were complete and accurate. This was found in 3 of 7 (Pts. #3, 5 and 4) clinical records reviewed. 3. Patient #4, was admitted to the Home Health Services on 05/11/23 with the Diagnoses: Primary General Osteoarthritis and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 11/28/23. The SN visit notes were incomplete. The record lacked the SN visit notes after 11/13/23, as required by the State. The SN failed to document the assessments of vitals signs of 11/13/23 in the vital sign chart. 4.The Illinois Administrative Code 245.200 h) 1 A-G h) “Clinical Records” was reviewed on 11/30/23 at 11:00 AM and required “ Signed and dated clinical notes for each contact that are written the day of service and incorporated into the patient’s clinical record at least weekly”. 5. The above findings were confirmed during the interview with the Acting Administrator/ Agency Manager on 11/30/23 between11:00 AM and 12:00 PM. Findings include: 1. Patient #3 was admitted to Home Health Services on 06/22/23 with Diagnoses: Peripheral Vascular Disease, Essential Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/29/23. The SN visit note dated 11/23/23 (week 11/19/23 to 11/25/23) was incomplete and lacked current assessments. 2. Patient #5 was admitted to Home Health Services on 06/23/23 with Diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery without Angina pectoris and Hypertension. The clinical record was reviewed on 11/29/23. The SN visit note dated 11/24/23 (week of 11/19/23 to 11/25/23 was incomplete and and lacked current assessments.”