St. Francis Medical Center

“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.”