S&C QCOR HHA 2567s
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HHAs 2567s
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Time Interval

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Provider Characteristics

Use these filters if you want to limit the report to providers that have certain characteristics. To select more than one option, hold down the Ctrl (individual point-and-click) OR Shift keys (select through a range) while you click on the additional desired option(s).

Survey Type & Deficiency Tags

Use these filters if you want to limit the reports to providers on specific survey types, or to reports that were cited for specific HHA deficiency tags and tag types. To select more than one option, hold down the Ctrl (individual point-and-click) OR Shift keys (select through a range) while you click on the additional desired option(s).

CCN and Facility Name

Use these filters if you know the name (or partial name) of the facility you are searching for, or the CMS Certification Number (CCN) for the facility you are searching for.

Other Survey Characteristics

Select one of the options below to filter by surveys that cite deficiencies or by surveys that are deficiency-free. By default, only surveys that cite deficiencies are displayed. Selecting "All" displays all surveys.

CMS Certification Number Facility Name Address City State CMS Region Date of CMS Survey Survey Event ID Survey Type Statement of Deficiencies Report
▼ 157442 Community Hca, Inc 4640 W Jefferson Blvd Fort Wayne IN 5 (Chicago) 01/10/2022 381CB-H1 Complaint, Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0570 Care planning, coordination, quality of care Condition
G0750 Home health aide services Condition
G0544 Update of the comprehensive assessment Standard
G0572 Plan of care Standard
G0798 Home health aide assignments and duties Standard
G0942 Governing body Standard
G0430 Be free from abuse Element
G0484 Document complaint and resolution Element
G0574 Plan of care must include the following Element
G0706 Interdisciplinary assessment of the patient Element
G0800 Services provided by HH aide Element
G0804 Aides are members of interdisciplinary team Element
G0810 If concern identified, direct observation Element
▼ 157442 Community Hca, Inc 4640 W Jefferson Blvd Fort Wayne IN 5 (Chicago) 07/08/2020 TYYO11 Complaint, Focused Infection Control, Other-Fed
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0682 Infection Prevention Standard
G0684 Infection control Standard
G0686 Infection control education Standard
G0484 Document complaint and resolution Element
▼ 157442 Community Hca, Inc 4640 W Jefferson Blvd Fort Wayne IN 5 (Chicago) 04/15/2019 MMO111 Complaint, Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
E0004 Develop EP Plan, Review and Update Annually Standard
G0572 Plan of care Standard
G0682 Infection Prevention Standard
G0798 Home health aide assignments and duties Standard
G0536 A review of all current medications Element
G0954 Ensures qualified pre-designated person Element
G0972 Report all branch locations to SA Element
▼ 157445 Gibson General Hospital Inc 1808 Sherman Dr Princeton IN 5 (Chicago) 08/14/2023 60468-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
E0024 Policies/Procedures-Volunteers and Staffing Standard
G0572 Plan of care Standard
G0682 Infection Prevention Standard
G0574 Plan of care must include the following Element
G0576 All orders recorded in plan of care Element
▼ 157445 Gibson General Hospital Inc 1808 Sherman Dr Princeton IN 5 (Chicago) 12/04/2020 X90411 Focused Infection Control, Other-Fed, Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0572 Plan of care Standard
G0682 Infection Prevention Standard
G0684 Infection control Standard
G0942 Governing body Standard
G0944 Administrator must: Standard
G1024 Authentication Standard
G0412 Written notice of patient's rights Element
G0440 Payment from federally funded programs Element
G0574 Plan of care must include the following Element
G0616 Patient medication schedule/instructions Element
G0716 Preparing clinical notes Element
G0856 Officer, a director, agent, managing employee Element
G0978 Must have a written agreement Element
▼ 157445 Gibson General Hospital Inc 1808 Sherman Dr Princeton IN 5 (Chicago) 01/08/2018 DH4P11 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0121 COMPLIANCE W/ ACCEPTED PROFESSIONAL STD Standard
G0143 COORDINATION OF PATIENT SERVICES Standard
G0158 ACCEPTANCE OF PATIENTS, POC, MED SUPER Standard
G0334 COMPLETION OF THE COMPREHENSIVE ASSESSMENT Standard
G0341 UPDATE OF THE COMPREHENSIVE ASSESSMENT Standard
▼ 157452 Zoe Inc 621 Broadway New Haven IN 5 (Chicago) 03/24/2026 22BF26-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0682 Infection Prevention Standard
G0768 Competency evaluation Standard
G0574 Plan of care must include the following Element
▼ 157452 Zoe Inc 621 Broadway New Haven IN 5 (Chicago) 09/22/2023 60A11-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0544 Update of the comprehensive assessment Standard
G0682 Infection Prevention Standard
G0768 Competency evaluation Standard
G1030 Retrieval of records Standard
G0446 Contact info Federal/State-funded entities Element
G0574 Plan of care must include the following Element
▼ 157452 Zoe Inc 621 Broadway New Haven IN 5 (Chicago) 10/09/2020 P9Y811 Focused Infection Control, Other-Fed, Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0572 Plan of care Standard
G1024 Authentication Standard
G0520 5 calendar days after start of care Element
G0574 Plan of care must include the following Element
G0590 Promptly alert relevant physician of changes Element
G0606 Integrate all services Element
G0800 Services provided by HH aide Element
▼ 157452 Zoe Inc 621 Broadway New Haven IN 5 (Chicago) 08/08/2018 0H4411 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
E0030 Names and Contact Information Standard
G0720 Participate in the HHA's QAPI program; Element
G0722 Participate in HHA-sponsored in-service Element
G0952 Ensure that HHA employs qualified personnel Element