Every finding on record at Osf Healthcare System

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 9/12/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification for health standards was conducted on 9/11/2025. The Facility was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by:

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 that 2 of 7 patients (Pt #11 and Pt #15), where home visits were conducted, the Home Health Agency (HHA) failed to ensure all medications were reviewed for accuracy. Findings include: 1. Pt #11 Start of Care (SOC): 8/7/25.Diagnosis: Ataxia following cerebral infarction. A home visit was conducted on 9/9/25 at approximately 10:00 AM with home health aide (HHA) (E #5). The Agency’s Plan of Care had the following home medication discrepancies: a) Isosorbide dinitrate (relaxes blood vessels) 30 mg (milligram) tablet four times a day by mouth is active on the Agency’s medication list. Pt #11 has not been taking this medication since 2024. b) Vitamin D 3 (vitamin D deficiency) 50 mcg (microgram) tablet daily by mouth is active on the Agency’s medication list. Pt#11 is no longer taking Vitamin D 3. 2. Pt #15 Start of Care: 8/25/2025. Diagnosis: Disruption of external operation (surgical) wound. A home visit was conducted on 9/10/2025 at approximately 10:00 AM with Pt #15 and the Registered Nurse (RN) (E#4). Pt #15’s medication list was reviewed with Pt #15’s home medication. The medication list stated “…gabapentin (NEURONTIN) (medication used to treat seizures and nerve pain) 300 mg (milligrams, a measurement for medication) …Take 100 mg by mouth 3 (three) times daily…” Gabapentin 300 mg tablets were found in Pt #15’s medication basket and labeled “…take 300 mg daily at bedtime…” 3. On 9/11/2025 at approximately 1:30 PM, the policy titled “Medication Reconciliation” (effective 7/24/2025) was reviewed. This policy reads “…PROCESS…1. Record and/or update the patients’ height and weight…as well as allergies and medication list in the electronic health record (EHR) upon each admission or encounter…” 4. During an interview on 9/11/25 at approximately 11:00 AM, the Quality RN (registered nurse) (E# 2) reviewed Pt #11 and Pt #15’s Agency’s medication list and verbally agreed that the medication discrepancies were not acknowledged and should have been.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/08/2022. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP).

A recertificaion survey was conducted on 09/08/2022. The Facility was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E - Employee Pt - Patient HHA - Home Health Aide SOC - Start of Care

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined for 1 of 17 (Pt #5) records reviewed, the Agency failed to record weights at every skilled nurse visit. This has the potential to affect all patients who receive care by the Agency with a current census of 126 patients. Findings include: 1. Pt #5 Start of Care (SOC): 08/09/2022 Diagnosis: Atherosclerosis of extremities with gangrene bilateral legs. Pt #5 has a "Pertinent Diagnosis" of congestive heart failure. The record was reviewed on 09/09/2022 at approximately 10:00 AM. The plan of care dated 08/09/2022, stated "Skilled Nursing: HEART FAILURE ORDER.... Skilled assessment with focus on: weight, edema, dyspnea, cardiac and pulmonary assessment." The skilled nursing visits dated, 08/09/2022, 08/10/2022, 08/16/2022 and 09/06/2022 lacked Pt #5's weight. 2. An interview with the Coordinator Regulatory of RN Quality and Safety (E #2) was conducted on 09/07/2022 at approximately 1:00 PM. E #2 reviewed Pt #5's record and confirmed there were no weights recorded for those dates and stated, "The nurse is not following the plan of care."

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 document review and interview, it was determined for 1 of 17 (Pt #6) records reviewed, the Agency failed to ensure orders for oxygen were written. This has the potential to affect all patients who receive care by the Agency with a current census of 126 patients. Findings include: 1. Pt #6's home visit was conducted on 09/07/2022 at 10:00 AM with Home Health Registered Nurse (E #4). Pt #6 was observed to be receiving oxygen via nasal cannula. Mother stated "If (Pt #6)'s oxygen drops to the low 90s, I will apply oxygen." 2. Pt #6 Start of Care: 07/11/2022 Diagnosis: Encounter for change or removal of non-surgical wound dressing. Pt #6's record was reviewed on 09/07/2022 at approximately 1:30 PM. The plan of care dated 07/11/2022 did not include orders for oxygen. 3. An interview with the Coordinator Regulatory of RN Quality and Safety (E #2) was conducted on 09/07/2022 at approximately 3:00 PM. E #2 reviewed Pt #6's record and confirmed there were no orders written for oxygen and should have been.

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 document review and interview, it was determined in 1 of 3 (Pt #9) patient records reviewed, receiving home health aide (HHA) services, the Agency failed to ensure a home health aide care plan was followed. This has the potential to affect all patients receiving HHA services at this Agency with a current census of 126 patients. Findings include: 1. Pt #9 SOC: 7/17/22 Diagnosis: Hypertensive Heart Failure and Chronic Kidney Disease with Heart Failure. The Home Health Aide (HHA) plan of care dated 8/11/22, included an order for the HHA to "Take vital signs pulse, temperature, blood pressure, respirations, and weight" at each visit. The following HHA visits lacked documentation that weights were taken: 8/15/22 (no weight), 8/18/22 (no weight), 8/22/22 (no weight) 2. An interview was conducted on 9/7/22 at approximately 2:30 PM, with the Coordinator Regulatory RN Quality and Safety (E #2). E #2 agreed with the above findings that the weights were not completed and should have been.