Every finding on record at St. Francis Medical Center

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/06/2025. The Agency was in compliance with the Condition, 42 CFR 484.102, Emergency Preparedness for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 6/6/2025. The Agency was not in compliance with 42 CFR 484, Standards for Home Health Agencies, for this survey. Abbreviations: Pt = Patient E = Employee

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, staff interview, and document review, the facility failed to ensure a clean surface barrier was placed for clean equipment brought into the home during a home visit. Findings include: 1. During the observed home visit for patient (Pt #9) on 6/5/2025 at approximately 2:10pm the RN Case Manager-Home Health (E #5) was observed setting her supply bag directly on the floor of Pt #9’s residence without a barrier between the floor and the supply bag. The supply bag remained directly on the floor for the duration of the home visit. 2. In an interview with E #5 and the Supervisor-Nursing Home Health (E #6) on 6/5/2025 at approximately 3:00pm, E #5 and E #6 Verbally confirmed the bag was placed directly on the floor without a barrier. 3. Visual inspection of the bag on 6/5/2025 at approximately 3:00pm with E #5 and E #6 confirmed the bag did have raised plastic feet but was not a rolling bag. 4. Review of the facilities “Preparing the Bag” (Quick Sheet Procedure document), states, “9. Do not place the bag directly on the floor unless it is a rolling bag.”

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on staff interview and document review, the facility failed to ensure the administrator was appointed by the governing body. Findings include: 1. A review of a section of the Board of Directors meeting minutes dated September 18, 2023 states “(Vice President of Operations of Home Health) provided an overview of the organizational structure for Home Health, HME and HIP…The Executive Committee of the Board of Directors reviewed and accepted the Administration/Service Area Profile for OSF Home Care and OSF Rehabilitation Services”. The section of the meeting minutes also included the organizational chart with the name of E #4 circled under the title “Home Health Director”. 2. An interview was conducted on 6/5/2025 at approximately 3:30 PM, with the Director of Home Health Operations (E #7), Manager of Home Health (E #1), and Manager of Home Health (E #3). During discussion regarding appointment of the administrator, E #1 stated this was done in 2023 when E #4 was promoted from Clinical Manager to Director of Home Health Operations. E #7 confirmed this and noted this was done by the President of Home Health. There was continued discussion regarding documentation in meeting minutes of this by the governing body. E #7 stated the Home Health leadership team including the President, Vice President and both directors occur regularly, with meeting minutes taken, and believes the appointment of E #4 as administrator would be in those minutes, but further noted they do not believe the Home Health leadership team is considered the governing body, as they do not have full legal authority, rather the Board of Directors for the parent organization is designated as the governing body. E #7 stated they would get clarification on this. 3. A follow-up interview was completed on 6/6/2025 at approximately 10:45 AM, with the Director of Home Health Operations (E #7) and Manager of Home Health (E #1). During continued discussion regarding the governing body, E #7 confirmed that the governing body is the Board of Directors for the parent organization. E #7 further stated that the appointment of the administrator was presented to the Board of Directors by the Vice President of Home Health in 2023, with E #1 referring back to a copy of meeting minutes they provided the previous day, but was not “specifically spelled out” as such in the meeting minutes.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on document review and interview, the facility failed to ensure a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, was provided in writing, as authorized by the administrator and governing body. Findings include: 1. A document was requested from the facility on 6/4/2025 at approximately 3:00 PM demonstrating authorization in writing by the administrator and governing body, the pre-designation of a person to assume the same responsibilities and obligations as the administrator when the administrator is not available. The facility was unable to produce this document. 2. An interview was conducted on 6/5/2025 at approximately 3:30 PM, with the Director of Home Health Operations (E #7), Manager of Home Health (E #1), and Manager of Home Health (E #3). During discussion regarding a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, E #1 stated that they and E #3 work together to ensure this occurs. During further discussion, however, E #1, E #3 and E #7 agreed that though a process is in place, this pre-designation is not in writing as authorized by the administrator and governing body. 3. A follow-up interview was completed on 6/6/2025 at approximately 10:45 AM, with the Director of Home Health Operations (E #7) and Manager of Home Health (E #1). During continued discussion regarding a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, E #7 further clarified that they would be the pre-designated person for the administrator (E #4), but as both E #7 and E #4 are both in leadership positions and could potentially be away from the facility at the same time, the process further designates to E #1 and E #3.

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 05/27/22. The Agency was in compliance with the Standards for Establishment of the Emergency Program for Home Health Agencies, 42 CFR 484.22, for this survey.

A recertification survey was conducted in conjunction with an Emergency Preparedness survey on 05/26/2022. The Agency was in compliance with the Standards for Emergency Preparedness, 42 CFR 484.22 and was not in compliance with the Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E- Employee mg- milligram POC- Plan of Care Pt- Patient SOC: Start of Care

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 document review and staff interview, it was determined for 1 of 7 (Pt #5) patients, in which home visits were conducted, the Agency failed to ensure medication lists were accurate and discrepancies were clarified. This has the potential to affect all patients receiving care at the Home Health Agency with a current census of 611 patients. Findings include: 1. The policy titled "Medication Reconciliation and Drug Review (A8600-0)” (approved 5/6/2022) was reviewed on 5/26/2022 at approximately 11:00 AM. The policy stated "The clinician will review and validate the medication profile on each visit and will identify new or changed medications.” 2. Pt#5 Start of Care (SOC) 5/6/2022 Diagnosis: Cognitive Decline A home visit was conducted on 5/25/2022 at approximately 10:00 AM with the Occupational Therapist (E #2). The medication list provided by the agency was compared to the medication list at the Supportive Living Facility. The following discrepancies were noted a. The medication list at the start of care 5/9/2022 indicated Zyrtec 5 mg (milligrams) by mouth daily. The medication list at the Supportive Living Facility did not have Zyrtec 5 mg listed. Pt #5 was not being administered Zyrtec. b. Tylenol 650 mg by mouth every 4 hours as needed for pain was added to the Supportive Living medication list on 2/8/2022 and did not appear on the Home Health medication list as of 5/25/2022. 3. An interview was conducted on 5/25/2022 at approximately 10:50 AM with the Supportive Living Facilities Registered Clinical Nurse (E#3). E#3 stated “We have asked the Home Health staff to check in with us before or after seeing our patients, so we can get a condition update and check medications, but they do not.” 4. An interview was conducted on 5/25/2022 at approximately 2:00 PM with the Coordinator of Quality and Safety (E#1). E#1 reviewed Pt#5’s chart and agreed the medication list was not update and the home health policy was not followed.

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 document review and staff interview, it was determined for 1 of 2 (Pt #12) patients, with a diagnosis of heart failure, the Agency failed to ensure care was provided as indicated in the Plan of Care (POC). This has the potential to affect all patients receiving care at the home health with a current census of 611 patients. Findings include: 1. Pt#12 Start of Care(SOC) 4/29/2022 Diagnosis: Alzheimers, Congestive Heart Failure. The clinical record of Pt #12 was reviewed on 5/26/2022 at approximately 4:00 PM. The record contained an order to “call Home Care first for weight gain of 3 pounds overnight or 5 pounds in one week. 2. The skilled nurse visit note of 5/13/2022 indicated a weight of 192 pounds, the following skilled nurse visit on 5/24/2022 noted a weight of 203 pounds. This indicated a 11 pound weight gain in 11 days. The record lacked documentation that Home Care was notified of the weight gain. 3. On 5/26/2022 at approximately 10:00 AM, an interview was conducted with the Coordinator of Quality and Safety (E#1). E#1 reviewed the documentation and agreed with the findings, and questioned the accuracy of the weight.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on document review, observation, and interview, it was determined for 1 of 7 (Pt #1) patients observed during home visits, the Agency failed to ensure infection control measures were observed to prevent the potential for cross-contamination, as per Agency policy. This has the potential to affect all patients serviced by the Agency with a current census of 611 patients. Findings include: 1. The policy titled "Care and Use of Home Visit Bags and Equipment (A5007-0) (effective 6/2/2021)" was reviewed on 5/25/22 at approximately 4:15 PM. The policy noted"...Purpose:...1.All clinical Mission Partners (employees) will be provided with and should utilize...issued home visit bags...2. Germicidal hand cleanser...germicidal wipes should be carried in the outside pocket of the bag..." 2. During a home visit conducted on 5/24/22 at approximately 11:40 AM with the Aide for Pt. #1 Start of Care 5/16/22 with Diagnosis of Subdural Hemorrhage. The Aide was noted to have a home visit bag similar to a tote bag. The bag lacked compartments for clean and dirty supplies. The bag also lacked compartment on outside for sanitizing equipment. 3. During an interview on 5/26/22 at approximately 10:30 AM with the Registered Nurse Coordinator Quality and Safety (E#1), E#1 verbally confirmed staff is given home visit bag that are to be used at the visits. The bags contain separate compartments for clean/ dirty supplies and compartment on outside for sanitizer.