OSF Healthcare Home Care

“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 clinical record review and staff interviews, for 1 of 2 (Pt. #8) Pts. reviewed requiring a gastrostomy tube, the Agency failed to ensure that the POC was followed. Findings include: 1.Pt. #8 was admitted for Home Health services on 11/08/25 with the diagnoses of but not limited to, Sepsis, Unspecified Organism and Encounter for Attention to Gastrostomy. The clinical record was reviewed on 12/02/25 and included the POC effective 11/08/25 which required, “Skilled Nursing: Skilled Nurse to assess tube site… Tube site care: Cleanse daily with soap and water. Cover with gauze dressing and secure with tape as needed. Skin barrier film wipes as needed to protect skin from tape/moisture.” The clinical record lacked documentation the above intervention was implemented. 2. During an interview on 12/03/25 at 12:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor confirmed the above findings.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder and staff interviews, the Agency failed to provide the name of the Administrator. This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) clinical records reviewed. Findings include: 1. The Agency Pt. admission folder was reviewed on 09/29/25. The folder lacked information identifying the Administrator’s name. 2. The clinical records of the following Pts. were reviewed on 09/30/25, 12/02/25, and 12/03/25. Pt. #1. SOC 06/26/25. Pt. #2. SOC 08/31/23. Pt. #3. SOC 09/15/25. Pt. #4. SOC 09/26/25. Pt. #5. SOC 11/30/25. Pt. #6. SOC 09/16/25. Pt. #7. SOC 02/16/25. Pt. #8. SOC 11/08/25. Pt. #9. SOC 10/26/25. Pt. #10. SOC 12/11/23. Pt. #11. SOC 11/10/25. Pt. #12. SOC 09/30/25. Pt. #13. SOC 04/09/25. Pt. #14. SOC 05/15/25. Pt. #15. SOC 01/24/25. Pt. #16. SOC 03/03/25. Pt. #17. SOC 02/10/25. The clinical records reviewed lacked the Administrator’s name. 3. The following home visits were conducted on 09/30/25 and 12/02/25. Pt. #1. SOC 06/26/25. Pt. #2. SOC 08/31/23. Pt. #3. SOC 09/15/25. Pt. #4. SOC 09/26/25. Pt. #5. SOC 11/30/25. Pt. #6. SOC 09/16/25. Pt. #7. SOC 02/16/25. 4. During an interview on 12/03/25 at 12:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor 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 review and staff interviews, the Agency failed to assess the need for Pneumococcal Pneumonia vaccines in 2 of 17 (Pts. #10 and 13) clinical records reviewed. 2. Pt. #13 was admitted for Home Health services on 04/09/25 with multiple diagnoses, but not limited to, “Acute Cystitis without Hematuria, Metabolic Encephalopathy, Other Specified Chronic Obstructive Pulmonary Disease, Bilateral primary Osteoarthritis of Knee, Unspecified Anxiety Disorder, and Unspecified Depression. The clinical record was reviewed on 09/30/25 and 12/03/25. The clinical record contained the SN – OASIS Start of Care form completed by the RN and dated 04/09/25. The form lacked documentation the RN assessed the Pt. for the Pneumococcal Pneumonia vaccine. 3. During the entrance interview conducted on 09/29/25 (10:46 AM) with the Home Health Manager, Clinical Rehabilitation Supervisor, and the Supervisor. The Clinical Rehabilitation Supervisor stated, during the SOC visit the admitting clinician assesses the need for the Pneumonia vaccine, and the information is documented in the SOC form. 4. During interviews on 12/03/25 at 12:00 PM and 1:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director and Interim Home Health Manager confirmed the above findings. Findings include: 1. Pt. #10 was admitted for Home Health services on 12/11/23 with the diagnosis of Strain of Muscle, Fascia and Tendon of Right Hip. The clinical record was reviewed on 12/03/25. The record lacked documentation of a Pneumococcal Pneumonia immunization assessment.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review, document review, and staff interviews, the Agency failed to ensure the MSW coordinated care to reduce the risk of hospitalization, and/or injury. This was found in 1 of 2 (Pt. #13) closed clinical records reviewed, wherein MSW service was provided. Findings include: 1. Pt. #13 was admitted for home health services on 04/09/25 with multiple diagnoses, but not limited to, “Acute Cystitis without Hematuria, Metabolic Encephalopathy, Other Specified Chronic Obstructive Pulmonary Disease, Bilateral primary Osteoarthritis of Knee, Unspecified Anxiety Disorder, and Unspecified Depression. The closed clinical record was reviewed on 09/30/25 and 12/03/25. The closed clinical record contained the SN – OASIS Start of Care form completed by the RN and dated 04/09/25. The form included documentation the Pt. was alert and oriented, the Pt. had reported “25 falls in 3 months”. The pain assessment included the Pt. experienced pain that rated 6 out of 10 (pain rating: 0 = no pain to 10 = severe pain). The neurological assessment included the Pt. experienced “Issues: anxiety, fatigue. The cardiovascular assessment included “Issues: dyspnea on exertion, fatigues easily, extremity pain. The risk for hospitalization screening included, “History of falls… Decline in mental, emotional, or behavioral status in the past 3 months… Currently taking 5 or more medications”. The section titled, “Admission Certification” included, “Patient lives in 2 bedroom apartment complex alone… home care aide that comes in 3 times a week… Patient has occasional assistance from… who lives over an hour away. Patient’s other… lived with patient previously but passed away… Patient reports that … is looking into assisted living facility for patient… Social Work Focus: Advance Care Planning, resources for assisted living facilities…” The PT Initial Evaluation dated 04/10/25 contained, “Patient stated that she had a fall prior to the physical therapy initial evaluation.” Pt. reported pain 5 out of 10. “Physical Therapy Evaluation… the patient was noted to be extraordinarily fatigued… only ambulate several feet at a time before needed to sit in her rollator walker… The patient stated that she feels that her current caregiver does not help with as much as she could be doing. The patient cannot cook on her own due to extreme fatigue and poor anxiety tolerance, and is unable to perform any cleaning or self-care duties… The patient is not appropriate for skilled home care physical therapy services. Due to the patient’s inability to take care of all household tasks, chores, responsibilities, and reporting poor caregiver compliance, the patient requires a higher level of care due to being unable to take care of herself…” The OT – Initial Evaluation conducted on 04/14/25 contained documentation that the Pt. complained of pain that rated 3 out of 10. “total dependence” (completely depending on another person to perform the task or function independently) for picking up objects from the floor, trash, bed making, laundry, light and heavy cleaning… reports her legs give out on her unexpectedly at times…” The SN visit note dated 04/14/25 completed by the RN and labeled as “Priority” contained documentation that the Pt. was “anxious, forgetful, disoriented/confused, dyspnea on exertion… fatigues easily, extremity pain”. The pain assessment included a pain rating of 8 out of 10. The MSW – Initial Evaluation dated 04/14/25 included documentation that the Pt. was “forgetful”. Interventions included “Advance Care Planning… We will complete HC (Healthcare) POA (Power of Attorney) at next visit… We discussed ALF (Assisted Living Facility) options…”. On 05/02/25 the PT completed the OASIS Transfer form that included, “Reason for Emergency Care… Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis…” The record lacked documentation that the MSW and/or other team members coordinated care with the family as the patient’s physical and cognitive status declined, or that the MSW notified the Agency’s Supervisor(s)/ Manager(s)/ Director of the patient’s declining status, or that the MSW coordinated with community resources, including making the appropriate referral(s) to prevent the patient’s hospitalization. 2. The job description for the “Medical Social Worker-HC” was reviewed on 12/03/25 at 10:00 AM and included, “Primary job responsibilities and accountability: Initiates a plan of treatment to reduce or alleviate problems to ensure the best possible care to the patient… Recommends other disciplines, program… as needed by the patient and/or family…” 3. During an interview on 12/03/25 at 1:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor confirmed the above findings.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on clinical record review and staff interviews, the Agency failed to ensure the supervising OT conducted the OT discharge. This was found in 1 of 3 (Pt. #4) closed clinical records, wherein OT services were provided. Findings include: 1. Pt. #4 was admitted for Home Health services on 09/26/25 with the diagnosis of, but not limited to, Acute and Chronic Respiratory Failure with Hypoxia. The closed clinical record was reviewed on 09/30/25 and 12/03/25. The closed clinical record contained the form titled, “OT – Discipline Discharge” completed by the COTA and dated 10/10/25. On 10/13/25, the OT completed the “OT – Discharge Summary” that indicated an onsite visit was not conducted, but that the Pt. was discharged from OT service on 10/10/25 based on the COTA’s assessment/visit on 10/10/25. The record lacked documentation that the OT conducted an on-site visit/supervision of the COTA to determine whether an OT discharge was appropriate. 2. During an interview on 12/03/25 at 1:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor confirmed the above findings.”