Every finding on record at Franciscan Care Services, Inc.

Franciscan Healthcare Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

An unannounced complaint investigation and a recertification survey was completed at Franciscan Healthcare Home Health on 2/12/26. The allegation related to the complaint was unsubstantiated. The agency census was 15. No deficiencies were cited related to the complaint investigation.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure patient’s medication orders, on the Home Health Certification and Plan of Care (POC) and the medication profile (a real-time document used by the agency that lists the patient’s medication) were accurate and/or failed to identify discrepancies between medication lists to ensure to patient's physician has a current, accurate medication list to verify for 1 of 7 patient records reviewed (Patient 3). The census was 15. Findings are: A. Review of the agency policy and procedure titled, 740.047, Medication Administration, issued 09/1993, revealed: 1. All drugs and treatments ordered by the patient's physician are to be recorded in the clinical record... on the Plan of Care and the Medication Record (profile). 2. Medications are to be reviewed during each skilled nurse visit for compliance, medication errors, adverse effects and allergic reactions. B. Review of the agency policy and procedure titled, 740.050, Plan of Care and Treatment, issued 09/1993, revealed: 1. The patient's attending physician and the home care nurse develop the coordinated plan of care after the initial visit to the patient's home. 2. The original plan of care is sent to the attending physician for review, verification of orders and signature. Any revisions, additions or deletions are made prior to sending to the physician. C. Review of Patient 3's clinical record revealed: 1. The patient's start of care was 1/6/26. 2. The discharge instructions (information provided from the transferring facility to the home health agency at the time the patient is admitted for home health services), dated 1/5/26, included orders to discontinue the following medications: furosemide (a "water pill") 40 milligram (mg) tablets, take one tablet by mouth daily and losartan (a blood pressure medication) 25 mg, take one tablet by mouth daily. 3. The Home Health Care Certification and Plan of Care for the certification period of 1/6/26 through 3/6/26 (sent to the physician for review upon admission to the home health agency) included orders for furosemide 40 mg tablets, take one tablet by mouth daily and losartan 25 mg, take one tablet by mouth daily. 4. The Medication Profile as printed on 2/9/26 included orders for furosemide 40 mg tablets, take one tablet by mouth daily and losartan 25 mg, take one tablet by mouth daily. 5. There was no documentation in the clinical record that a discrepancy was identified between the patient's discharge instructions, the POC, and the Medication Profile, and no documentation the physician was notified of a discrepancy. D. During an interview of 2/11/26 at 3:30 PM, the RN Home Health Manager confirmed the agency failed to ensure Patient 3's POC and Medication Profile were accurate and failed to identify discrepancies between medication lists to ensure the patient's physician has a current, accurate medication list to verify.

St. Francis Home Health Care is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include information on the progress towards the patient and agency identified measurable outcomes and goals on the revised/updated plan of care for 1 of 1 patient records reviewed who had an updated plan of care (Patient 2). The census was 34. Findings are: A. Review of the agency policy and procedure titled, 740.050: Plan of Care and Treatment, last reviewed 2/2022, revealed the policy does not identify the requirement to include information on the patient's progress towards the patient and agency identified measurable outcomes and goals on the revised/updated plan of care. B. Review of Patient 2's clinical record revealed: 1. The start of care was 2/25/22. 2. The updated Home Health Certification and Plan of Care for the certification period of 8/24/22 through 10/22/22 and 10/23/22 through 12/21/22 did not include information on the progress towards the patient and agency identified measurable outcomes and goals. C. During an interview on 11/2/22 at 2:30 PM, the Manager of Home Health (Clinical Manager) (CM) revealed and confirmed: 1. The agency policy and procedure did not include the requirement include information on the progress towards the patient and agency identified measurable outcomes and goals on the revised/updated plan of care. 2. The updated Home Health Certification and Plan of Care for the certification period of 8/24/22 through 10/22/22 and 10/23/22 through 12/21/22 did not include information on the progress towards the patient and agency identified measurable outcomes and goals. 3. This failure extended to all current agency patients who have a revised/updated plan of care as it is not the practice of the agency to include information on the patients progress towards the patient and agency identified measurable outcomes and goals on the revised/updated plan of care.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, the observation of the provision of cares, and staff interview, the agency failed to include patient specific interventions and instructions for the services provided by the home health aide on the home health aide plan of care developed by the skilled nurse for 4 of 5 patient records reviewed who received home health aide services (Patient 1, 3, 4, and 5), and failed to have a policy and procedure in place for the development of the home health aide plan of care. The census was 34. Findings are: A. Review of the agency policy and procedures revealed the agency did not have a policy and procedure for developing an individualized home health aide plan of care. B. Review of Patient 1's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/26/22 through 12/24/22 included: a. Orders for home health aide (HHA) 1 time per week for 1 week, then 2 times per week for 8 weeks beginning week of 10/26/22. b. Patient supplies included a wheeled (rolling) walker and shower bench. c. A primary diagnosis of aftercare following joint replacement surgery (left knee replacement). d. Medications include warfarin (a medication used to help prevent clots from forming-it can cause serious bleeding, including unusual pain/swelling/discomfort, unusual/easy bruising, prolonged bleeding from cuts or gums, persistent/frequent, nosebleeds, pink/dark urine, vomit that is bloody or looks like coffee grounds, bloody/black/tarry stools. e. The left knee incision has a dressing covering the incision. 2. The Home Health Aide Care Plan (HHA POC) (a written document meant to provide direction and instruction for the HHA to provide care and services to the patient) revealed: a. Multiple generic devices for ambulation versus the actual device to be used with ambulation (the wheeled walker). b. There was no information regarding the medication warfarin and signs of bleeding to report to the nurse. c. There was no information regarding the dressing and incision to the patient's left knee. d. There was no direction for the HHA to provide a sponge bath until an appropriate shower bench was available. 3. An Aide Visit Note dated 10/27/22 revealed the aide provided a sponge bath to the patient instead of the assigned shower due to the patient did not have a correct shower chair. C. During the observation of the provision of cares by the Occupation Therapist (OT) to Patient 1 on 11/1/22 at 8:00 AM, the patient was observed to use a wheeled walker with ambulation, and was observed to have a dressing covering the left knee incision. The OT informed the patient a new shower bench would arrive with the HHA during the HHA visit on 11/1/22. D. Review of Patient 3's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/19/22 through 12/17/22 included: a. Orders for home health aide (HHA) 2 times per week for 8 weeks beginning week of 10/24/22. b. Patient supplies included a wheeled (rolling) walker. c. A primary diagnosis of Type II Diabetes Mellitus with hyperglycemia (elevated blood glucose levels). 2. The HHA POC revealed: a. Multiple generic devices for ambulation versus the actual device to be used with ambulation (the wheeled walker). b. Included directions to provide range of motion (ROM) exercises (exercises to joints to increase strength and mobility). It does not specify what exercises, location of the exercises, or how much assist to provide while providing ROM exercises. c. Assist with meal preparation, set-up , and feeding. Includes intervention of special diet instructions. It does not include what type of special diet instructions are to be followed. E. Review of Patient 4's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/14/22 through 12/12/22 included: a. Orders for home health aide (HHA) 1 times per week for 9 weeks beginning week of 10/16/22. b. Patient supplies included a wheeled (rolling) walker. c. Medications include warfarin. d. A primary diagnosis of Parkinson's Disease. 2. The HHA POC revealed: a. Interventions include: ambulate only with assistance, and assist with transfers. It does not include the type of device to use with ambulation and transfers (wheeled/rolling walker). b. There was no information regarding the medication warfarin and signs of bleeding to report to the nurse. 3. An Occupational Therapy Visit Note, initial evaluation, dated 10/18/22 revealed the patient had trouble remembering to use the assistive device (wheeled/ walker) which is needed for mobility and safety. F. Review of Patient 5's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/28/22 through 12/26/22 included: a. Orders for home health aide (HHA) 2 times per week for 9 weeks beginning week of 10/30/22. b. Patient supplies included a walker. c. Orders for no lifting greater than 10 pounds for 4 weeks, no lifting arm above shoulder for 4 weeks, may shower, but do not submerge incision in water for 1 week, leave steri- strips in place until follow up appointment on 11/1/22, no lotions or creams to incision site, monitor incision for bleeding and infection (drainage, redness, swelling, fever, and chills). It does not identify which arm or the location of the incision. d. Patient has a new pacemaker. 2. The HHA POC revealed: a. Interventions include: transfer with assistance. It does not include the type of device to use with transfers (walker). b. There was no direction to the aide for no lifting greater than 10 pounds for 4 weeks, no lifting arm above shoulder for 4 weeks, may shower, but do not submerge incision in water for 1 week, leave steri-strips in place until follow up appointment on 11/1/22, no lotions or creams to incision site, monitor incision for bleeding and infection (drainage, redness, swelling, fever, and chills). c. Does not identify which arm the precautions pertains to. G. During an interview on 11/2/22 at 2:30 PM the Manager of Home Health (Clinical Manager, CM) confirmed the HHA POC's for Patients 1, 3, 4, and 5 do not provide patient specific interventions and instructions for the home health aide to follow while providing HHA care and services to the agency patients. The CM also confirmed the agency did not have a policy specific to the development, revision, and updates to the HHA POC to ensure skilled nurses are aware of all aspects expected on the HHA POC.