Chicago Professional Healthcare, Inc.

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, the Agency failed to ensure the Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Plan as required. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 06/18/26. The Plan included tabletop exercises for the year 2023 Blizzard, 2024 Workplace Violence, 2025 Thunderstorm and 2026 Tornado. The Plan lacked documentation that the Agency activated its Emergency Preparedness plan for an actual emergency or conducted/participated in full-scale or facility-based exercises, as required. 2. During a staff interview with the Administrator and Consultant on 06/18/26 at 10:30 AM, the Administrator confirmed the above findings.”

“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 58 of 121 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 06/01/25 to 05/31/26, was reviewed on 06/18/26. The report documented 58 of 121 (47.93%) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator on 06/18/26 at 9:30 AM, the Administrator confirmed the above findings.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on home visit observation, Agency policy review and staff interview, in 1 of 3 (Pt. #1) home visits, the Agency failed to ensure infection control measures were observed to prevent the potential for cross-contamination, as per Agency policy. Findings include: 1. Pt. #1 was admitted for Home Health Services on 04/15/26 with the Diagnoses of but not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 06/16/26. A home visit for Pt. #1 was conducted with the Employee #7 (visiting RN) on 06/16/26 at 3:00 PM. It was observed that Employee #7 put the bag on top of the Pt’s bed without a barrier. An interview was conducted with Employee #7 on 06/16/26 at 3:20 PM, Employee #7 stated that typically a plastic bag is used as a barrier before setting the bag down. During the same interview, Employee #7 confirmed that no barrier was used. 2. The Agency policy titled: “Nursing Bag Technique Procedure” was reviewed on 06/17/26 and required: “…. Procedure: 3. Place the bag in a clean area, preferable on a wooden table. If a clean area cannot be found, the bag should always be placed on something like a newspaper to avoid contaminating the outside of the bag. Do not place your bag on stuffed furniture….” 3.During an interview with the Administrator, Director of Nursing, Consultant and Intern on 06/16/26 at 2:55 PM, the Administrative staff confirmed the above findings.”

“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 review of the Agency’s Pt. admission folder, review of clinical records, observation during home visit and staff interviews, in 3 of 7 (Pts. # 1, 2 and 3) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. Findings include: 1. During the entrance interview with the Administrator, on 06/15/26 at 1:30 PM, the Administrator presented the Department letter of acknowledgment for a change in Administrator dated February 2, 2026. 2. The Agency’s Pt. admission folder was reviewed on 06/16/25. The folder lacked the current Administrator’s name to file a complaint and/or grievance. 3. The following home visits were conducted on 06/16/25: Pt. #1. SOC 04/15/26 Pt. #2. SOC 04/20/26 Pt. #3. SOC 04/08/26 During the home visits, the Pt. admission folder were observed, and lacked the name of the current Administrator. 4. The clinical records of the following Pts. were reviewed from 06/16/26 to 06/17/26: Pt. #1 SOC 04/15/26 Pt. #2 SOC 04/20/26 Pt. #3 SOC 04/08/26 The clinical records lacked documentation that the Pt./patient’s representative was provided the name of the current Administrator to file a complaint or grievance. 5. During an interview with the Administrator, Director of Nursing, Consultant and Intern on 06/17/26 between 1:15 PM to 2:55 PM, the Administrative staff confirmed the above findings.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on clinical record reviews, home visit observation and staff interview, in 6 of 7 (Pts. # 1, 2, 3, 4, 5 and 6) clinical records reviewed, the Agency failed to ensure Pts./ Pts. representative were informed in advance the disciplines to provide care/service and frequency of visits provided by each discipline. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 06/16/26. The admission folder included a Patient handbook with a form titled: “Initial Care Planning” for the admitting clinician to document the proposed services / disciplines and their visit frequencies. 2. The following clinical records were reviewed from 06/16/26 to 06/17/26 and lacked documentation of the services/disciplines and proposed visit frequencies: Pt. #1 Start of Care (SOC) 04/15/26 Pt. #2 SOC 04/20/26 Pt. #3 SOC 04/08/26 Pt. #4 SOC 03/04/25 Pt. #5 SOC 05/13/25 Pt. #6 SOC 12/19/23 3. The following home visits were conducted on 06/16/26 for Pts. #1 at 11:00 AM, Pt. #2 at 12: 00 PM and Pt. #3 at 3:00 PM. During the home visits, the Pt. admission folders were observed and lacked documentation that the Pt. / representative was notified of the discipline (s) to provide service, and the proposed visit frequency in writing. 4. During interviews with the Administrator, Director of Nursing, Consultant and Intern on 06/17/26 between 1:15 PM to 2:55 PM , the Administrative staff confirmed that the Pts. were given the same Pt. admission documents at the Start of Care. During the same interview, 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 record review and staff interviews, in 2 of 7 (Pts. #1 and 5) clinical records reviewed, the Agency failed to ensure that Physician orders in the Plans of Care were followed. Findings include: 1.Pt. #1 was admitted for Home Health Services on 04/15/26 with the Diagnoses of but not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 06/16/26. The POC effective 04/15/26 to 06/13/26 included;” Physical therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence….” As of 06/16/26, the clinical record lacked documentation to show that Physical therapy services were provided or modification of Physician orders in the Plan of Care. 2.Pt. #5 was admitted for Home Health Services on 05/13/25 with the Diagnoses of but not limited to Essential (Primary) Hypertension. The closed clinical record was reviewed on 06/16/26. The POC effective 05/13/25 to 07/11/25, that required: “….Notify Physician of vital sign parameters out of range:….Systolic Blood Pressure: greater than (>) 160 mmHg less than (<) 90 mmHg….” The SN note dated 07/02/26, included a Systolic Blood Pressure reading of 170 and lacked a Physician notification for Systolic Blood pressure falling outside parameters. 3.During an interview with the Administrator, Director of Nursing, Consultant and Intern on 06/16/26 at 2:55 PM, the Administrative staff confirmed the above findings.”