Every finding on record at Osf Healthcare System

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 8/1/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 08/01/25. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, for this survey.

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 observation, document review and interview, it was determined for 1 of 7 (Pt #17) patients, where home visits were conducted, the Home Health Agency (HHA) failed to ensure that medications available to the patient were not expired. Findings include: 1. On 07/31/25 at 12:00 PM, a home visit was conducted at Pt #17’s residence. Pt #17’s start of care with home health services which include physical therapy (PT), occupational therapy (OT), and skilled nursing (SN) began on 6/20/25 for surgical aftercare following a left endarterectomy (surgical procedure to remove plaque buildup from the inner lining of an artery). During the visit the physical therapy assistant (PTA) (E#5) was observed reviewing the patient’s medications which were in a box on the table. During review of medication bottles, E#5 found two bottles of methocarbamol (muscle relaxant) 500 mg (milligrams) tablets to take 500 mg by mouth two times daily, as needed for muscle spasm. After this surveyor asked E#5 to inspect the bottles expiration dates, it was noted that one of the bottles expired 02/25. E#5 then informed the caretaker that it needed to be thrown out. The caretaker reluctantly stated, “I know, just leave this side of the med box alone. I will take care of it.” and then walked out of the room. The meds were not discarded during the visit. 2. On 7/31/25, the policy "Medication Reconciliation and Drug Review (approved 6/17/25), was reviewed. Under "Process: Medication Reconciliation: Home Health… 4. Separate discontinued/expired medications in the home and encourage the patient or caregiver to destroy. Educate patient/caregiver to refrain from taking any discontinued/expired medications and document accordingly.” 3. On 8/1/25 at approximately 10:00AM, all home health visits were reviewed from start of care, 6/20/25, which included SN, PT, and OT visits. Notes revealed the following: Physical therapist (PT) (E #6) visit on 6/20/2025 at 11:00 AM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Physical therapist (PT) (E #6) visit on 6/25/2025 at 11:00 AM noted "...Medication Management...Medication Review New Medication: yes, Medication: cefpodoxime (antibiotic to treat bacterial infections), Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Physical therapy assistant (PTA) (E #5) visit on 6/30/2025 at 12:00 PM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Physical therapist (PT) (E #6) visit on 7/16/2025 at 10:30 AM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Registered Nurse (RN) (E #7) visit on 7/18/2025 at 1:00 PM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Physical therapy assistant (PTA) (E #5) visit on 7/24/2025 at 1:00 PM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Registered Nurse (RN) (E #7) visit on 7/25/2025 at 1:00 PM PM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Physical therapy assistant (PTA) (E #5) visit on 7/29/2025 at 12:30 PM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." Physical therapy assistant (PTA) (E #5) visit on 7/31/2025 at 11:30 AM noted "...Medication Management...Medication Review New Medication: no, Medication discontinued: no, New/changed OTC (over the counter) Medication: no, Medication Needs/Issues Identified: none..." 4. On 07/31/25 at 2:15 PM, an interview with PTA, E#5, was conducted. E#5 stated that she was concerned on why this was not discovered before as there have been multiple home visits with this patient since 6/20/25 with various disciplines. E#5 stated that she contacted the case manager regarding this matter and verbally agrees this should have been taken care of at start of care, 6/20/25.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 10/20/22. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP), for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 10/20/2022. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR, as evidenced by: Abbreviations: E-employee OT - occupational therapy Pt - patient PT - physical therapy SN - skilled nurse

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined the Agency failed to ensure patients who were transferred to another home health agency or discharged to a skilled nursing facility were provided data on quality measures and data on resource use measures. This has the potential to affect all 126 current patients receiving care from the agency. Findings include: 1. On 10/19/2022 at 9:30 AM, the policy "Transfer and Discharge-Home Health" effective 02/02/2022, was reviewed. Under "3. a." it reads "For patient who transfer to another Home Health agency or are discharged to a skilled nursing facility.........the patient and or their caregiver will be provided data on quality measures and data on resource use measures." 2. On 10/17/2022 at 12:00 PM, an interview with Social Worker (E #8) was conducted. When asked how patients are given choices for post-acute care selection, E #8 explained "most of the patients know which facility they want to go to so we don't provide them with a list of providers and don't provide data on quality measures." 3. On 10/19/202 at 10:00 AM, an interview with the Quality Manager (E #6) was conducted. E #6 confirmed the Agency was not providing patients a list of providers or quality measures for patients being discharged to skilled nursing facilities.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined for 1 of 17 patients receiving care (Pt #11), the nurse failed to document communication with all physicians involved in the patient's care to ensure development and coordination of the ongoing plan of care. This failure has the potential to affect all patients, currently a census of 126. Findings include: 1. A review of the medical record for patient (Pt) #11 was completed on 10/19/22. Pt #11 was admitted for home health services on 9/13/22 with diagnoses of diabetes mellitus, diabetic ulcer of great toe (L) with amputation. The plan of care dated 9/13/22 included the following orders: skilled nurse (SN) 1x a week for 1 week, 2x and week for 4 weeks, and 1x a week for 4 weeks, physical therapy (PT) 1x a week for 1 week and 2x a week for 3 weeks, and occupational therapy (OT) 1x a week for 1 week and 1 x a week for 3 weeks. Documentation in the orders for the nurse indicate nursing visits to provide wound care to the open amputation wound. Review of the nursing visits from 9/13/22 through 10/17/22 failed to document the physicians who were providing the assessment and care of the open wound. The wound measurements and photos in Pt #11's record show the wound to continue to have eschar tissue and moderate to large amount of drainage. There was no documentation indicating the surgeon/podiatrist and primary physician were coordinating care with each other and the HHA. There was no nurse documentation of which physician was providing ongoing assessment and orders and no physician updates were noted. 2. An interview was conducted with the HHA Manager (E #2) on 10/20/22 at 10:15 am. E#2 reported after requesting information from the nurses providing care to Pt #11, E#2 was made aware Pt #11 has been seen by a podiatrist weekly, but no documentation of the visits, outcomes or plan was completed by the nurses. E#2 also reported the surgeon is giving the orders for the wound care, but there is no documentation of coordination between the surgeon and the podiatrist. "This is an opportunity for us to improve."

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on documentation and staff interview for 2 of 17 (Pt# 9 and Pt #13) clinical records reviewed the Agency failed to ensure integration of services, to assure the identification of patient needs, treatment effectiveness and the coordination of care is provided by all disciplines. This failure has the potential to affect all patients receiving home care services. Current census-126. Findings include: The clinical record review of Pt #9 was conducted on 10/18/22. Pt #9 was admitted for services on 9/5/22 with diagnosis of stage 3 lung cancer. The physician's plan of care ordered skilled nurse (SN) visits 2 times a week for 2 weeks, 1 time a week for 7 weeks; physical therapy (PT) visits 1 time a week for 1 week, 2 times a week for 4 weeks; occupational therapy (OT) 1 time a week for 1 week, 2 times a week for 4 weeks. Documentation indicated Pt #9 had low oxygen saturation, pain and fluid retention. Pt #9 was transferred to inpatient hospital on 9/19/22. A resumption of care was completed on 9/29/22. A chest tube was placed during the hospitalization. A care conference was conducted on 9/27/22. Documentation on the care conference lacked any information about Pt #9's current condition, needs, or changes in the plan of care. Pt #9 received services until transfer to hospital without discharge on 9/17/22. Pt #9 expired in the hospital on 10/12/22. 2. The clinical record review of Pt # 13 was reviewed on 10/19/22. Pt #13 was admitted for services on 8/14/22 with diagnoses of acute cholecystitis and Alzheimer's. The physician's plan of care ordered SN visits 2 times a week for 2 weeks, 1 time a week for 6 weeks; PT visits 1 time a week for 1 week, two times a week for 3 weeks; OT visits 1 time a week for 1 week, 2 times a week for 2 weeks. Documentation indicated between 8/17/22-8/30/22, Pt #13 had multiple missed visits (6) due to patient refusal or patient did not answer phone. Documentation on the care conference on 9/2/22 lacked any information about the missed visits or refusal of care. Pt #13 was transferred to hospital without discharge on 9/17/22. Pt #13 expired in the hospital on 9/24/22. 3. On 10/20/22 at 11:00 AM, an interview was conducted with the Quality Coordinator (E#6). E# 6 was asked for a policy regarding care conferencing. E#6 stated, "we don't have a policy." 4. On 10/20/22 at 11:25 AM, an interview was conducted with the clinical manager (E#2). E#2 stated, "patients are care conferenced 2 weeks after certification, and 2 weeks before recertification and if patient is having concerns or issues. We try to have a discussion at the end of care conference to go over patients having problems."