Every finding on record at St Francis of Assisi Healthcare, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 04/29/26. 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 04/29/26. Standard level deficiencies cited. Abbreviations: % = percent x = times wk = week # = number % = percent AM = morning SN = Skilled Nurse POC / PsOC = Plan of care / Plans of Care SOC = Start of care MD = Medical Doctor RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report for the last 12 months and staff interview, the Agency failed to submit 137 of 439 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 04/01/25 to 03/31/26, was reviewed on 04/29/26. The report documented 137 of 439 (29.21%) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing and Office Manager on 04/29/26 at 2:30 PM, the Administrative staff confirmed the above findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, in 4 of 7 (Pts. #3, 4, 5 and 6) clinical records reviewed, the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. Findings include: 1. Pt. #3 was admitted to home health services on 10/24/25 with a diagnosis of Type 1 Diabetes Mellitus with other diabetic kidney complication. The clinical record was reviewed on 04/29/26. The record contained a “Face to Face” document faxed from the physician’s office dated 10/20/25. The initial comprehensive assessment was conducted by the RN on 10/24/25. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 2. Pt. #4 was admitted to home health services on 09/03/25 with a diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 04/29/26. The record contained a physician “Encounter” document faxed from the physician’s office dated 08/05/25. The initial comprehensive assessment was conducted by the RN on 09/03/25. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 3. Pt. #5 was admitted to home health services on 02/09/26 with a diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 04/29/26. The record contained a “Physicians Face-to-Face Encounter” document faxed from the physician’s office dated 01/15/26. The initial comprehensive assessment was conducted by the RN on 02/09/26. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 4. Pt. #6 was admitted to home health services on 04/09/25 with a diagnosis of Parkinsonism, unspecified. The clinical record was reviewed on 04/29/26. The record contained the document “Referrals/Response Letter” dated 03/25/26. The initial comprehensive assessment was conducted by the RN on 04/09/25. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 5. During an interview with the Office Manager and Director of Nursing on 04/29/26 at 2:00 PM it was stated that the initial assessment should be conducted within 48 hours of the referral date, the date documented on the Face-to-Face physician form or on a specified physician order date. During the same interview, the above findings were confirmed.

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 clinical record reviews and staff interviews, in 3 of 7 (Pts. #1, 3 and 5) clinical records, the Agency failed to ensure the POC was followed. 2. Pt. #3 was admitted for home health services on 10/24/25 with the diagnosis of Type 1 Diabetes Mellitus with other diabetic kidney complication. The clinical record was reviewed on 04/28/26 and included a POC effective 04/22/26. The POC required, “SN to weigh patient at every SN visit and notify MD of weight gain 2 pounds/day or 5 pounds/week. The record lacked documentation of Pt. #3’s weight on the SN notes dated, 03/12/26, 03/17/26, 03/26/26, 03/31/26, 04/10/26. 3. Pt. #5 was admitted for home health services on 02/09/26 with the diagnoses of but not limited to Essential Primary Hypertension and Type 2 Diabetes Mellitus with other oral complications. The clinical record was reviewed on 04/29/26 and included a POC effective 04/10/26. The POC required, “SN to monitor blood sugar every visit and as needed and to notify MD with result…” The record lacked documentation of Pt. #1’s blood glucose monitoring on the SN notes dated, 04/13/26 and 04/20/26. 4. During interviews with the Director of Nursing and Office Manager on 04/29/26 from 1:35 PM to 3:00 PM, the above findings were confirmed. 1. Pt. #1 was admitted for home health services on 10/03/25 with the diagnosis of Essential Primary Hypertension. The clinical record was reviewed on 04/28/26. The clinical record included a signed Physical Therapy (PT) plan of care dated 01/30/26, with PT frequency and duration of 1 time a week for 9 weeks. The clinical record lack any PT visits after 01/30/26 to the end of the certification period, modification of Physician orders or communication as to why the plan of care was not followed. 2. Pt. #3 was admitted for home health services on 10/24/25 with the diagnosis of Type 1 Diabetes Mellitus with other diabetic kidney complication. The clinical record was reviewed on 04/28/26 and included a POC effective 04/22/26. The POC required, “SN to weigh patient at every SN visit and notify MD of weight gain 2 pounds/day or 5 pounds/week. The record lacked documentation of Pt. #3’s weight on the SN notes dated, 03/12/26, 03/17/26, 03/26/26, 03/31/26, 04/10/26. 3. Pt. #5 was admitted for home health services on 02/09/26 with the diagnoses of but not limited to Essential Primary Hypertension and Type 2 Diabetes Mellitus with other oral complications. The clinical record was reviewed on 04/29/26 and included a POC effective 04/10/26. The POC required, “SN to monitor blood sugar every visit and as needed and to notify MD with result…” The record lacked documentation of Pt. #1’s blood glucose monitoring on the SN notes dated, 04/13/26 and 04/20/26. 4. During interviews with the Director of Nursing and Office Manager on 04/29/26 from 1:35 PM to 3:00 PM, the Administrative staff confirmed the above findings.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record reviews, Agency policy review and staff interviews, in 6 of 7 (Pts. #1, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to assess patients' Influenza and/or Pneumonia vaccination status. Findings include: 1.The following clinical records were reviewed from 04/27/26 to 04/29/26: Pt. #1 SOC 10/03/25 lack Influenza and Pneumonia vaccination assessment. Pt. #3 SOC 10/24/25 lack Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 09/03/25 lack Influenza and Pneumonia vaccination assessment. Pt. #5 SOC 02/09/26 lack Influenza vaccination assessment. Pt. #6 SOC 04/09/25 lack Pneumonia vaccination assessment. Pt. #7 SOC 07/25/25 lack Pneumonia vaccination assessment. The clinical records lacked documentation that the Influenza and/or Pneumonia vaccination was assessed. 2. The Agency policy titled: “Vaccinations” was reviewed on 04/29/26 and required: “….Upon initiation of home health services, the admitting clinician will complete an assessment to determine the patient’s influenza and pneumococcal vaccination status… a form shall be completed indicating the need, patient response, arrangement, and follow- up activities and included in the patient’s medical record….” 3. During interviews with the Director of Nursing and Office Manager on 04/29/26 between 1:35 PM to 3:00 PM, the Administrative staff confirmed the above findings.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: POC = Plan of Care SOC = Start of Care SN = Skilled Nurse Pt / Pts = Patient / Patients

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: A. Based on clinical records review and Staff interview it was determined that Agency Staff did not implement patient interventions as ordered by the physician in the Plan of Care. This was found in 4 of 7 clinical records review. (Pts. # 3, 5, 1 and 6) 3. Pt. # 1 SOC 07/15/2022 Diagnosis: Type 2 Diabetes Mellitus without complications.The clinical record was reviewed on 01/17/2023 at 1:00 PM. The POC for certification period of 12/21/2022 to 02/18/2023 required the SN “Notify Physician of vital sign parameters out of range: …. Blood Sugar, Fasting: greater than 160, less than 60, Blood sugar, Random: greater than 260, less than 60...” The POC also included “SN to obtain blood glucose level every SN visit….” The record included an SOC assessment dated 12/21/2022 and an SN visit dated 01/06/2023 that lacked blood glucose assessments. 4. Pt. #6 SOC 07/15/2022 Diagnosis: Type 2 Diabetes Mellitus with diabetic polyneuropathy. The clinical record was reviewed on 01/17/2023 at 2:00 PM. The signed POC for certification period 09/13/2022 to 11/11/2022, required the SN “Notify Physician of vital sign parameters out of range:….Blood Sugar, Fasting: greater than 160, less than 60, Blood sugar, Random: greater than 260, less than 60....” The POC also included “SN to perform finger stick for blood glucose analysis weekly….”. The record included 2 SN visits dated 09/16/2022 and 09/23/2022 that lacked blood glucose assessments. 5. During interviews with the Administrator, Clinical Manager and Nurse Coordinator on 01/19/2023 from 10:00 AM to 11:30 AM, the Nurse Coordinator confirmed the above findings. Findings include: 1. Pt. # 3 SOC 09/23/2022 Diagnosis: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 01/17/2023 at 1:00 PM. The clinical record contained a POC for certification period 11/22/22 to 01/20/2023 that required SN to notify physician of blood sugar, fasting greater than 160 or less than 60. Random blood sugar greater than 250 and less than 60. The clinical record contained a SN visit dated 12/17/22 with no documented assessment of blood sugar. 2. Pt. # 5 SOC 09/03/2022 Diagnosis: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 01/18/2023 at 11:30 AM. The clinical record contained a POC for certification period 11/02/22 to 12/31/2022 that required SN to notify physician of blood sugar, fasting greater than 160 or less than 60. Random blood sugar greater than 250 and less than 60. The clinical record contained SN visit notes dated 11/15 and 12/09/22 with no documented assessment of blood sugar.