Safe Life Home Health Care, LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, staff interview, and record review, the Home Health Agency failed to ensure physicians’ orders were obtained and/or followed to meet the needs of the patient . This has the potential to affect all patients receiving services. Findings include: In 4 of 17 clinical records reviewed (Pts. #6, 8, 12 and 15) the Agency failed to ensure care was provided in accordance with physicians’ orders. (580) The cumulative effect of these systematic practices may have the potential to affect all services and care provided to patients.”

“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 the review of the Error Summary report and staff interview, for 879 of 3448 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days after the assessment was completed, which resulted in a warning. Findings include: 1. The Error Summary report for 06/05/25 to 05/04/26 was reviewed on 08/03/26 at 11:30 AM. The report included “Error # -3330” for 879 of 3448 late submissions, which was 25.49 % of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Administrator and the Chief Clinical Officer on 08/06/26 at 4:00 PM, it was confirmed the error occurred.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical records review, and staff interviews, it was determined that in 17 of 17 (Pts. # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) clinical records reviewed, the Agency failed to provide the complete information to file a concern or complaint with the Illinois Department of Public Health Central Complaint Registry Hotline. Findings include: 1.The Agency’s Pt. admission folder was reviewed on 08/03/26. The folder included the “Complaint/Grievance Procedure” form which included the following information: “You may also contact and report to Illinois Home Health Hotline (24 hours on call) at, 1-800-252-4343”. 2. The clinical records of the following Pts. were reviewed from 08/04/25 to 08/06/26. Pt. #1. SOC 07/21/26 Pt. received SN, PT and OT services. Pt. #2. SOC 06/18/26 Pt. received SN and PT services. Pt. #3. SOC 06/08/26 Pt. received SN services. Pt. #4. SOC 04/09/26 Pt. received SN and PT services. Pt. #5. SOC 07/21/26 Pt. received SN, PT and OT services. Pt. #6. SOC 07/27/26 Pt. received SN and PT services. Pt. #7. SOC 05/11/26 Pt. received SN, PT and OT services. Pt. #8. SOC 05/03/26 Pt. received SN and HHA services. Pt. #9. SOC 06/15/26 Pt. received SN, PT and OT services. Pt. #10. SOC 02/21/26 Pt. received SN and PT services. Pt. #11. SOC 07/08/26 Pt. received SN, PT, OT and MSW services. Pt. #12. SOC 01/15/26 Pt. received SN and ST services. Pt. #13. SOC 09/29/25 Pt. received SN, PT, OT, HHA and MSW services. Pt. #14. SOC 09/06/25 Pt. received SN, PT and OT services. Pt. #15. SOC 09/08/25 Pt. received SN and PT services. Pt. #16. SOC 06/27/25 Pt. received SN, PT, OT services. Pt. #17. SOC 01/31/26 Pt. received PT and OT services. 3. The following home visits were conducted on 08/03/26, 08/04/26 and 08/05/26: Pt. #1. SOC 07/21/26 Pt. received SN, PT and OT services. Pt. #2. SOC 06/18/26 Pt. received SN and PT services. Pt. #3. SOC 06/08/26 Pt. received SN services. Pt. #4. SOC 04/09/26 Pt. received SN and PT services. Pt. #5. SOC 07/21/26 Pt. received SN, PT and OT services. Pt. #6. SOC 07/27/26 Pt. received SN and PT services. Pt. #7. SOC 05/11/26 Pt. received SN, PT and OT services. During the visits of Pts. #1, 2, 3, 4, 5, 6, and 7 the patient’s admission folder was observed, and lacked complete information indicating the Pt./representative were provided clarifying information to file a complaint with the Illinois Department of Public Health. 4. During an interview with the Administrator and Chief Clinical Officer on 08/06/26 at 2:30 PM, the administrative team 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 observation during a home visit, clinical record reviews, and staff interviews, for 4 of 17 patients (Pts. #6, #8, #15, and #12), the Agency failed to ensure physician orders were obtained or followed. Pt. #12 was admitted to home health on 01/15/26 with the diagnosis of Enterostomy Malfunction. The clinical record was reviewed on 08/04/26. The record included a POC for the certification period of 01/15/26 to 03/15/26, which required: “wound care: cleanse wounds with wound cleanser, apply Santyl, Calcium Alginate, and apply border foam dressing. Perform dressing change daily and as needed if dressing becomes soiled, saturated, or dislodged.” The clinical record lacked documentation that wound care was performed on 01/17/26, 01/20/26, and 01/22/26.Findings include: 1. Pt. #6 was admitted to home health on 07/27/26 with the diagnosis of “Gastrointestinal hemorrhage.” A home visit was conducted on 08/05/26 with the Home Health Aide. During the home visit, Pt. #6 was prepared for a bed bath. Pt. #6 stated the right heel was sore. The right heel was covered with a cushioned pad, which was removed by family prior to the bed bath. The right heel had a hard, thick, black layer of tissue. The clinical record was reviewed on 08/06/26. The record included a POC effective 07/27/26 that required: “SN to assess, instruct, and perform wound care to pressure ulcer of right heel, unstageable: Paint with betadine, allow to dry, keep open to air, and do not cover with a dressing… caregiver to perform wound care on non-SN visit days.” The SN notes dated 07/30/26 and 08/03/26 also included the following documentation: “Paint with betadine, allow to dry, keep open to air. Due to drainage and pain with touching, lightly covered with 4x4 gauze and paper tape. Call out to PCP (Primary Care Physician) ... She is out of the office and covering physician has only done a telehealth visit. Requested from agency to please add visiting MD and wound care consult, as it does not seem this is the appropriate treatment due to pain and discharge.” As of 08/06/26, there no new wound care orders. The wound care provided was not in accordance with the physician/practitioner’s orders. 2. Pt. #8 was admitted to home health on 05/03/26 with the diagnosis of Infection following a procedure, superficial incisional surgical site, subsequent encounter. The clinical record was reviewed on 08/04/26. The record included a POC for the certification period 05/03/26 to 07/01/26, which required: “SN to assess/monitor weights and edema QV (every visit) or Q week (every week).” The SN visit notes for 06/03/26, 06/05/26, 06/10/26, 06/12/26, 06/16/26, 06/20/26, and 06/25/26 lacked documentation of the patient’s weight. The POC also required clinicians to perform wound care three times a week and as needed. The clinical record lacked documentation that wound care was performed on 06/03/26 and 06/05/26. A physician order dated 07/20/26 required: “Wound Care: Discontinue previous order of wound care to left chest. Clean left chest wound with normal saline, apply Alginate AG (silver), cover with foam, ABD pad, and secure with tape 2x/week.” The SN visit notes for 07/22/26, 07/25/26, 07/27/26, 07/29/26, and 07/31/26 documented instead: “Treatment Performed This Visit: Wound cleansed with NSS (normal saline solution), applied calcium alginate, foam, ABD, secured with tape.” The wound care provided was not in accordance with the physician/practitioner’s orders. 3. Pt. #15 was admitted to home health on 09/08/25 with the diagnosis of Third‑degree burn. The clinical record was reviewed on 08/06/26. The record included a POC for the certification period 09/08/25 to 11/06/25, which required: “Orders and Treatments: MSW evaluation and treatment – week of 09/28/25.” The clinical record lacked documentation that an MSW evaluation and treatment were provided. The POC also required the SN to perform wound care on visit days and the patient/caregiver to perform wound care on non-SN visit days. The SN note dated 09/16/25 lacked documentation that wound care was provided. The physician’s orders were not followed. 4. Pt. #12 was admitted to home health on 01/15/26 with the diagnosis of Enterostomy Malfunction. The clinical record was reviewed on 08/04/26. The record included a POC for the certification period of 01/15/26 to 03/15/26, which required: “wound care: cleanse wounds with wound cleanser, apply Santyl, Calcium Alginate, and apply border foam dressing. Perform dressing change daily and as needed if dressing becomes soiled, saturated, or dislodged.” The clinical record lacked documentation that wound care was performed on 01/17/26, 01/20/26, and 01/22/26.”

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on clinical records review, policy review, and staff interviews the Agency failed to ensure staff protected the rights of the patients. This has the potential to affect all patient outcomes. Findings: 1. In 3 of 4 clinical records reviewed (Pts. #1, #2, and #3) the Agency failed to ensure complaints and grievances were followed up and resolved. (432) 2. in 1 of 4 (Pt. #3) clinical records reviewed, the Agency failed to ensure the Pt. and/or the Pt.’s representative was informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. (434) The cumulative effect of these systemic practices resulted in Agency’s inability to provide and coordinate care effectively to ensure Pts. received quality care and services needed and ordered in the PsOC.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on clinical records review, policy review, and staff interviews the Agency failed to ensure staff provided care in accordance with physicians’ orders and coordinated care with health care team. This has the potential to affect all patient outcomes. Findings: 1. In 3 of 4 clinical records reviewed (Pts. #1, #2, and #4) the Agency failed to ensure care was provided in accordance with physicians’ orders. (580) 2. In 1 of 4 clinical records reviewed (Pt. #4), the Agency failed to ensure change in condition was reported to the physician. (590) The cumulative effect of these systemic practices resulted in Agency’s inability to provide and coordinate care effectively to ensure Pts. received quality care and services needed and ordered in the PsOC.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy review, document review, and staff interviews, for 3 of 3 clinical records reviewed (Pts. #1, #2, and #3) the Agency failed to ensure complaints and grievances were followed up and resolved. Findings include: 1. Pt. #1 was admitted to home health on 01/22/26 with the diagnosis of Encounter for change or removal of surgical wound dressing. A review of the Agency’s complaint log included an entry dated 04/21/26 indicating the Pt.’s family requested reassignment of an RN. The Agency was unable to provide an alternate RN. and the family. During an interview with Employee (E) #2 (Chief Clinical Officer) on 07/13/26, E #2 indicated no other RN was available in the area. The Agency would typically refer patients to other Agencies able to provide staff. There was no documentation verifying that alternative staffing options were explored or that referrals to other Agencies were made. No evidence of complaint resolution was provided. 2. Pt. #2 was admitted with the diagnosis of Unspecified open wound of right lower leg. The clinical record was reviewed on 07/13/26. The Agency’s complaint log included documentation that on 02/09/26, the Pt. reported wound care instructions were not fully provided during a nursing visit and requested written instructions. The complaint log indicated that the RN provided education and written instructions; however, review of SN notes dated 02/09/26, 02/11/26, and 02/13/26 showed no documentation of written wound care instructions provided. The Agency failed to provide documentation verifying that the complaint was investigated or resolved. 3. Pt. #3 was admitted on 12/29/25 with the diagnosis of Urinary Tract Infection. The record review on 07/13/26 found a complaint logged on 01/08/26 in which the patient stated they were unsure which disciplines were visiting and requested a written weekly schedule. The “Admission Consent” form signed at SOC lacked documentation of frequency of visits of the SN, Speech Therapist, Home Health Aide, Physical Therapist, and Occupational Therapist. As of 07/13/26, the section designated for discipline frequencies remained blank. No additional documentation was provided to demonstrate follow-up or resolution of the complaint. 4. A review of the Agency’s policy titled “Complaint Resolution” on 07/13/26 has the following requirements: “Agency will investigate complaints…Document both the existence of the complaint and the resolution of the complaint…The patient will receive a response within three (3) business days…” The Agency failed to follow its own policy regarding documentation and resolution of complaint. 5. Interviews with the Administrator (E#1) and E #2 (Chief Clinical Officer) were conducted on 07/13/26 at 5:30 PM. E#2 stated that follow-up was completed for complaints/grievances but was not documented. The findings above were confirmed during the interview.”

“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 review of the complaint log, Agency’s Pt. admission folder, document review, clinical records, and staff interviews, in 1 of 4 (Pt. #3) clinical records reviewed, the Agency failed to ensure the Pt. and/or the Pt.’s representative was informed in writing of the frequency of visits provided by each discipline. Findings include: 1. The Agency’s complaint log was reviewed on 07/13/26 and included documentation that Pt. #3 filed a complaint on 01/08/26: “Patient was unsure of which disciplines were visiting and when and requested a written weekly schedule…” 2. Pt. #3 was admitted on 12/29/25 with the diagnosis of Urinary tract infection. The clinical record was reviewed on 07/13/26. The record included the form titled, “Admission Consent” completed by the RN, signed by the Patient #3, and dated with the SOC date. The form lacked documentation that the Pt. was notified of frequency of visits of each discipline (Skilled Nurse, Home Health Aide, Physical Therapist, Speech Therapist, and Occupational Therapist) providing services, prior to providing patient care and services. 3. The record did not include documentation that the Agency provided the Pt. with a written weekly schedule as requested. 4. The Patient Bill of Rights and Responsibilities require, “...Participate in, be informed and consent or refuse care in advance...with respect to the disciplines that will furnish the care...the frequency of visits...” 5. During an interview with the Administrator and Chief Clinical Officer on 07/13/26 at 5:30 PM, it was stated that the frequency of the visits of the disciplines should be discussed with the patients at the SOC. During the same interview, the above findings were confirmed.”

“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 reviews, Agency policy review, and staff interviews, for 3 of 4 records reviewed (Pts. #1, 2 and 4) the Agency failed to ensure care was provided in accordance with physicians’ orders. Findings include: 1. Pt. #1 was admitted to home health on 01/22/26 with the diagnosis of Encounter for change or removal of surgical wound dressing. The clinical record was reviewed on 07/13/26. The record indicated that the Agency conducted the initial comprehensive assessment on 01/22/26. At the start of care, the SN documented that Pt. #1 did not have a pressure ulcer and had at least one observable surgical wound. The assessment included the following wound treatment as per physician order: “Performed wound care using aseptic technique. Soaked with Vashe, cleansed with saline, patted dry, applied Aquacel Ag (silver) to the incision lines, applied four-by-four ABD pad to stump and posterior heel. Wrapped with Kerlix and Ace bandage with mild compression, applied four-inch [rebrel] to foot just underneath for well-padded posterior splint. Labeled with date, time, and number of elements.“ The clinical record included a physician progress note dated 01/26/26: “Returns to clinic to follow up ... Since discharge from hospital, ... reports having 1 dressing change last Thursday/Friday and nurse did not have appropriate supplies; therefore, a dry dressing was applied. There is no ‘Webril’ (cotton undercast padding) to the splint dressing; Skin: new pressure injury to posterior heel approximately 2.5 centimeters in diameter...On examination today, padded posterior splint had been applied at previous home health wound care visit, which unfortunately developed a pressure injury to the posterior left heel…” According to the physician note, Pt. #1 developed a pressure ulcer directly as a result of the non-adherence to physician provided instructions by the home health nurse. The physician notes also included wound care orders and frequency—once weekly on Thursday or Friday—and listed medications and treatments required. Review of the clinical records showed that SN notes dated 02/01/26 (week 02/01/26 to 02/07/26), 02/10/26 and 02/12/26 (week 02/08/26 to 02/14/26), 02/17/26 and 02/19/26 (week 02/15/26 to 02/21/26), 02/24/26 and 02/26/26 (week 02/22/26 to 02/28/26), 03/03/26 and 03/05/26 (week 03/01/26 to 03/07/26) and 03/12/26, and 03/14/26 (week 03/08/26 to 03/14/26) lacked any documentation of weekly wound care provided as ordered. SN failed to follow the physician’s orders. 2. Pt. #2 was admitted to home health with the diagnosis of Unspecified open wound of right lower leg. The clinical record was reviewed on 07/13/26. The POC effective 06/02/26 included wound care orders: (Wound #2) Anterior left lower leg – clean with wound care solution, apply Medi-honey to wound bed, cover with Vaseline gauze, wrap. The SN note dated 06/05/26 documented treatment with Hydrogel and foam dressing. A physician order dated 06/08/26 included instructions for: (Wound #3) Right lower leg – cleanse with Vashe, apply Hydrofera Blue and silver hydrogel, cover with bordered foam. SN notes dated 06/10/26 and 06/12/26 included documentation of treatment with Hydrogel and foam dressing instead. SN failed to follow the physician’s orders. SN notes dated 06/24/26, 07/02/26, and 07/08/26 included documentation of vital signs outside POC parameters, requiring physician notification; however, the record lacked documentation of notification to the physician. On 06/24/26 the Pt.’s blood pressure was 83/60 in the right arm and 74/52 in the left arm, and the physician was to be informed when the systolic blood pressure was below 90. On 07/02/26, the Pt.’s pulse was 111 and the physician was to be informed for a pulse over 110. On 07/08/26, the Pt.’s blood pressure in the left arm was 80/56 and the physician was not informed. SN failed to follow the physician’s orders. 3. Pt. #4 was admitted to home health on 03/17/26 with the diagnosis of Pressure ulcer of right heel, stage III. The clinical record was reviewed on 07/13/26. On 05/08/26, the NP ordered to cleanse wound with wound cleanser, apply Honey Gel, cover with foam dressing, and secure with kerlix three times per week. On 05/12/26 the SN documented, “Treatment Performed This Visit…Applied mesalt cut to size. Secured with roll gauze and paper tape.” NP note on 05/15/26 stated, “Follow-up for right heel wound; continue home health wound care. Last week’s order was changed to Medi Honey instead of Mesalt. Today’s dressing contained Mesalt and no Medi Honey.” On 06/19/26, a new wound care order was received for the right heel, Omeza dressing and abdominal pads and left second toe, Medi Honey and silver calcium alginate. On 06/22/26, the SN note stated the right heel and left second toe had Medi Honey dressings applied. The wound care provided was not in accordance with the physician/NP’s orders. 4. Agency policies were reviewed on 07/13/26. The “Care Planning Process” policy requires: “Medications, services, and treatments are administered only as ordered by a physician or allowed practitioner.” The “Plan of Care and Physician/Practitioners Orders” policy requires: “20. Care and services will be provided according to physician/practitioner orders. Orders are current and updated.” The “Wound Care Management” policy requires documentation of the order followed, wound assessment and measurements, care and products used, packing in/out, patient response, education provided, and communication with the physician/practitioner. the Agency failed to follow their policies. 5. During an interview on 07/13/26 at 5:30 PM, the Administrator stated that Plans of Care and physician orders contained the most current orders and that services, care, and treatment must be followed. The Chief Clinical Officer stated that nurses should report vital signs outside of the parameter ranges and document all care provided. The Administrator and Chief Clinical Officer confirmed the above findings.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on a clinical record review, Agency policy review and staff interviews, for 1 of 4 clinical records reviewed (Pt. #4), the Agency failed to ensure the physician was notified regarding a change in the patient’s condition. Findings include: 1. Patient #4 was admitted to home health on 03/17/26 with a diagnosis of a stage III pressure ulcer of the right heel. The clinical record was reviewed on 07/13/26. The record included a SN note dated 06/01/26 with the documentation: “New onset wound to left second toe; MediHoney applied and secured with foam.” The SN visit notes lacked documentation that the physician or practitioner was notified of the newly identified wound on the left second toe. 2. The Agency policies required: “Plan of Care and Physician/Practitioners Orders: 15. The Agency must promptly alert the relevant physician/practitioner to any changes in the patient’s condition or needed that suggest that outcomes are not being achieved and or that the plan of care should be altered...28. Changes in the patient’s condition that require a change in the plan of care must be documented in the patient’s clinical record...” 3. During an interview conducted with the Chief Clinical Officer on 07/13/26 at 5:30 PM, it was stated that the physician should be notified of any change in a patient’s condition, including the onset of a new wound. During the same interview, the above finding was confirmed.”