Best Illinois Home Health Care, 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 the review of the Error Summary report and Staff interview, it was determined in 126 of 239 reports submitted for the last 12 months, the Agency failed to submit timely reports, resulting in a warning. Finding include: 1. The Error Summary report for 07/01/23 -06/3024, was reviewed on 07/02/24 at 9:30 AM. The report included error # -3330 for 126 of 239 submissions, 52.72 % of the reports submitted were more than 30 days after completing the assessment. 2. During an interview with the Administrator on 07/03/24 at 10:00 AM, the Administrator confirmed that the error occurred.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 4 of 7 (Pts. #3, 4, 1 and 6) clinical records reviewed, the clinical records were not completed as required. 3. Pt. #1 was admitted to Home Health Services on 04/02/24 with Diagnosis of: Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 07/02/24. The Advance Beneficiary Notice of Non-Coverage (ABN) form signed by the Pt. and dated 04/02/24, lacked complete information on what is not covered, as the form required. The Vaccine agreement form for Pt. #1, documented that Pt. #1 was not interested in receiving both Influenza vaccine and Pneumonia vaccine but lacked information on reason for not receiving vaccine, as the form required. The clinical record contained an Aide Care plan for episode 06/01/24 to 07/30/24, that was incomplete. The Aide care plan lacked the frequency for the vital signs. 4. Pt. # 6 was admitted to Home Health Services on 02/06/24 with Diagnosis of: Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 07/02/24. The Advance Beneficiary Notice of Non-Coverage (ABN) form signed by the Pt. and dated 02/06/24, lacked complete information on what is not covered, as the form required. 5. The Agency policy titled: “….Advance Beneficiary Notice (ABN)” was reviewed on 07/03/24 and required: “….7. Agency must complete Blank (F) to ensure the patient has all available information decision about whether or not to obtain potentially non-covered services….” 6. During an interview with the Administrator and Director of Nursing on 07/03/24 between 10:00 AM to 11:45 AM, the Administrator confirmed the above findings. Findings include: 1.Pt. #3 was admitted to the Home Health Services on 02/12/24 with the Diagnosis of: Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 07/02/24. The clinical record contained a Aide care plan dated 06/10/24, that was incomplete. The Aide care plan lacked the frequency for the vitals signs. 2. Pt. #4 was admitted to the Home Health Services on 05/04/24 with the Diagnosis of: Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 07/02/24. The clinical record contained a Aide care plan dated 06/28/24, that was incomplete. The Aide care plan lacked the frequency for the vitals signs.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 5 of 7 (Pts. #4, 5, 1, 2 and 6) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 3. Pt. #1 was admitted to Home Health Services on 04/02/24 with Diagnosis of: Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 07/02/24. The POC effective 06/11/24 to 07/30/24, required: “….Notify Physician:….Pain level….Blood sugar….” The SN note dated 06/21/24, lacked a pain assessment, as ordered. The SN note dated 06/28/24, lacked a Blood sugar assessment, as ordered. 4. Pt. #2 was admitted to Home Health Services on 02/15/24 with Diagnosis of: Essential (Primary)Hypertension. The clinical record was reviewed on 07/02/24. The PsOC effective 04/15/24 to 06/13/24 and 06/14/24 to 08/12/24, required: “….Notify Physician: Systolic BP: Greater Than (>)150….” The SN note dated 06/07/24, documented BP of 152/88. There was no documentation or communication that Physician was notified of BP out of range as ordered. 5. Pt. # 6 was admitted to Home Health Services on 02/06/24 with Diagnosis of: Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 07/02/24. The POC effective 02/06/24 to 04/05/24, required: “…. OT frequency: evaluation, and, treatment”. The record lacked an OT evaluation. There was no modification of orders or communication as to why OT evaluation was not done, as ordered. 6. During interviews with the Administrator and Director of Nursing on 07/03/24 between 10:00 AM to 11:45 AM, both confirmed the above findings. Findings include: Pt. #4 was admitted to the Home Health Services on 05/04/24 with the Diagnosis of: Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 07/02/24. The clinical record contained a POC dated 05/04/24, that required SN to assess the patient’s pain 1 time a week for 9 weeks. The clinical record lacked the pain assessment by the SN for 05/18/24, 06/05/24 and 06/12/24. 2. Pt. #5 was admitted to the Home Health Services on 07/15/23 with the Diagnosis of: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 07/02/24. The clinical record contained a POC dated 05/10/24, that required SN to assess the patient 1 time a week for 1 week and 2 times a week 8 weeks. The clinical record lacked the SN assessment for 06/25/24 and 06/29/24.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of clinical records and Staff interview, it was determined that in 1 of 2 (Pt. #6) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the discharge summary. Findings include: 1. Pt. #6 was admitted to Home Health Services on 02/06/24 with Diagnosis of: Aftercare Following Joint Replacement Surgery. The clinical record was reviewed on 07/02/24. The discharge summary dated 03/22/24, lacked documentation that the discharge summary was sent to the Physician. 2. During an interview with the Administrator and Director of Nursing on 07/03/24 at 11:00AM , the Administrator confirmed the above findings.”