Every finding on record at Osf Healthcare System

The Emergency Preparedness Plan requirements were evaluated in conjunction with the recertification survey on 03/12/26. The Agency was in compliance with 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 03/12/26. Standard level deficiencies cited. Abbreviations: SOC = Start of Care POC = Plan of Care SN = Skilled Nurse Pt. = Patient ROC = Resumption of Care ST = Speech Therapy PT = Physical Therapy mmHG = Millimeters of Mercury

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, in 2 of 17 clinical records reviewed (Pts# 6 and 11), the Agency failed to provide services included in the POC. 2. Pt # 11 was admitted to home health on 02/06/26 with a diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 03/11/26. The record included a POC for a certification period of 02/06/26 to 04/06/26. The POC included an order for “SN to obtain weight every visit and notify RN/Physician of weight gain or loss of 3 lbs. within 1 day or 5 lbs. within one week.” The SN visit notes dated 02/10/26 and 03/10/26 lacked weight assessments as per plan of care. 3. During an interview with the Administrator, Agency Supervisor, and Quality and Safety Coordinator on 03/11/26 at 2:15 PM, the Administrator, Agency Supervisor, and Quality and Safety Coordinator confirmed the clinical record lacked documentation of patient’s weight by the SN with the above findings. Findings include: 1. Pt. #6 was admitted to home health services on 03/02/26 with the diagnoses of Acute kidney failure and unspecified Type 2 Diabetes mellitus with diabetic chronic kidney disease. The clinical record was reviewed on 03/10/26. The record included the POC for the certification period of 03/02/216 to 04/30/26 that required, “SN: Intervention: Diabetes: SN to instruct Pt. and caregiver….report blood sugar greater than 250 or less than 70 to physician.” The SN visit notes dated 03/02/26 and 03/10/26 lacked documentation that the patient’s blood glucose was assessed and recorded on the clinical record by the SN.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records, home visit observation and interview, and staff interview, for 4 of 17 records reviewed (Pts. #1, 2, 3 and 8), the Agency failed to incorporate all medications, services and patient specific interventions into the plan of care. 2. Pt. #2 was admitted to home health on 02/07/26 with the primary diagnosis of Hypertensive Heart and Chronic Kidney Disease. The clinical record was reviewed on 03/09/26 and 03/10/26 and included a POC effective 02/07/26 through 04/07/26. The POC documented, "Durable Medical Equipment...Oxygen concentrator...Oxygen tanks portable..." During the home visit on 03/09/26 at 1:40 PM the patient was on oxygen per nasal canula. The POC lacked an order for oxygen use and the prescribed amount. The POC effecive 02/07/26 through 04/07/26 also included the medication hydrocodone-aceitaminophen (Norco) to be taken by mouth for pain as needed every four hours. During the home visit on 03/09/26 at 1:40 PM, the patient stated he only had tylenol for pain and no longer took Norco. The plan of care lacked an updated medication list. The clinical record also included an ROC dated 02/20/26 that documented "...Intervention: Heart Failure... call Home Care first for weight gain of 3 pounds overnight or 5 pounds in 1 week. Weigh and record everyday..." During the home visit on 03/09/26 the patient stated he could not weigh himself because his scale could not record his weight. The POC failed to include a patient specific intervention related to the patients inability to monitor his own weight. 3. Pt. #3 was admitted to home health on 02/12/26 with the primary diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 03/09/26 and 3/10/26 and included a POC effective 02/12/26 through 04/12/26. The POC documented, "Durable Medical Equipment...Oxygen concentrator...portable oxygen..." During the home visit on 03/09/26 at 2:35 PM the patient was on oxygen per nasal canula. The POC lacked an order for the use of oxygen and the prescribed amount. 4. Pt. #8 was admitted to home health on 11/16/25 with the diagnosis of Dysphagia following cerebral infarction. The record included a POC effective 01/15/26 to 03/15/26. The POC included orders for ST one time a week for seven weeks. The record included SN notes dated 02/10/26 and 02/17/26. The plan of care lacked orders for the SN visits. No order modifications were noted in the record. 5. During an interview with the Administrator, Agency Supervisor and Quality and Safety Coordinator at 2:15 through 3:00 PM, the Administrative team confirmed the prescription for Oxygen should be included on the medication profile in the POC. The above findings were also confirmed. Findings included: Pt # 1 was admitted to home health on 01/09/26 with a diagnosis of Venous Insufficiency. The clinical record was reviewed on 03/09/26. The record included a POC for a certification period of 01/09/26 to 03/09/26. The POC included interventions for Wound #3, left venous leg ulcer, that included wound care 2x a week. “…Cleanse wound with wound cleanser, Apply zinc oxide to periwound, apply adaptic to wound, cover wound with ABD gauze, secure wound with rolled gauze…” During a Wound Care physician office visit on 01/29/26, the physician documentation included: “Assessment and Plan: left venous leg ulcer; healed, no need for dressings… Instructions: may transition to compression stocking. 20-30 mmhg”. SN visit note dated 02/03/26, included wound care documentation “wound care performed, patient tolerated well”. The SN note included the same wound interventions listed on 01/09/26. The plan of care lacked the change in intervention for the healed wound. The record also included a Wound Care physician office visit on 02/12/26, the physician documentation included: “Assessment and Plan: left venous leg ulcer; ulcer has re-opened. Instructions: Vaseline gauze, ABD pad, Kerlix, Ace Figure 8, and Tubigrip”. SN visit on 02/16/26, wound care documentation “wound care performed, patient tolerated well”. The SN note included the same wound interventions listed on the POC dated 01/09/26. The plan of care lacked updated interventions for the wound.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on patient clinical records review, Agency's Admission Folder review and staff interview, in 17 of 17 (Pts. # 1-17) clinical records reviewed, the Agency failed to provide the name and contact information of the Agency Supervisor to the patient and / or representative on admission. Findings include: 1.The Admission Folder was reviewed on 03/09/26. The Folder lacked documentation of the Agency Supervisor's name and contact information. 2. The following patient clinical records were reviewed between 03/09/26 and 03/11/26. The clinical records lacked documentation that the patient or representative were notified of the Agency Supervisor's name and contact information. Pt. #1 SOC 01/09/26 Pt. #2 SOC 02/07/26 Pt. #3 SOC 02/12/26 Pt. #4 SOC 03/04/26 Pt. #5 SOC 03/06/26 Pt. #6 SOC 03/02/26 Pt. #7 SOC 11/07/25 Pt. #8 SOC 01/16/25 Pt. #9 SOC 01/31/26 Pt. #10 SOC 12/12/25 Pt. #11 SOC 02/06/26 Pt. #12 SOC 02/03/26 Pt. #13 SOC 03/20/25 Pt. #14 SOC 12/19/25 Pt. #15 SOC 01/04/26 Pt. #16 SOC 09/26/25 Pt. #17 SOC 01/07/26 3. During an interview with the Administrator, Agency Supervisor, and the Quality and Safety Coordinator on 03/11/26 at 2:15 PM, the Administrator, Agency Supervisor, and Quality and Safety Coordinator confirmed the above findings.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on the on-site observation and staff interview, the Agency failed to have an Agency supervisor available at all times during operating hours of the Agency. Findings include: 1. During an interview with the Administrator on 03/09/26 at 11:00 am. The Administrator stated that the Agency Supervisor was not available. The Administrator was unable to provide documentation of staff designated as the alternate Agency Supervisor. 2. During the survey day 03/09/26, it was observed that the Administrator was covering the role of the Agency Supervisor and the Administrator. 3. During an interview with the Administrator on 03/10/26 at 10:00 am, the Administrator stated and confirmed the Agency has no documentation to indicate staff designated to cover in the absence of the Agency Supervisor. During the same interview the Administrator confirmed she was covering both roles on 03/09/26.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: COVID-19 = Coronavirus disease 2019

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on Agency’s Vaccination policy review and staff interview, it was determined the Agency failed to develop a contingency plan for Staff who are not fully vaccinated for COVID-19. Findings include: 1. The Agency’s policy titled “Vaccination and Immunity Validation Program effective 02/02/22" was reviewed on 12/07/22 at 11:00 AM. The policy required…”...4…a....Religious and Medical Exemptions are the only two acceptable reasons for refusal of vaccination and are reviewed on a case-by-case basis.” The Agency's policy lacked a detailed mitigation process once the employees are granted vaccine exemption for COVID-19. No policy revisions were made after 02/02/22. 2. During an interview with the Administrator, Interim Agency Supervisor and Quality Safety Coordinator on 12/08/22 at 2:00 PM, finding of the Agency vaccination policy not containing a contingency plan for exempt employees who are not fully vaccinated for COVID-19 was confirmed.