Every finding on record at Accentcare Fairiew Home Health - East LLC

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted 10/21/24 to 10/24/24, during a recertification survey. The facility was in full compliance and no deficiencies were issued.

On 10/21/24 through 10/24/24 a recertification survey was conducted. This resulted in an extended survey at Accentcare Fairview Home Health East. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. The Condition of Participation: Patient rights 484.50 at G434, G442, G454, G458 and G468 were found not met. Unduplicated census previous 12 months: 920 Total home visits conducted: 7 Accentcare Fairview Home Health East 3507 Highpoint DR. N. Suite S140 Oakdale, MN. List Hours of Operation:8am-5PM List total number of records reviewed: 17 In addition to the recertification, the following complaints were reviewed. As a result: H71669132C/108726 H7078034C/97913

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on interview and document review, the agency failed to protect and promote patient rights as outlined in the Combined Federal and State Home Care Bill of Rights. The agency failed to discharge 2 of 5 patients (P1, P2) for an appropriate cause, inform patients and their representatives of pending discharge, allow participation in the discharge planning process and assist patients with obtaining post discharge care and services when continuing care and service needs were identified. These combined failures resulted in Condition level noncompliance. See 434: the agency failed to ensure 1 of 17 patients (P1) was informed and consented to services or care being provided, including any ongoing changes in services. See G442: the agency failed to give written notice in advance of the agency terminating on-going services for 2 of 5 patients (P1, P2). See G454: the agency failed to notify the patient, her representative and other physicians involved with the patient's care the agency was considering a discharge for 1 of 5 patients (P1) who was discharged from the agency. See G458: the agency failed to ensure patient's physician agreed discharge was appropriate with goals met and patient no longer required home health care services for 1 of 5 patients (P2) See G468: the agency failed to provide 2 of 5 patients (P1, P2) with information required related to other available home care providers at the time of a facility-initiated discharge

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to ensure 1 of 17 patients (P1) was informed and consented to services or care being provided, including any ongoing changes in services. Findings Include: P1's start of care (SOC) was 3/4/24. P1's plan of care (POC) for the certification period 7/2/24 to 8/30/24, included diagnoses of chronic venous hypertension with ulcer of left lower extremity, non-pressure chronic ulcer other than left lower leg, manic episode, rheumatoid arthritis, and hemiplegia. The POC further indicated P1 received skilled nurse visits (SNV) two times weekly for two weeks, one time week for two weeks, one visits every other week for four weeks, then one time per week for one week for various assessments, wound care evaluation and treatment and education. Occupational therapy and social worker visits were ordered for one visit. Record review of P1's physician orders revealed the following: -On 7/16/24, an order was obtained by RN-B for skilled nurse visit (SNV) performed with observation and assessment of hypertension with ulcers to both lower extremities, depression, pain assessment and education, fall prevention, home safety training, performed medication reconciliation and education regarding high-risk medications. No additional visits required at that time due to patient had wound care provided by medical nurses. May schedule up to two as needed (PRN) visit for re-evaluation if future needs were identified. -On 7/25/24, an order was obtained by LPN-A for wound care to new right lower extremity wound. Keep clean and dry and leave open to air. continue to monitor. On left lower extremity ulcer, clean with normal saline, pat dry, apply skin prep to peri wound, apply medical grade honey gel, cover with bordered foam and change dressing two times per week and PRN for soiled or dislodged dressing. Record review of P1's care coordination and visit notes 7/2/24 through 8/27/24 identified the following: -On 7/18/24, a nurse visit was conducted by licensed practical nurse (LPN)-A with wound care provided. Continuing education was needed on wound management and pain. Patient agreed to elevate lower extremities, seek medical care for increased pain, swelling, redness or warmth and try ice pack on legs and Tylenol as needed for pain. P1's care giver was not contacted. -On 7/23/24, a nurse visit was conducted by LPN-A with wound care performed. It was noted client had an appointment scheduled on 8/5/24, with a primary care physician. Continued education was given on wound care management, and pain. Pt agreed to have care giver manage wounds on non-nursing days and keep her scheduled appointments. P1's care giver was not contacted. -on 7/30/24, P1 contacted an agency nurse regarding concerns related to her nursing visits frequency, which had recently been significantly reduced from two times per week to one visit every two weeks. P1 requested to talk with her case manager registered nurse (RN)-B. It was noted RN-B would be notified to contact P1. -on 7/31/24, clinical manager (CM)-A obtained order from P1's primary physician to discharge P1 from home care services as she had not been seen in clinic for two months and the nurse practitioner would be unable to continue signing orders for her care. The agency did have a plan of care that remained active until 8/30/24 and P1 had an pending appointment to establish care with a primary physician on 8/5/24. -on 7/31/24, FM-C called the agency, angry P1 was not receiving wound care and services as ordered. FM-C stated P1 needed on-going wound care. CM-A notified FM-C the provider would no longer sign orders for home care services due to P1 was non-compliant and did not keep her scheduled appointments with her provider. CM-A notified FM-C the agency had obtained an order for P1 to be discharged from home care services. P1's medical record lacked signed service agreements regarding the reduction in services, documentation a reduction in frequency of nurse visits was discussed with P1 or signed documentation P1 had been notified of the significantly reduced SNV to occur after the 7/23/24, nurse visit that had been provided two times per week. There was no evidence P1's primary care giver, FM-C, had been notified of the significantly reduced skilled nurse visits nor that she was notified and agreed to complete the two times per week dressing changes. During interview on 10/21/24, at 3:50 p.m. FM-C stated P1 had nurse visits two times per week to evaluate and change dressing to an ulcer on P1's leg that would not heal. The home care agency just stopped coming out to see P1. The agency had not called to notify anyone they were no longer going to come out, they just stopped nurse visits to P1 without any warning. FM-C had gotten involved about a week after the agency had stopped their visits and called the agency when P1 notified her the agency was only going to come every two weeks from now on and not the two times per week they were doing. The agency had shown FM-C how to change the dressing but had never mentioned to her that she would need to take them over. The first time she heard they were no longer going to see P1 was when FM-C had called the agency on 7/31/24 and she was P1's appointed health care agent. During telephone interview on 10/22/24, at 10:50 a.m. social worker for the Department of Human Services (SW)-D stated she had visited P1 and FM-C on 8/8/24, to investigate a self-neglect report from the agency. The agency was concerned if P1 or FM-C were caring for P1's wounds properly and about P1's dirty home environment. P1 had been seen by the wound care clinic that week and her home environment was clean during SW-D's visit. SW-D felt there was poor communication between the home care agency and the patient. P1 had reported to her, there had been no indication the agency was going to reduce her services or of the pending discharge. P1 relied heavily on assistance from FM-C to coordinate appointments and lots of other things. SW-D was concerned with P1's lack of services and was trying to help her coordinate other services. Before other services could be coordinated, she heard P1 was in the hospital. The vulnerable adult report had indicated P1 had received skilled nurse visits and social work visits and due to missed appointments the physician had dropped services. SW-D stated that was not true, P1 had a doctor appointment prior to when SW-D had seen her on 8/8/24 and had another appointment schedule the following week. When interviewed on 10/22/24, at 12:45 p.m. P1's primary care provider, nurse practitioner (NP) states she had last seen P1 on 5/15/24, at the wound care clinic. She had missed four appointments since then and it was the clinic's policy to discharge after a certain number of missed appointments. She had not personally taken any calls from the home care agency. Her office had called while she was on vacation on 7/31/24, and asked if it was okay to discharge P1 from home care since she did not have a primary provider to sign orders and she had told them yes. She had signed P1's recertification for services 7/1/24 through 8/30/24 for home care, and at that time, had asked for a social worker visit to work with her and so they were still trying to find some options for her. During telephone interview on 10/22/24, at 3:00 p.m. LPN-A stated she had completed visits for P1 on 7/18/24, and 7/23/24. She could not remember if she had discussed discharge with P1, but it was the agency practice to discuss discharge ongoing. She had talked with P1 about decreasing her nurse visit frequency but could not remember if she had specifically talked with P1's care giver FM-C. The agency did not complete service agreements to show patient participation for changes in services. She did not have written documentation that reducing nurse visits had been discussed or agreed upon. LPN-A had noticed a change in P1's wounds and new wound on the other leg on her visit 7/23/24, so had called her doctor at the veteran's agency (VA) clinic for wound care orders. On P1's last visit from the agency on 7/23/24, LPN-A had not been aware that P1 was going to have decrease nurse visit frequency, or a pending discharge so had not discussed that with P1 or P1's primary care giver FM-C. When interviewed on 10/22/24, at 3:30 p.m. CM-A stated P1's wounds had been healing and so the team had discussed decreasing the frequency of nurse visits. She thought the plan had been to reduce P1's visits to 1xwk to monitor the wound and go from there. The MD decided he was not going to sign orders for P1 anymore. CM-A had called the physician and because P1 did not follow recommendations and skipped medical appointments it would be okay for the agency to discharge her from home care services. She was not aware LPN-A had obtained orders from P1's VA physician for wound care on 7/25/24. During telephone interview on 10/23/24, at 8:30 a.m. RN-B stated she was never P1's case manager. She kept getting listed as her case manager in the medical record, but she had never made any nurse visits to P1. She was not sure who was her case manager. It may have been a travel nurse that was no longer employed at the agency. The agency's policy, Patients' Rights, Responsibilities and Consent, with review date 2/15/22, indicated patient's rights included to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to the completion of all assessments, the care to be furnished, based on the comprehensive assessment, establishment and revision of the plan of care, disciplines that would furnish the care, the frequency of visits, expected outcomes of care, including patient identified goals and anticipated risks and benefits, any factors that could impact treatment and any changes in the care to be furnished. Patients had the right to be notified verbally and in writing prior to the start of care and as changes occurred. Patients had the right to receive proper written notice consistent in advance of a specific serv ice being furnished if the agency believed that the service may be non-covered care or in advance of the agency reducing or terminating ongoing care.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to give written notice in advance of the agency terminating on-going services for 2 of 5 patients (P1, P2) who were reviewed for discharges. P1's start of care (SOC) was 3/4/24. P1's plan of care (POC) for the certification period 7/2/24 to 8/30/24, included diagnoses of chronic venous hypertension with ulcer of left lower extremity, non-pressure chronic ulcer other than left lower leg, manic episode, rheumatoid arthritis, and hemiplegia. The POC further indicated P1 received skilled nurse visits (SNV) two times weekly for two weeks, one time week for two weeks, one visits every other week for four weeks, then one time per week for one week for various assessments, treatment and education. Occupational therapy and social worker were ordered for one visit. Record review of P1's care coordination and visit notes 7/2/24 through 8/27/24 identified the following: -On 7/23/24, a nurse visit was conducted by licensed practical nurse (LPN)-A with wound care performed. Reduction of services and/or pending discharge was not documented in the visit note or care coordination note. No further nurse visits were documented after 7/23/24. -on 7/31/24, clinical manager (CM)-A obtained order from nurse practitioner (NP)-B to discharge P1 from home care services as she had not been seen in clinic for two months and unable to continue signing orders for her care. -on 7/31/24, family member (FM)-C called the agency, angry P1 was not receiving wound care and services as ordered. FM-C stated P1 just needed on-going wound care. CM-A notified FM-C the provider would no longer sign orders for home care services due to P1 was non-compliant and did not keep her scheduled appointments with her provider. CM-A notified provider had given the orders for P1 to be discharged from home care services. P1's medical record lacked documentation P1 or FM-C had received written notice in advance of the agency discharging P1 on 7/31/24. During telephone interview on 10/21/24, at 3:50 p.m. FM-C stated the home care agency just stopped coming out to see P1. FM-C called the agency on 7/31/24, and was notified P1 was discharged. She was P1's appointed health care agent and neither she or P1 had received any advance notice of the discharge. During telephone interview on 10/22/24, at 3:00 p.m. LPN-A stated the agency did not complete service agreements to document patients were notified of pending decrease or termination of services. LPN-A was not aware the 7/23/24 visit would be P1's last visit. She had not been notified P1 was going to be discharged so she had not discussed a pending discharge with P1 or FM-C, nor had she given P1 a written notice of discharge. When interviewed on 10/22/24, at 3:30 p.m. clinical manger (CM)-A stated she had called P1's physician and because P1 did not follow recommendations and skipped her medical appointments it would be okay for the agency to discharge her from home care services as the agency did not have a provider to sign orders. P1 was not given advance notice of the discharge as required. P2's SOC was 1/22/21. P2's POC for the certification period 11/18/21 to 1/16/21, included diagnoses of pneumonitis due to inhalation of food or vomit, malignant neoplasm (cancer) of tongue, dysphagia (swallowing difficulty), malignant neoplasm of head, face and neck, pain, diabetes, depression, encounter for attention to tracheostomy (artificial tube in neck to breathe), and encounter for attention to gastrostomy (artificial tube in stomach for nutrition). The POC further indicated P2 received SNV one time per week for one week, one time every three weeks for three weeks, then one visit every two weeks for two weeks for various assessments, medication management, infection control, management of diabetes and symptoms, and education. Review of P2's coordination and visit notes identified the following: -On 12/28/21, a skilled nurse visit (SNV) was completed. Medications were setup and assessments completed. No discharge plan was documented as patient was unable to manage medications. -On 1/7/24, registered nurse (RN)-D documented a case conference note for recertification due to the issue of not able to manage complex or high-risk medications regimen which required ongoing skilled nurse treatment. -On 1/14/22, RN-E completed a desk discharge for P2, without home visit. The discharge was documented as a RN discharge data collection only with no visit made. P2's physician order dated 1/27/24, indicated payor change with new start of care needed. P2's medical record lacked evidence P2 had been notified of pending discharge prior to being discharged from the agency on 1/14/24. During interview on 10/22/24, at 3:30 p.m. clinical manager (CM)-A stated P2 had a recertification visit in January 2022. P2 had a fee source change soon after, so the agency did a desk discharge and then P2 should have been admitted immediately again for services but was not. It had just gotten missed. She should have been set up for another start of care and that was not done so her services got unintentionally dropped. P2 was not notified of pending discharge and did not receive written notification of discharge. The Minnesota Department of Health Combined Federal and State Bill of Rights, last revised November 2019, identified patients would receive at least ten calendar days advance notice of the termination of a service by a home care provider. The agency's policy, Patients' Rights, Responsibilities and Consent, with review date 2/15/22, indicated the patient's rights included patients had the right to be notified verbally and in writing prior to the start of care and as changes occurred. Patients had the right to receive proper written notice consistent in advance of a specific serv ice being furnished if the agency believed that the service may be non-covered care or in advance of the agency reducing or terminating ongoing care. The agency's Transfer and Discharge policy with last revision date 6/13/24, directed agency staff to notify the patient, the patient's representative, attending physician, podiatrist, or allowed practitioner of the patient's condition and reason for discharge. In addition, the patient would be provided with verbal and/or written instructions regarding, as appropriate: i. Community services available to the patient; ii. Medication use and/or a copy of the final medication profile; iii. Home exercise plan; iv. Any procedures and/or treatments to be performed; and/or v. Follow-up visits for physician care

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to notify the patient, her representative and other physicians involved with the patient's care the agency was considering a discharge for 1 of 5 patients (P1) who was discharged from the agency. P1's start of care (SOC) was 3/4/24. P1's plan of care (POC) for the certification period 7/2/24 to 8/30/24, included diagnoses of chronic venous hypertension with ulcer of left lower extremity, non-pressure chronic ulcer other than left lower leg, manic episode, rheumatoid arthritis, and hemiplegia. The POC further indicated P1 received skilled nurse visits (SNV) two times weekly for two weeks, one time week for two weeks, one visits every other week for four weeks, then one time per week for one week for various assessments, wound care evaluation and treatment and education. Occupational therapy and social worker were ordered for one visit. Review of P1's medical record identified the following: Care Coordination note 7/30/24, P1 contacted an agency nurse regarding concerns related to the reduction in frequency of nursing visits from two times per week to one time every other week. P1 requested to talk with her case manager registered nurse (RN)-B. It was noted RN-B would be notified to contact P1, however no return call had been documented. Care Coordination note 7/31/24, clinical manager (CM)-A obtained order from nurse practitioner (NP)-B to discharge P1 from home care services as she had not been seen in clinic for two months and NP-B unable to continue signing orders for her care. Care Coordination note 7/31/24, FM-C called the agency, angry that P1 was not receiving wound care and services as ordered. FM-C stated P1 needed on-going wound care. CM-A notified FM-C the provider would no longer sign orders for home care services due to P1 was non-compliant and did not keep her scheduled appointments with her provider. CM-A notified FM-C the agency had obtained an order for P1 to be discharged from home care services. During interview on 10/21/24, at 3:50 p.m. FM-C stated P1 had nurse visits two times per week to evaluate and change dressing to an ulcer on P1's leg that would not heal. The home care agency just stopped coming out to see P1. The agency had not called to notify anyone they were no longer going to come out, they just stopped nurse visits to P1 without any warning. FM-C had gotten involved about a week after the agency had stopped their visits and called the agency when P1 had told her they were only going to come every two weeks and not the two times per week they were doing. The first time she heard they were no longer going to see P1 was when FM-C had called the agency on 7/31/24 and she was P1's appointed health care agent. During telephone interview on 10/22/24, at 10:50 a.m. social worker for the Department of Human Services (SW)-D stated she had visited P1 and FM-C on 8/8/24, to investigate a self-neglect report from the agency. The agency was concerned P1 or FM-C were caring for P1's wounds properly and about P1's dirty home environment. P1 had been seen by the wound care clinic that week and her home environment was clean during SW-D's visit. SW-D felt there was poor communication between the home care agency and the patient. P1 relied heavily on assistance from FM-C to coordinate appointments and lots of other things. The vulnerable adult report had indicated P1 had received skilled nurse visits and social work visits and due to missed appointments the physician had dropped services. SW-D stated that was not true, P1 had a doctor appointment prior to when SW-D had seen her on 8/8/24 and had another appointment scheduled the following week. During telephone interview on 10/22/24, at 3:00 p.m. LPN-A stated she had completed visits for P1 on 7/18/24, and 7/23/24. On P1's last visit from the agency on 7/23/24, LPN-A had not been aware that P1 was going to have decrease nurse visit frequency, or a pending discharge so had not discussed that with P1 or P1's primary care giver FM-C. When interviewed on 10/22/24, at 3:30 p.m. CM-A stated she had called P1's physician and P1 had not followed recommendations to promote wound healing and had skipped scheduled medical appointments. The physician had given the agency permission to discharge as the primary physician would no longer follow the patient. She was not aware P1 had a veteran's agency (VA) physician involved who had given orders for wound care, and the agency had not notified that physician P1 was discharged for cause. The agency policy Physician Plan of Care with revision date 3/1/19, identified any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative, caregiver and all physicians issuing orders for the home health agency plan of care. The agency policy Transfer and Discharge of Patients with revision date 6/13/24, identified a patient may be discharged for reasons including safety concerns, or the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the Agency to operate effectively is seriously impaired. The patient/patient representative and physician, podiatrist or allowed practitioner would be advised of the plan to discharge/transfer. The clinical manager or designee would make efforts to resolve problems prior to discharge/transfer. The agency would have documentation of their efforts made to resolve issues.

Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure patient's physician agreed discharge was appropriate with goals met and patient no longer required home health care services for 1 of 5 patients (P2) reviewed for discharge from agency. P2's SOC was 1/22/21. P2's POC for the certification period 11/18/21 to 1/16/21, included diagnoses of pneumonitis due to inhalation of food or vomit, malignant neoplasm (cancer) of tongue, dysphagia (swallowing difficulty), malignant neoplasm of head, face and neck, pain, diabetes, depression, encounter for attention to tracheostomy (artificial tube in neck to breathe), and encounter for attention to gastrostomy (artificial tube in stomach for nutrition). The POC further indicated P2 received skilled nurse visits (SNV) one time per week for one week, one time every three weeks for three weeks, then one visit every two weeks for two weeks for various assessments, medication management, infection control, management of diabetes and symptoms, and education. Review of P2's medical record identified the following: Coordination care note dated 12/28/21, identified a SNV was completed. Medications were setup and assessments completed. A discharge plan was not documented as P2 was unable to manage her medications. -On 1/7/22, registered nurse (RN)-D documented a case conference note for recertification due to the issue of not able to manage complex or high-risk medications regimen which required ongoing skilled nurse treatment. -On 1/14/22, RN-E completed a desk discharge for P2, without home visit. The discharge was documented as a RN discharge data collection only with no visit made. P2's physician order dated 1/27/22, indicated payor change with new start of care needed. P2's medical record lacked evidence of physician notification or order to discharge from home health care services. There was no evidence P2's primary physician had been consulted regarding a potential discharge of services. During interview on 10/23/24, clinical manager (CM)-A stated P2's services had gotten dropped prematurely and she had been discharged in error. P2's discharge was completed due to a change with P2's fee source and a new start of care was needed following the paper desk discharge. The physician was not notified of the discharge due to services were omitted in error. The agency's policy Transfer and Discharge of Patients, last revised 6/13/24 identified when the physician, podiatrist, or allowed practitioner responsible for the home health plan of care and the agency agree that the measurable outcomes and goals outlined in the plan of care have been achieved, and the patient no longer needs the services. The RN/qualified therapist would ensure that the treatment goals and patient outcomes have been met or are no longer applicable. The Agency staff would notify the patient, the patient's representative, attending physician, podiatrist, or allowed practitioner of the patient's condition and reason for discharge.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to provide 2 of 5 patients (P1, P2) reviewed for discharge, with information required related to other available home care providers at the time of a facility-initiated discharge. P1's start of care (SOC) was 3/4/24. P1's plan of care (POC) for the certification period 7/2/24 to 8/30/24, included diagnoses of chronic venous hypertension with ulcer of left lower extremity, non-pressure chronic ulcer other than left lower leg, manic episode, rheumatoid arthritis, and hemiplegia. The POC further indicated P1 received skilled nurse visits (SNV) two times weekly for two weeks, one time week for two weeks, one visits every other week for four weeks, then one time per week for one week for various assessments, wound care evaluation and treatment and education. Occupational therapy and social worker were ordered for one visit. P1's ordered home care services were stopped on 7/31/24, due to non-compliance and failing to keep scheduled medical appointments. P1's care coordination note dated 7/31/24, identified P1 was discharged by the agency as she no longer had a physician following her. Nurse practitioner (NP)-B was unwilling to sign orders related to P1 because she frequently missed her scheduled medical appointments. P1 did have an appointment to establish care at the veteran's clinic on 8/5/24. Per documentation, P1 had wounds that were not healing and new pressure ulcer on her elbow due to resting it on the bed. P1 had a recent nurse visit and was able to verbalize what was needed to help her wounds heal but P1 has chosen not to follow the plan of care. Family has been taught how to do wound care and had provided wound care between nurse visits in the past and were felt to be capable to provide care until P1 could find a provider to follow her for home health. An order was received to discharge P1 from home care services. P1's medical record lacked evidence P1 had received information related to other available home care providers in the area. During interview on 10/21/24, at 3:55 p.m. family member (FM)-C stated the agency just stopped coming to see P1 without any notice. The agency did not provide P1 with a list of alternative health care agencies in the area that may provide care and services. During telephone interview on 10/22/24 at 10:50 a.m. social worker for the Department of Human Services (SW)-A stated she had visited P1 and FM-C on 8/8/24. They asked her if there were other agencies in the area that could provide P1's care as they had not been provided with a list of alternative health care agencies, When interviewed on 10/22/24, at 3:00 p.m. licensed practical nurse (LPN)-A stated she had not provided P1 or FM-C with a list of other providers in the area when she completed her last visit on 7/23/24, because she had not been aware of the pending discharge. When interviewed on 10/22/24, at 3:30 p.m. clinical manager (CM)-A stated the agency had not provided P1 a list of other home care providers in the area at the time of the facility-initiated discharge. P2's SOC was 1/22/21. P2's POC for the certification period 11/18/21 to 1/16/21, included diagnoses of pneumonitis due to inhalation of food or vomit, malignant neoplasm (cancer) of tongue, dysphagia (swallowing difficulty), malignant neoplasm of head, face and neck, pain, diabetes, depression, encounter for attention to tracheostomy (artificial tube in neck to breathe), and encounter for attention to gastrostomy (artificial tube in stomach for nutrition). The POC further indicated P2 received skilled nurse visits (SNV) one time per week for one week, one time every three weeks for three weeks, then one visit every two weeks for two weeks for various assessments, medication management, infection control, management of diabetes and symptoms, and education. On 1/14/22, RN-E completed a desk discharge for P2, without home visit. The discharge was documented as a RN discharge data collection only with no visit made. Physician order dated 1/27/22, indicated P2 had a payor change with new start of care needed. P2's medical record lacked evidence P2 had received information related to other available home care providers in the area prior to being discharged from the agency on 1/14/22. During interview on 10/23/24, at 3:30 p.m. CM-A stated a desk discharge had been completed due to a change in her payor source. A new start of care should have been initiated but it was missed. P2 had not been given information or listing regarding alternative home care providers in the area that could provide care prior to the facility-initiated discharge as required. The agency's Transfer and Discharge of Patients policy, revised 6/13/24, identified the patient would be provided with verbal and/or written instructions regarding, as appropriate for community services available to the patient, medication use and/or a copy of the final medication profile, home exercise plan, any procedures and treatments to be performed and follow up visits for physician 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 observation, interview and document review, the agency failed to ensure all medications, including dose, route, frequency and time of administration, was comprehensively assessed and documented for 3 of 7 patients (P7, P9, P12) whose medications were reviewed during home visits. P7’s plan of care (POC) for certification period 10/17/24 to 12/15/24, indicated P7’s start of care (SOC) was 8/18/24, and diagnosis included acute cystitis (a bladder infection), hypertensive heart disease with heart failure (high blood pressure), anxiety, major depressive disorder (depression), and migraine. POC included a comprehensive medication list. During skilled nurse visit on 10/21/24 at 1:33 p.m., patient inquired about a medication not on her medication list, divalproex 1 tab daily for migraines. P7 asked registered nurse (RN)-A what the medication was used for. RN-A explained use of the medication and inquired how long P7 had been taking it. P7 stated she had been taking since she was discharged from the hospital. P7 indicated she took it PRN, not as prescribed as once daily. P7 stated she was unaware she was supposed to be taking it daily. Medication label indicated a fill date of 9/10/24. Divalproex was not listed on P7’s medication list on POC. During comprehensive medication review during the visit, multiple medication discrepancies were found. In addition to the divalproex, P7 stated she has stopped taking clonidine hcl 0.1 mg about a month ago. Clonidine was listed as an active medication on POC. P7 stated she thought she was still taking duloxetine 60 mg daily. Duloxetine was not found in P7’s home. P7 stated she had been feeling increased anxiety lately and had an appointment scheduled with her primary care provider (PCP) in a few days to address anxiety. P7 had a bottle of calcium 600 mg with D3 with an expiration date on the bottle of November 2023. Calcium with D3 was not included on P7’s POC and she stated she was not aware the medication was expired. P7 stated she had been taking pregabalin 150 mg once daily. Pregabalin was listed on POC as taking twice daily. P7 stated she had not been taking vitamin C or zinc gluconate daily as listed on the POC. P7 stated she did not have a current medication list in her home. During interview on 10/21/24 at 2:26 p.m., RN-A stated a medication reconciliation should be competed at start of care and changes updated with every visit. The PCP should be contacted with any discrepancies for clarification and orders. RN-A confirmed medication discrepancies and stated she would be updating the provider. RN-A stated it was concerning P7 did not have her duloxetine in her home and was experiencing increased anxiety. P9’s POC for certification period 9/1/24 to 10/30/24, indicated P9’s SOC was 9/1/24, and diagnosis included zoster without complications (shingles), malignant neoplasm of left breast (breast cancer), hypertensive heart disease (high blood pressure), type 2 diabetes, and chronic obstructive pulmonary disease (a lung disease caused by damage to the airway). POC included a comprehensive medication list. During a home visit on 10/22/24 at 1:31 p.m., P9 indicated her daughter assisted with managing her medications. Multiple discrepancies were found during a comprehensive review of medications. P9 was taking armodafinil 200 mg daily. POC listed armodafinil at 150 mg daily. P9 was taking gabapentin 100 mg three times a day. POC included gabapentin 100 mg for five days. POC did not include a start and stop date. P9 was taking omeprazole 20 mg twice a day; POC included omeprazole once per day. P9 was taking prednisone 5 mg daily as a long term medication. POC included prednisone as a taped medication. POC did not indicate start and stop dates for prednisone. P9 reported taking the following medications not listed on the POC: krill oil 500 mg daily, niacin 500 mg daily, iron slow release 45 mg daily, and cranberry 15000 mg twice a day. P9 stated she did not have a current medication list in her home. P9 was also observed to be on oxygen, which was not on the medication list. During interview on 10/23/24 at 3:00 p.m., clinical manger (CM) stated the medication review could have been better and confirmed every patient should have an up to date medication list in their home. During interview on 10/23/24 at 3 p.m., clinical manager (CM) stated medications should be reviewed at start of care by comparing the bottles in the home with a current medication list. All discrepancies should be addressed with the provider and documented. CM stated all patients should have a current medication list in their home. CM stated medication changes should be reviewed at every home visit and education on proper disposal should happen if a medication was discontinued. CM stated medication reconciliation was important to ensure there are not interaction and so providers are aware of what was being taken. P12's plan of care (POC) 10/9/24 through 12/7/24, identified a start of care date 10/9/24. Diagnoses included presence of left artificial hip joint aftercare following joint replacement. heart disease with heart failure, atrial fibrillation (irregular heartbeat), diabetes and a history of falls. Skilled nurse visits (SNV) were ordered 1 visit every week for three weeks then every two weeks for six weeks for various assessments, evaluation, perform and teach wound care and education regarding medications and co-morbid conditions. Physical therapy (PT) was ordered one visit per week for one week then two visits per week for one week then one visit per week for five weeks evaluate rehab potential, home environment and safety and to increase functional independence. Medications included Tylenol 650 milligrams (mg) as needed (PRN), cetirizine 10 mg daily, Eliquis (a blood thinner) 5 mg two times per day (BID), fish oil 1000 mg daily, furosemide 20 mg PRN for edema (swelling), metformin (to treat diabetes) 500 mg daily, metoprolol (for blood pressure) 50 mg BID, mometasone nasal spray (to treat allergy symptoms) PRN, multivitamin 50 plus daily, rosuvastatin (for cholesterol) 10 mg daily, and vitamin D3 1000 units daily, During a home visit on 10/22/24, at 10:00 a.m. P12 stated she was not taking fish oil, a multivitamin, or vitamin D3 as she suspected they may be contributing to some nausea she was experiencing. P12 brought out her bottle of Eliquis, which was labeled 2.5 mg tablets and reported she took one tablet from the bottle every morning and night. P12 stated she had been taking the same Eliquis dose since her heart disease diagnoses two years ago and did not remember having any changes with the medication. Review of P12's hospital discharge summary in her home identified order for Eliquis 5 mg BID, P12 was not aware her hospital discharge orders instructed her to take Eliquis 5 mg tablets BID. On review of medication bottles sent home with her from her hospital discharge identified a bottle of Eliquis 5 mg with instructions to take one tablet every day. P12 stated she had not noticed the changed dosage on the new bottle as she had been using up her old bottle first. Comparison of both bottles of Eliquis in the home identified Eliquis 5 mg BID was filled on 5/8/24, and Eliquis 2.5 mg BID was filled 10/3/24. When interviewed on 10/22/24, at 10:30 a.m. registered nurse (RN)-B stated she had physically looked at all the bottles P12 had on her counter, including the ones she had picked up after her hospitalization. The Eliquis bottle on the counter was the correct dose of 5mg BID. She had reviewed all P12's medications at start of care and recorded what P12 had reported to her that she was currently taking. RN-B was not aware P12 had another bottle of Eliquis in her possession. She did not know why the 2 bottles had different dosages and it would need to be clarified with P12's physician and the pharmacy as soon as possible. During interview on 10/22/24, at 3:30 p.m. the clinical manager (CM)-A stated a patient's medication list should reflect what the patient was actually taking. During interview on 10/23/24, at 8:30 a.m. RN-B stated she had clarified P12's Eliquis order with her physician. P12 was supposed to take Eliquis 5 mg BID. The physician was notified P12 had been taking an incorrect dose of the medication since her hospital return and would now correctly take the prescribed dose of 5 mg BID. The agency's policy Medications: Medication Reconciliation with revision date 5/1/23, identified a complete medication reconciliation should be performed at time of admission. Staff were to compare the medications the patient had in their home with the list of current medications from the discharging agency or provider. The staff were instructed to have the patient collect all medications, including prescribed and over-the-counter medications, and review and record name, dose, route indication and frequency. Staff were to note any differences between the labels, orders and patient use document and resolve the differences by either patient education or clarify orders from the provider.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to discharge 2 of 5 patients for appropriate cause and failed to develop and implement an effective discharge planning process to effectively transition patients from home health services to post home health services care for 2 of 5 patients (P1, P2) reviewed for discharge. P1's start of care (SOC) was 3/4/24. P1's plan of care (POC) for the certification period 7/2/24 to 8/30/24, included diagnoses of chronic venous hypertension with ulcer of left lower extremity, non-pressure chronic ulcer other than left lower leg, manic episode, rheumatoid arthritis, and hemiplegia. The POC further indicated P1 received skilled nurse visits (SNV) two times weekly for two weeks, one time week for two weeks, one visits every other week for four weeks, then one time per week for one week for various assessments, wound care evaluation and treatment and education. Occupational therapy and social worker visits were ordered for one visit. Review of P1's medical record identified the following: -on 7/23/24, licensed practical nurse (LPN)-A conducted a visit for wound care and assessment. Interventions for wound and skin care was discussed as well as planned care coordination with P1's Veteran's Agency (VA) physician. No change of frequency or duration of services were identified. -on 7/31/24, clinical manager (CM)-A obtained order from P1's primary physician to discharge P1 from home care services as she had not been seen in clinic for two months and the nurse practitioner would be unable to continue signing orders for her care. The agency did have a plan of care that remained active until 8/30/24 and P1 had an pending appointment to establish care with a primary physician on 8/5/24. -on 7/31/24, FM-C called the agency, angry P1 was not receiving wound care and services as ordered. FM-C stated P1 needed on-going wound care. CM-A notified FM-C the provider would no longer sign orders for home care services due to P1 was non-compliant and did not keep her scheduled appointments with her provider. CM-A notified FM-C the agency had obtained an order for P1 to be discharged from home care services. During interview on 10/22/24, at 3:00 p.m. LPN-A stated she had not been aware of P1's pending discharge during her visit on 7/23/24, so had not discussed discharge and post discharge care with P1 or her caregiver FM-C. When interviewed on 10/22/24, at 3:30 p.m. clinical manager (CM)-A stated on 7/31/24, she had called the nurse practitioner (NP)-A, who followed P1 for wound care, regarding P1's noncompliance with following recommendations and missed medical appointments and received an order to discharge P1. P1's caregiver was notified of the discharge during a telephone conversation and no further agency visits were conducted. P1's medical record lacked documentation of discharge planning, assistance with post-discharge care and obtaining services and medical appointments for after care. P1 and her representative were not aware of pending discharge and were unable to participate in the discharge planning process despite a continued need for home health services and wound care assessment and evaluation. P1's chosen VA provider had not been notified of details and response to her home health services or her pending discharge. P2's SOC was 1/22/21. P2's POC for the certification period 11/18/21 to 1/16/21, included diagnoses of pneumonitis due to inhalation of food or vomit, malignant neoplasm (cancer) of tongue, dysphagia (swallowing difficulty), malignant neoplasm of head, face and neck, pain, diabetes, depression, encounter for attention to tracheostomy (artificial tube in neck to breathe), and encounter for attention to gastrostomy (artificial tube in stomach for nutrition). The POC further indicated P2 received SNV one time per week for one week, one time every three weeks for three weeks, then one visit every two weeks for two weeks for various assessments, medication management, infection control, management of diabetes and symptoms, and education. Review of P2's coordination and visit notes identified the following: -On 12/28/21, a skilled nurse visit (SNV) was completed. Medications were setup and assessments completed. No discharge plan was documented as patient was unable to manage medications. -On 1/7/24, registered nurse (RN)-D documented a case conference note for recertification due to the issue of not able to manage complex or high-risk medications regimen which required ongoing skilled nurse treatment. -On 1/14/22, RN-E completed a desk discharge for P2, without home visit. The discharge was documented as a RN discharge data collection only with no visit made. A physician order dated 1/27/24, indicated a payor change had occurred with a new start of care needed. During interview on 10/22/24, at 3:30 p.m. CM-A stated the agency had completed a desk discharge for P2 due to a fee source change and P2 should have had a new start of care visit completed immediately for continued services. That was not done and so P2's services had gotten dropped prematurely. P2 had not been notified of pending discharge and did not receive discharge planning prior to the actual discharge. P2's medical record lacked documentation of discharge planning, assistance with post-discharge care and obtaining services and medical appointments for after care. P2 was not made aware of pending discharge and was unable to participate in the discharge planning process despite a continued need for home health services, need for assessment and evaluation and medication management. P2's chosen provider had not been notified of details and response to her home health services or her pending discharge.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to complete and send all necessary medical information pertaining to the patient's health care to involved practitioners to ensure the safe and effective transition of care for 1 of 5 patients (P2) reviewed for discharge. P2's SOC was 1/22/21. P2's POC for the certification period 11/18/21 to 1/16/21, included diagnoses of pneumonitis due to inhalation of food or vomit, malignant neoplasm (cancer) of tongue, dysphagia (swallowing difficulty), malignant neoplasm of head, face and neck, pain, diabetes, depression, encounter for attention to tracheostomy (artificial tube in neck to breathe), and encounter for attention to gastrostomy (artificial tube in stomach for nutrition). The POC further indicated P2 received skilled nurse visits (SNV) one time per week for one week, one time every three weeks for three weeks, then one visit every two weeks for two weeks for various assessments, medication management, infection control, management of diabetes and symptoms, and education. Care Coordination note dated 1/14/22, indicated RN-E completed a desk discharge for P2, without home visit. The discharge was documented as a RN discharge data collection only with no visit made. P2's physician order dated 1/27/22, indicated payor change with new start of care needed. P2's medical record lacked further nurse visits after the desk discharge dated 1/14/22. P2's medical record lacked evidence a discharge summary had been completed and/or P2's physician had been notified P2 had been discharged from home care services on 1/14/22. During interview on 10/24/24, at 11:30 a.m. clinical manager stated a desk discharge had been completed with the intention to restart services under a different fee source immediately following discharge. Because the start of care had been missed, P2 had her services dropped prematurely and no discharge summary had been done. The agency's Transfer and Discharge policy with last revision date 6/13/24, identified at the completion of all Agency services, the last RN, or qualified therapist providing skilled care, would complete the discharge assessment for planned discharges and prepare a discharge summary of care, including services by the home health aide, if applicable, and would coordinate care by notifying the patient's physician, podiatrist, or allowed practitioner and clinical manager. A completed discharge summary would be sent to the physician, podiatrist, allowed practitioner or other health care professional responsible for providing care and services to the patient

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 interview and document review the agency failed to provide services as ordered in the Plan of Care (POC) and failed to inform the physician of services that were not provided . In addition, the agency failed to document the clinical impact and educate the client of the clinical impact of the missed visit. for 4 of 17 patients (P3, P7, P14, P15) reviewed for receiving services as indicated per the POC. P7’s plan of care (POC) for the certification period 8/18/24 to 10/16/24, indicated P7’s start of care (SOC) was 8/18/24, and diagnosis included acute cystitis (a bladder infection), hypertensive heart disease with heart failure (high blood pressure), anxiety, major depressive disorder (depression), and migraine. POC further indicated P7 received skilled nurse visits (SNV) once per week for 7 weeks, then once every 2 weeks for 2 weeks. Review of P7’s clinical record lacked evidence of a SNV completed the weeks of 9/15/24 to 9/21/24. There was no indication in P7’s medical record the provider was notified when the SNV was not completed per POC. During interview on 10/23/24 at 3:00 p.m., clinical manager (CM) confirmed P7 had not received all of the visits per the POC, the physician had not been notified of the missed visits. CM stated her expectation is the physician would be notified of all missed visits and the medical record contained evidence of the notification. P15’s POC for certification period 8/31/24 to 10/29/24, indicated P15’s SOC was 8/31/24, and included diagnosis of atrial fibrillation, urinary tract infection, syncope and collapse (passing out), and hypertension. POC further indicated P15 would receive SNV once per week for 1 week, then once every 2 weeks for 2 weeks, then once per week for 1 week, then once every 2 weeks for 6 weeks. Physical therapy and a social worker were also included in the POC. Review of P15’s clinical record indicated a SNV was completed on 9/5/24 and 9/13/24. Verbal order documented 9/20/24 provided orders to move SNV to the following week for the week of 9/15/24 to 9/21/24. Clinical record failed to show completion of SNV from 9/21/24 through 10/23/24, a time span of 4 weeks. Clinical record failed to show evidence of updates to the provider. During interview on 10/23/24 at 2:57 p.m., CM confirmed the provider had not been updated on the missed visit for the week of 9/22/24 to 9/28/24. CM stated there was a note on 9/28/24 resident wanted to hold off on services, however the provider had not been updated on the patient’s request. CM stated the staff had not followed the process for updating the provider with missed visits. P3's plan of care (POC) 6/30/24 to 8/28/24, identified a start of care date 5/1/24. Diagnoses included multi-system degeneration of the autonomic nervous system, diabetes, kidney disease, chronic obstructive pulmonary disease, and malignant neoplasm of right kidney. Skilled nurse visits (SNV) were ordered one time per week for eight weeks for various assessments, wound care, treatments, education and evaluation. Physical therapy was ordered one time per week for two weeks, then one visit every two weeks for five weeks to improve physical functioning, safety, ambulation and gait training and improving strength and endurance. Review of P3's medical record lacked documentation of any skilled nurse visits for the weeks 7/14/24 and 8/18/24 and physical therapy visits for the weeks of 7/7/24, 8/4/24, and 8/18/24. There was no indication P3's physician had been notified when the SNV and PT visits were not conducted according to P3's POC. Further, there was no documentation of the clinical impact of the missed visits or that education was completed with P3 regarding the clinical impact of the missed visit. During interview on 10/24/24, at 3:45 p.m. the clinical manager stated she was unable to find documentation of the missing visits for P3 and was unable to find the reason the visits were omitted. Findings include: P14's plan of care (POC) for the certification period 7/5/24 to 9/2/24, indicated P14's start of care (SOC) was 5/6/24, and diagnoses included pressure ulcer of right upper back, Multiple Sclerosis, and Trigeminal Neuralgia (a chronic pain disorder that causes severe facial pain). P14 received skilled nurse visits (SNV) once a week for one week then twice per week for eight weeks for various assessments , which included vital signs (blood pressure, temperature, pulse) and wound care to upper right back. Review of P14's clinical record indicated a SNV was completed on 7/1/24, for recertification and a comprehensive assessment was completed. An order was obtained on 7/1/24, for SNV for once per week for 1 week then twice a week for eight weeks. Review of P14's clinical record for recertification period 7/5/24 to 9/2/24 revealed P14 received a SNV on 7/5/24, 7/8/24, 7/11/24, 7/18/24, 7/25/24, 8/5/24, 8/8/24, 8/12/24, 8/15/24, 8/19/24, 8/22/24, and 8/26/24. The record indicated a missed visit for 7/29/24 related to P14 refusal. There was no indication in P14's medical record the provider was notified when the SNV were not conducted according to the POC. Further, there was no documentation of the clinical impact of the missed visit or that education was completed with P14 regarding the clinical impact of the missed visit. During an interview on 10/23/24 at 10:04 a.m., registered nurse (RN)-A verified P14 had not received all the visits per the POC and the physician had not been notified of the missed visit. RN-A stated the physician should have been notified of the missed visit however, RN-A was unaware that the clinical impact of the missed visit should have been documented or that education of the clinical impact of the missed visit should have been done with P14. During an interview on 10/23/24 at 10:42 a.m., clinical manager (CM) verified P14 had not received all the visits per the POC, the physician had not been notified of the missed visit, no documentation was completed on the clinical impact of the missed visit and no education was provided to P14 regarding the clinical impact of the missed visit. CM stated the expectation was that the physician was notified of any missed visits. CM stated the agency needed a better process to ensure the physician is notified of missing visit. CM further stated she was unaware that the clinical impact of the missed visit should have been documented or that education of the clinical impact of the missed visit should have been done with P14. The agency Home Care Staffing Guidelines policy revised 9/18/24, identified when a patient is missed resulting in fewer visits than the physician/practitioner ordered, the clinician shall document the missed visit along with a description of any unmet needs and how the patient needs were met in the clinical record, and the agency will promptly notify the physician/ allowed practitioner of the missed visit.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to provide home health aide services as ordered on referral or notify physician when HHA was not needed for 1 of 17 patients (P12) reviewed for referrals. P12's plan of care (POC) 10/9/24 through 12/7/24, identified a start of care date 10/9/24. Diagnoses included presence of left artificial hip joint aftercare following joint replacement. heart disease with heart failure, atrial fibrillation (irregular heartbeat), diabetes and a history of falls. Skilled nurse visits (SNV) were ordered 1 visit every week for three weeks then every two weeks for six weeks for various assessments, evaluation, perform and teach wound care and education regarding medications and co-morbid conditions. Physical therapy (PT) was ordered one visit per week for one week then two visits per week for one week then one visit per week for five weeks evaluate rehab potential, home environment and safety and to increase functional independence. P12'sDocumentation of Face to Face and Certification for Home Health Services dated 10/3/24, identified the referral was initiated by P12's physician to start SNV and PT services for complex medication teaching and monitoring, gait training, home safety assessment, range of motion and therapeutic exercises. Additional services needed listed a need for home health aide (HHA) services. P12's SOC visit note dated 10/9/24, identified the plan of treatment, frequency and disciplines was discussed with the patient/caregiver and a referral was made to PT. However, the visit note lacked evidence HHA services had been offered as ordered or discussed. During interview during a home visit on 10/22/24, at 10:00 a.m. P12 stated she had been offered HHA services but had refused as she did not feel she needed that type of assistance. P12's medical record lacked evidence P12's physician had been notified of her refusal of the ordered HHA services as required. When interviewed on 10/22/24, at 3:30 p.m. the clinical manager (CM)-A stated it was the agency's practice to call for start of care orders for services needed and notify the physician at that time if some services were not needed or refused. An order to discontinue the HHA due to services not needed should have been included in P12's SOC order to notify the physician the service was not needed or wanted. The agency's policy Admission of Patients last revised 9/17/24, identified after completing the initial assessment, the nurse would contact the provider for approval of the plan of care, report the patient's status and obtain additional information and/or orders.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted 10/25/21 to 11/2/21, during a recertification survey. The facility was in full compliance and no deficiencies were issued.

A partial extended survey was conducted at Accentcare Fairview East Home Care October 25 through November 2, 2021 and was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Complaint investigations were also completed. Findings of the complaints were as follows: H7166009 -21862 substantiated with deficiency cited at G572 & 00265 H7166010- 21374 unsubstantiated BRANCH OFFICES: None Unduplicated Census 962 NUMBER OF HOME VISITS MADE: 7 NUMBER OF RECORDS REVIEWED: 17 HOURS OF OPERATION: 8:00 a.m. to 5:00 p.m.

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 interview and document review, the agency failed to ensure each patient had an intial assessment visit within 48 hours of the referral date for 5 of 17 patients (P3, P5, P10, P14, P17) reviewed in the sample. P17's POC dated 8/9//21 to 10/7/21, indicated the SOC date was 8/9/21. The POC included diagnoses of aftercare following surgery for neoplasm (cancer), malignant neoplasm of thyroid gland, nodes of head, face and neck, dysphagia (difficulty swallow) diabetes, hypertension, anxiety, depression, pain, paralysis of vocal cords and larynx, and tracheostomy status (opening at front of the neck to help with breathing). Review of P17's clinical record identified a referral for home care services from the University Of Minnesota Medical Center dated 8/3/21. Review of P17's medical record indicated the SOC assessment was not completed until 8/9/21. The clinical record failed to identify any reason why P17 had not been assessed within 48 hours of the referral date of 8/3/21, and lacked evidence P17's physician was notified of the delay in the SOC date. During interview on 10/27/21, at 10:44 a.m. the director of patient care services stated he reviewed the referrals for the agency, determined if there was a skilled need and assigned them to a clinician. He checked the expected SOC date on the referral and if the agency was unable to comply with the SOC date, he should obtain a verbal order for a SOC date the agency could furnish the services. He documented the physician contact in the communication notes as well as in a verbal order and/or generate a new referral. The director of patient care services verified this had not been occurring and did not know why. When interviewed on 10/27/21, at 4:54 p.m. the clinical operations director stated if a SOC visit could not be made within 48 hours of receipt of the referral for services it would be expected the clinician either generate a physician order or a new referral as well as document the reason in a communication note. The agency's policy, Admission Of Patients/Patient Identifiers, with revision date 6/28/21, indicated following a decision to admit a patient to the agency, it would be assigned and the initial assessment visits would be made within 48 hours of referral, within 48 hours of the patients return home, or on the physician ordered SOC date. The agency's policy, Availability Of Services-Acceptance, Admission, Ongoing and Discharge, with revision date 12/19, indicated the SOC assessment visit must be performed on the SOC date ordered by the physician, within 48 hours of the referral, within 48 hours of the patient's return home from the hospital or within 48 hours after election of hospice care, unless the physician, patient or representative had requested a different SOC date. P3's plan of care (POC) dated 9/8/21 to 11/6/21, indicated start of care (SOC) date of 9/8/21. The POC included diagnoses of extremely low birth weight of newborn, respiratory distress of newborn, respiratory failure of newborn, respiratory syncytial virus. The POC indicated skilled nursing one time per week for one week then one visit every four weeks for eight weeks to evaluate client and develop a pediatric plan of care, administer prescribed injection, assess and evaluate comorbid conditions. Review of P3's clinical record revealed signed order from physician at M Health Fairview Woodwinds dated 8/19/21 for Synagis (helps newborn to fight off infection) to be administered by home care nurse every 28-30 days unless determined by payer or requested by physician/parent to be done in clinic; dose the following months: November, December, January, February and March, and if able, starting ASAP due to early RSV season. P3's client coordination notes report indicated referral date of 9/1/21. SOC assessment was completed on 9/8/21. The clinical record lacked notification or orders to physician for delay in start of care. P5's plan of care (POC) dated 10/24/21 to 12/22/21, indicated start of care (SOC) date of (8/25/21). The POC included diagnoses of chronic venous hypertension with ulcer of bilateral lower extremity, non pressure chronic ulcer of right ankle, non pressure chronic ulcer of left ankle, lymphedema, paraplegia, hypothyroidism, and non pressure chronic ulcer of left foot. P5's POC indicated skilled nursing two times per week for eight weeks and one time per week for one week. Review of P5's clinical record revealed a referral from provider at M Health Fairview Vascular dated 8/2/21 for home care nursing. SOC was completed on 8/25/21. The clinical record lacked evidence of a physician order for the delay of SOC. P10's plan of care (POC) dated 10/11/21 to 12/9/21, indicated start of care (SOC) date of (10/11/21). The POC included diagnoses of type two diabetes with diabetic peripheral angiopathy without gangrene, muscle weakness, other chronic pain, low back pain, age- related osteoporosis, repeated falls, and alcohol dependence. P10's POC indicated physical therapy (PT) two times per week for three weeks, weekly for three weeks, once every two weeks for two weeks then weekly for one week to educate the client in fall prevention and provide balance training and instruct in home exercise program. Occupational therapy (OT) weekly for nine weeks to provide therapeutic exercises to restore functional strength, instruct in safe transfers and safe use of equipment. P10's POC indicated both PT and OT to provide medication management. Review of P10's clinical record indicated referral date of 10/7/21 from primary physician. SOC was completed on 10/11/21. P10's clinical record failed to identify any reason for delay of the SOC, and lacked evidence of a physician order for delayed SOC date.

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 observation, interview, and document review, the agency failed to complete a comprehensive drug review to ensure the accuracy of all medications/dosages for 4 of 17 patients (P9, P3, P7 and P10) whose medications were reviewed during home visits and record review. P3's plan of care (POC) dated 9/8/21 to 11/6/21, indicated start of care (SOC) date of 9/8/21. The POC included diagnoses of extremely low birth weight of newborn, respiratory distress of newborn, respiratory failure of newborn, respiratory syncytial virus. The POC indicated skilled nursing one time per week for one week then one visit every four weeks for eight weeks to evaluate client and develop a pediatric plan of care, administer prescribed injection, assess and evaluate comorbid conditions. P3's POC included the following medications: synagis 100 milligrams (mg)/ milliter (ml) 1.08 ml intramuscular (IM) monthly per weight. Upon review of the clinical record, provider ordered epinephrine (1:1000 amp) 0.01 mg/kg, IM as directed for adverse reaction. This was not included on the POC. When interviewed on 11/2/21 via email, at 2:14 p.m. COD-A stated the agency did not have any standing orders for any medications. P7's plan of care (POC) dated 9/22/21 to 11/20/21, indicated start of care (SOC) date of 7/24/21. The POC included diagnoses of chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, fracture of left lower leg, congestive heart failure, chronic pain, type two diabetes, schizoaffective disorder, nicotine dependence, dependence on supplemental oxygen and morbid obesity. P7's POC indicated physical therapy (PT) one time per week for one week to assist with gait/ambulation training, occupational therapy one time per week for six weeks to assist with safety and fine motor skills, and home health aide one time per week for one week, then two times per week for six weeks to assist with personal cares. P7's POC included the following medications: acetaminophen 300 milligrams (mg)-codeine 30 mg, two tablets oral (po) every (q) four hours as needed (prn); albuterol sulfate 2.5 mg/3 milliliters (ml) (0.083%) solution for nebulization q six hours prn; aspirin 325 mg po daily (qd); atorvastatin 40 mg po q bedtime (hs); buproprion HCL XL 150 mg 24 hour tablet po qd; vitamin D3 125 micrograms (mcg) po qd; clozapine 100 mg po qd with supper; clozapine 50mg po qd with supper; divalproex ER 250 mg tablet, take 750 mg po q hs; escitalopram 10 mg po qd, freestyle libre 14 day sensor kit, use as directed; furosemide 40 mg po qd; geri-kot po q hs; glipizide 5 mg po qd; incruse ellipta 62.5 mcg/actuation powder for inhalation one puff po qd; ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/ 3 ml nebulization solution four times daily (qid); lantus solostar U-100 insulin 100 unit/ml (3 ml) subcutaneuous pen, 10 ml qd; lisinopril 2.5 mg po q hs; mag-g 27mg magnesium (500 mg) tablet po two times per day (bid); memantine 10 mg po bid; metformin 500 mg, two tablets po bid; myrbetriq 50 mg extended release po qd; nicotine 4 mg buccal lozenge as directed; omeprazole 20 mg po qd; oyster shell calcium-vitamin D3 500 mg -200 unit po bid; polyethylene glycol 3350, 17 gram dose po qd; stool softener 100 mg capsule po bid; trulicity 1.5 mg/0.5 ml subcutaneous pen injector, inject 1.5 mg under the skin q seven days; vascepa one gram capsule, take two grams po bid; vitamin C 500 mg po qd; and vraylar 3 mg po qd. During home visit on 10/26/21, at 9:00 a.m. P7 and spouse confirmed that she was no longer taking buproprion HCL XL and the nicotine lozenges. She stated she quit smoking in August and quit the two named medications months ago. She stated on 10/13/21, the glipizide was discontinued and started on jardiance 10 mg po qd. P7 also stated that her dose of trulicity had doubled to two pens per week. The POC indicated lantus 10 ml qd, P7 stated she takes 20 units per day. P7 confirmed that she had a pain pump implanted that provided continued dosing of pain medication which was not indicated on the POC. Surveyor observed P7 on continuous oxygen, which was was also not indicated on the POC. When interviewed on 10/27/21 at 4:54 p.m. clinical operations director (COD)-A stated she expected the oxygen and pain pump to be included on the POC from SOC. She also stated the therapists are expected to ask the patients if there has been any medication changes at the home visits, which would in turn generate a verbal order and run a drug interaction report. P10's plan of care (POC) dated 10/11/21 to 12/9/21, indicated start of care (SOC) date of (10/11/21). The POC included diagnoses of type two diabetes with diabetic peripheral angiopathy without gangrene, muscle weakness, other chronic pain, low back pain, age-related osteoporosis, repeated falls, and alcohol dependence. P10's POC indicated physical therapy (PT) two times per week for three weeks, weekly for three weeks, once every two weeks for two weeks then weekly for one week to educate the client in fall prevention and provide balance training and instruct in home exercise program. Occupational therapy (OT) weekly for nine weeks to provide therapeutic exercises to restore functional strength, instruct in safe transfers and safe use of equipment. P10's POC indicated both PT and OT to provide medication management. P10's POC included the following medications: aspirin 81 mg po qd, atorvastatin 40 mg po q hs, B12 1,000 mg po qd, baclofen 10 mg 1/2 tablet po bid, CO Q-10 200 mg po bid, ferrous sulfate 325 mg po every other day (qod), lisinopril 40 mg po qd, magnesium 250 mg po qd, melatonin 5 mg po q hs, metoprolol succinate ER 100 mg po qd, miralax 17 gm dose po qd prn, mirtazapine15 mg po q hs, one touch ultra test strips-test blood sugars three times per day, oxybutynin chlroride 5 mg po bid, sodium chloride 1 gm po qd, tylenol extra strength 500 mg - one tablet po tid, vitamin D3 25 mcg po qd, and zegerid 20 mg-1.1 gm capsule one po qd. During home visit on 10/27/21, at 1:00 p.m. surveyor reviewed medications with P10. Observed two bottles of acetaminophen next to her recliner. One was 500 mg strength, the other was 650 mg strength. P10 stated she took two tablets of the 500 mg of acetaminophen in the morning and two tablets of the 650 mg acetaminophen in the evening. She also stated her physician did give her acetaminophen 300 mg-codeine 30 mg pain pills when she discharged from the hospital that she took "once in a while" when her pain was severe. The POC did not indicate the accurate dosage of acetaminophen P10 was taking, and it did not indicate the acetaminophen 300 mg-codeine 30mg. During home visit on 10/27/21, at 1:00 p.m. surveyor observed exercises occupational therapist (OT)-A performed with P10. OT-A did not ask P10 about any new medications or medication changes during the visit. When interviewed on 10/27/21, at 1:45 p.m. OT-A stated they do a "full bottle check" at SOC and at end of care. OT-A also stated she asks if patients have any medication changes at the home visits.. The facility policy titled Medications: Medication Reconciliation, with revision date 12/1/19, indicated a complete medication reconciliation would be performed at the time of admission to home care by comparing the medications the patient had in the home with the list of current medications from the primary care provider and comparing the information to the referral source information. The home health clinicians were responsible to develop a current list of medications. It was crucial the admitting clinician had the list of the patient's active/current medications from the primary care provider. Any differences that were noted between the medications labels, physician orders and patient use, including over the counter medications, would need to be documented and resolved either by patient education or clarified by orders from the provider. The clinician would carefully compare the medication list from the drugs in the patient's home to the medication list supplied by the primary care provider and identify any discrepancies between the two lists. If the discrepancies could not be resolved during the visit, the clinician would report and resolve the discrepancies with the provider with in one day and amend the medication profile as per the primary care provider's orders. P9's POC dated 10/5/21 to 12/3/21, indicated a SOC date of 10/5/21. The POC included diagnoses of normal pressure hydrocephalus, retina detachment of right eye, multiple sclerosis, atrial fibrillation, methyleneteetrahydrofolate reductase deficiency (a deficiency in an enzyme that plays a role in processing amino acids).and history of stroke. P9's POC indicated he received PT visits weekly for five weeks then every two weeks for four weeks, for various assessments, establish a home exercise program, instruct and evaluate gait, pain, safety in home, pressure ulcer prevention and medication management and OT one time per week for five weeks for various assessments and instruction. P9's POC included the following medications: alpha lipoic acid capsule (a supplement) 100mg by mouth (po) daily, aspirin 81 milligram (mg) po daily, COQ-10 (a supplement) 125 mg po daily, vitamin B12 1,000 microgram(mcg) per millimeter (ml) inject one ml in the muscle one time weekly, Emergenc-C 1,000 mg po daily, lisinopril 2.5 mg po daily, magnesium 400 mg po daily, multivitamin one tablet po daily, neomycin-polymyzin-dexameth 3.5 mg per ml eye drops as directed, prednisolone acetate 1% eye drops as directed daily, Preservision AREDS one cap. two times per day (BID). During a home visit on 10/27/21, at 9:00 a.m. P9's family member (FM)-A stated she setup P9's medications every week and had left his medications bottles she had setup on the table so they could be reviewed. P9's current medication bottles were compared to the medications listed on the POC, however, several medications in the home were not on the POC. The following medication bottles, which FM-A verified P9 took daily, were not listed on P9's POC: L-Methyfolate (supplement) one po daily, prevagen (supplement) one po daily, vitamin D3 1000 units po daily, protandim (supplement) one po daily, omega 3 (supplement) one po daily and Allerclear (antihistamine) one tablet po daily. FM-A stated P9 had been on the medications for quite some time, some for years, as some of the medications were needed to treat his enzyme deficiency. FM-A stated P9 also went to the local clinic every three months for a Botox injection to his left leg to treat his multiple sclerosis and weakness in that leg, however, Botox injections were not listed on the POC. There were also discrepancies with the medications that were listed on P9's POC. FM-A stated P9 took COQ-10 300 mg po daily not the 125 mg as listed on the POC. Review of P9's medical record indicated a referral had been initiated on 10/28/21, following a face to face physician visit on the same date. A referral and medication orders for the SOC visit date 10/5/21, was requested, however was not received. P9's medical record also lacked communication documentation or orders from the primary physician related to the discrepancies found with P9's medications as well as orders for the medications P9 reported to be taking daily. During interview on 10/27/21, at 10:30 a.m. physical therapist (PT)-A stated he had patients bring out all their medication bottles at SOC and verified with the patient on what was actually being taken and the bottles in the home. PT-A thought P9 probably had not brought out all of his bottles at the SOC visit. PT-A indicated he reviewed the patient medications with patients at the SOC and reviewed the medications with the referral orders, he was unsure why all the referral medications were not listed on the POC. He would ask patients every visit if they were having any issues or changes with medications, however, the focus of his visits was therapy. During telephone interview on 10/28/21, at 9:06 a.m. clinical supervisor (CS)-A stated she reviewed the POC's after they were locked, including review of the medications with the referral orders. She indicated therapy needed to do a full medication review when they were in the patient's homes doing the SOC visit but this was not a strong assessment skill for them. The therapist should have the referral medication list with them at the SOC visit at minimal and compare it to what the patient was taking. She was unsure why the patient medications were not getting on the POC accurately, as she also checked the medications against the referral medication list and felt it could be related to the SOC process as well as the new computer system. When interviewed on 10/27/21, at 4:54 p.m. the clinical operations director (COD)-A stated the physical therapist did the medication reconciliation at the SOC when it was a therapy only admission. The therapist was to follow the medication reconciliation policy, which included asking the patient about any medications they were taking in the home. The therapist was expected to verify what medications were on the referral and what medications were in the home and call the provider with any discrepancies. If medications were listed on the referral and not on the POC, it would have been verified with the provider the medications were no longer active and documented as a physician communication. A verbal order would have been done and the medication list would have been updated.

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 interview and document review the agency failed to provide services as ordered in the plan of care (POC) and failed to inform the physician of services that were not provided for 5 of 17 patients (P1, P4, P13, P15, P17) reviewed for receiving services as indicated per the POC. Findings include: P1's POC dated 10/26/21 to 12/24/21, indicated a start of care (SOC) date of 2/28/21. The POC included diagnoses of peripheral venous insufficiency, non pressure chronic ulcers, encounter for change or removal of wound dressing, lymphedema (build up in the soft body tissues), hypertension, obesity, anxiety, depression, and panniculitis (painful bumps or nodules). P1 required skilled nurse visits (SNV) ordered two times per week for one week and three times per week for eight weeks for various assessments and wound care and home health aide (HHA) ordered two times per week for one week and three times per week for eight weeks, however was lacking a description of services. P1's POC dated 6/28/21 to 8/26/21, included orders for SNV three times per week for eight weeks and two times per week for one week for various assessments and wound care and HHA visits three times per week for eight weeks and two times per week for one week, however, was lacking a description of the HHA services. Review of P1's clinical record revealed missed SNV the week of 7/4/21 and 8/15/21. The record lacked documentation that P1's physician was notified of the missed visits. P1's POC dated 8/27/21 to 10/25/21, included orders for SNV one time per week for one week, three times per week for seven weeks, four times per week for one week and one time per week for one week for various assessments and wound care and HHA visits one time per week for one week, three times per week for eights weeks and one time per week for one week, however, was lacking a description of the HHA services. Review of P1's clinical record revealed missed HHA visit the week of 10/17/21. The record lacked documentation that P1's physician was notified of the missed visit. P4's POC dated 10/11/21 to 12/9/21, indicated a SOC date of 8/12/21. The POC included diagnoses of diabetes, non pressure ulcer of the lower legs, kidney disease, edema (fluid build up in the soft tissues), and heart disease. P4 required SNV two times per week for nine weeks for various assessments and wound care, physical therapy (PT) one time per week for one week for an evaluation visit and occupational therapy (OT) one time per week for one week for an evaluation visit. P4's POC dated 8/12/21 to 10/10/21, included orders for SNV one time per week for one week and two times per week for eight weeks for various assessments and instruction. Review of P4's clinical record revealed missed SNV the week of 8/15/21 and 8/29/21. The record lacked documentation that P4's physician was notified of the missed visits. P13's POC dated 8/1/21 to 9/29/21, indicated a SOC date of 12/10/19. The POC included diagnoses of dehiscence of amputation stump (wound separation), disorder of the skin related to radiation, persistent postprocedural fistula (abnormal connection between two body parts), lymphedema, peripheral vascular disease, atrial fibrillation, and hypertension. P13 required SNV six times per week for eight weeks then three times per week for one week. P13's POC dated 4/3/21 to 6/1/21, included orders for SNV one time per week for one week, six times per week for eight weeks and two times per week for one week for various assessments and wound care. Review of P13's clinical record revealed missed SNV the week 5/2/21. The record lacked documentation P13's physician was notified of the missed visit. P13's POC dated 6/2/21 to 7/31/21, included orders for SNV four times per week for one week and six times per week for eight weeks for various assessments and wound care. Review of P13's clinical record revealed missed SNV the week of 6/20/21. The record lacked documentation P13's physician was notified of the missed visit. P13's POC dated 8/1/21 to 9/29/21, included orders for SNV six times per week for eight weeks and three times per week for one week for various assessments and wound care. Review of P13's clinical record revealed missed SNV the week of 8/15/21. The record lacked documentation P13's physician was notified of the missed visits. P15's POC dated 3/12/21 to 5/10/21, indicated a SOC date of 3/12/21. The POC included diagnoses of fracture of right humerus, kidney failure, heart disease, diabetes, myasthenia gravis, dysphagia (difficulty swallowing) and hypotension. P15 required PT visits one time per week for one week, two times per week for two weeks, three times per week for one week and two times per week for one week. Review of P15's clinical record revealed missed PT visits week 3/29/21. Review of email communication with the director of clinical operations on 11/2/21, at 12:32 p.m. indicated two physical therapy visits were made and one physical therapy supervision was made, however the record did not identify a third physical therapy visit as ordered for the week of 3/29/21. The record lacked documentation that P15's physician was notified of the missed visits. P17's POC dated 8/9/21 to 10/7/21, indicated a SOC date of 8/9/21. The POC included diagnoses of aftercare following surgery for neoplasm (cancer), malignant neoplasm of thyroid gland, nodes of head, face and neck, dysphagia, diabetes, hypertension, anxiety, depression, pain, and paralysis of the vocal chords and larynx. P17 required SNV one time per week for six weeks, one time every two weeks for two weeks and one time per week for one week for various assessments and treatment. PT visits one time per week for one week for an evaluation visits and occupational therapy (OT) one time per week for two weeks, one time every three weeks for three weeks, two times per week for three weeks and one time per week for one week for various assessments, education and training. Review of P17's clinical record revealed missed SNV week of 8/15/21, 9/12/21 and 9/19/21. The record lacked documentation that P17's physician was notified of the missed visits. During interview on 10/27/21, at 4:54 p.m. the director of clinical operations stated the agency did not obtain a physician order for missed visits, however, the clinician was expected to do a communication note with the physician and the agency notified the physician of missed visits via fax. Faxed documentation for the above missed visits was requested, however, none were received. Review of the agency's policy, Physician Plan Of Care, revised 6/10/21, indicated notification of the physician was required when there was an inability to perform an ordered visit.

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: Based on interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 1 of 17 patients ( P9) and failed to notify the physician the services were not provided. P9's POC dated 10/5/21 to 12/3/21, indicated a SOC date of 10/5/21. The POC included diagnoses of normal pressure hydrocephalus, retina detachment of right eye, multiple sclerosis, atrial fibrillation, methyleneteetrahydrofolate reductase deficiency (a deficiency in an enzyme that plays a role in processing amino acids).and history of stroke. P9's POC indicated he received PT visits weekly for five weeks then every two weeks for four weeks, for various assessments, establish a home exercise program, instruct and evaluate gait, pain, safety in home, pressure ulcer prevention and medication management and OT one time per week for five weeks for various assessments and instruction. Review of P9's clinical record revealed a Home Care Nursing Referral dated 10/28/21, which included documentation of a Medicare Certified Home Health Agency Provider Attestation of Face to Face documentation, signed by the provider on 10/28/21, indicated nursing, occupational therapy (OT) and physical therapy(PT) services were medically necessary home health services for P9, and certified P9 was homebound. P9's clinical record lacked documentation that a nursing assessment visit was completed. There was no indication the provider was notified when the nursing assessment visit was not conducted as ordered on the physician referral orders. The director of patient care services was interviewed on 10/27/21, at 11:22 a.m. during which he indicated he reviewed the agency's referrals and determined who would make the initial SOC visit. If it was determined there was no need for skilled nursing, a whole new order would need to be requested for home care services. In that case, he would call the referral source and ask them to send a new referral without the nursing ordered. When interviewed through email conversations on 11/2/21, at 12:32 p.m. the director of clinical operations (DCO) indicated the referrals the agency received from the hospital system were predefined to order registered nurse, home health aide and physical therapy services. The actual services the physician ordered could be located in the face to face documentation or in updated orders in the patient's medical record. P9's clinical record lacked updated orders which would indicate no nursing services would be provided as were ordered on the face to face documentation. The agency's policy, Admission Of Patients/Patient identifiers, revised 6/28/21, directs the clinician to contact the primary providers as soon as possible after the completion of the initial evaluation for review, approval of the POC and to give a report of the patient's status and obtain additional necessary orders. The agency's policy, Physician Plan Of Care, revised 6/10/21, indicated if, after the evaluation visits, it was determined the initial orders for the POC do not meet the patient's needs, the assessing clinician would contact the primary physician to approve additions or modifications to the original plan.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to perform skilled nursing visits (SNV) only as ordered by a physician for 1 of 17 patients (P11) and failed to obtain physician orders for physical therapy visits for 1 of 17 patients (P16) reviewed for home care services. P16's plan of care (POC) dated 7/30/21 to 9/27/21, indicated start of care (SOC) date of 7/30/21. The POC included diagnoses of urinary tract infection, alzheimer's disease, dementia, heart failure, macular degeneration, and hypothyroidism. P16's POC indicated physical therapy (PT) one time per week for two weeks, two times per week for three weeks and weekly for four weeks. Review of P16's clinical record revealed an extra PT visit was completed the week of 8/23/21. The clinical record revealed a verbal order created on 8/17/21 which indicated PT effective 8/15/21 two times per week for two weeks, then weekly for four weeks, but indicated do not send to provider. When interviewed via email on 11/1/21, at 4:53 p.m. clinical operations director (COD)-A stated the verbal order did not need to be sent for signature "because they (therapist) wrote the supervisory visit on their (therapist) system and our (agency) system will write the frequency that was remaining. The frequency did not change." Review of policy "Physician Plan of Care," revised 6/10/21, indicated any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or NPPs issuing orders for the HHA plan of care. Findings include: P11's plan of care (POC) dated 9/15/21 to 11/13/21, indicated start of care (SOC) date was 5/18/21. P11's POC included diagnoses of heart disease, hypertension, post traumatic stress disorder and history of stroke. P11 required SNV one time per week for one week, one time every three weeks for six weeks and one time per week for one week. Review of P11's clinical record revealed an extra, as needed, (prn) SNV was made on 6/8/21, however, the physician did not order prn visits and there was no physician order obtained to complete this visit. During email conversations on 11/2/21, at 12:32 p.m. the clinical director of operations indicated prn visits were included in the POC when it was felt they may be needed. Review of the agency's policy Physician Plan Of Care, revised 6/10/21, indicated any revision to the plan of care due to changes in the patent health status must be communicated to the patient, caregivers and all physicians or nurse practitioner's issuing orders for the POC.

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, interview and document review, the agency failed to ensure field staff wore proper personal protective equipment (PPE), based on the current guidance from the Center for Disease Control (CDC), while providing home care service to 3 of 7 patients (P6, P9, P10) observed during a home visit. Findings include: P6's plan of care (POC) dated 9/29/21 to 11/27/21, indicated start of care (SOC) was 6/12/19. The POC included diagnoses of chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), anorexia (eating disorder), adjustment disorder with anxiety and depression, hypertension, malnutrition, nicotine dependence, and dependence on supplemental oxygen. P6 required skilled nurse visits one time per week for one week and one time every two weeks for six weeks for various assessments and medication management. During a home visit on 10/26/21, at 1:30 p.m. registered nurse (RN)-A and an unidentified interpreter entered P6's home. RN-A was wearing a surgical mask that covered her nose and mouth, however, was not wearing eye protection. RN-A greeted P6 and her family member (FM)-F, drew up a chair in P6's small bedroom, three feet next to P6, who was seated on her bed, and proceeded to perform a complete nursing assessment. P6 and FM-F were not wearing a face mask or eye protection. RN-A documented assessment on her laptop as she proceeded with her assessment. RN-A was in close contact and frequently required to touch P6's person during the assessment and visit, which lasted greater than one hour. While she remained seated within three feet of P6, RN-A set up P6's medications.. Although RN-A was sitting directly beside and in front of P6, she was never observed to wear eye protection during the home visits, per the Minnesota Department of Health (MDH) and Centers for Disease Control and Prevention (CDC) guidelines when providing direct patient care. During an interview on 10/26/21, at 2:45 p.m. RN-A stated the agency did not require staff to wear eye protection for home visits and patient care. The staff were to wear face shields when providing care in congregate living settings, however, they were not required in home care settings. She indicated the agency required eye protection for all patient care a while ago, in the past but did not now. P9's POC dated 10/5/21 to 12/3/21, indicated a SOC date of 10/5/21. The POC included diagnoses of normal pressure hydrocephalus, retina detachment of right eye, multiple sclerosis, atrial fibrillation, methyleneteetrahydrofolate reductase deficiency (a deficiency in an enzyme that plays a role in processing amino acids).and history of stroke. P9's POC indicated he received PT visits weekly for five weeks then every two weeks for four weeks, for various assessments, establish a home exercise program, instruct and evaluate gait, pain, safety in home, pressure ulcer prevention and medication management and OT one time per week for five weeks for various assessments and instruction. During a home visit on 10/27/21, at 9:00 a.m. physical therapist (PT)-A entered P9's home wearing a surgical mask that covered his mouth and nose. He was not wearing eye protection. PT-A greeted P9 and his family member (FM)-E, P9 was wearing a face mask, however, he wore the mask under his nose and FM-E was not wearing a face mask. PT-A assessed P9's vital signs, requiring him to be shoulder to shoulder with P9 for several minutes. After PT-A's initial assessment, he remained within two to three feet of P9 through out his one hour visit, performing various exercises and ambulation as well as bathroom assessment. Although PT-A was within two to three feet distance of P9 through out the hour long visit, he was never observed to wear eye protection during the home visit, per MDH and CDC guidelines when providing direct patient care. P10's plan of care (POC) dated 10/11/21 to 12/9/21, indicated start of care (SOC) date of (10/11/21). The POC included diagnoses of type two diabetes with diabetic peripheral angiopathy without gangrene, muscle weakness, other chronic pain, low back pain, age- related osteoporosis, repeated falls, and alcohol dependence. P10's POC indicated physical therapy (PT) two times per week for three weeks, weekly for three weeks, once every two weeks for two weeks then weekly for one week to educate the client in fall prevention and provide balance training and instruct in home exercise program. Occupational therapy (OT) weekly for nine weeks to provide therapeutic exercises to restore functional strength, instruct in safe transfers and safe use of equipment. P10's POC indicated both PT and OT to provide medication management. During home visit on 10/27/21, at 1:00 p.m. surveyor observed P10's cares with occupational therapist (OT)-A. OT-A did not have eye protection on for duration of visit, totaling 45 minutes. When interviewed on 10/27/21, at 1:45 p.m. OT-A stated staff was instructed to wear eye protection in facilities, but they did not have to wear it in client homes. During an interview on 10/27/21, at 10:10 a.m. PT-A stated the agency no longer required staff to wear eye protection when providing patient care in their homes. PT-A indicated he had just checked on this issue prior to starting his visits this morning. During email conversation and interview with the director of clinical operations (DCO) on 10/27/21, at 3:44 p.m. The DCO indicated CDC and MDH guidelines indicated eye shields were recommended but not required. The agency requires staff to wear eye protection for patient care with covid presumed or positive cases and eye protection was available for staff to wear anytime the staff should want them, however, they were not required for all patient care. Because recommendations indicated eye protection should be worn for patient care but did not specifically indicate they must be worn, the agency has not required their staff to wear the eye protection for all patient care at this time. Review of the agency's policy, Disease Response, Management and Employee Matters: Coronavirus (COVID-19) Exposure, revised 7/1/21, indicated universal masking was required for all patient/caregiver interactions, avoid shaking hands and sanitize work areas and equipment after each use. Review of the agency's policy, Personal Protective Equipment (PPE) COVID-19 Guidelines, dated 10/14/21, indicated individuals with a presumed or confirmed diagnosis of COVID-19 would require the healthcare worker to utilize the following PPE: N95 respirator mask, gown, gloves, and eye protection. The policy did not address PPE use for general patient care population.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure communication with all physicians and health care professionals involved in the plan of care for 1 of 17 patients (P5), when all providers involved were not notified of treatment or frequency changes. P5's plan of care (POC) dated 10/24/21 to 12/22/21, indicated start of care (SOC) date of (8/25/21). The POC included diagnoses of chronic venous hypertension with ulcer of bilateral lower extremity, non pressure chronic ulcer of right ankle, non pressure chronic ulcer of left ankle, lymphedema, paraplegia, hypothyroidism, and non pressure chronic ulcer of left foot. P5's POC indicated skilled nursing two times per week for eight weeks and one time per week for one week. Review of P5's clinical record revealed the initial referral for services and all interim verbal orders were sent to and signed by Laura Kenney, NP, as follows: Referral dated 8/2/21, wound care orders/SN two times per week dated 9/4/21, wound cares to be done three times per week and as needed (PRN) dated 9/11/21, wound care orders dated 9/18/21, wound care orders three times per week dated 9/21/21, decrease SN to two times per week dated 10/15/21, wound care orders dated 10/18/21, SN to continue wound care two times per week for nine weeks and three PRN for wound care dated 10/22/21. The POC's dated 8/25/21- 10/23/21 and 10/24/21-12/22/21 were sent to and signed by Mark Roberts, MD. When interviewed through email conversation on 11/1/21 at 11:46 a.m. and 12:28 p.m. regarding multiple and consulting providers, the CDO referred the surveyor to agency policy "Physician Plan of Care," revised 6/10/21. When interviewed on 11/2/21, at 12:05 p.m. M Health Fairview Vascular clinic manager confirmed the orders for the NP did come through the portal for signature. She was not familiar with the physician Mark Roberts as he was not affiliated with the clinic. Review of policy "Physician Plan of Care," revised 6/10/21, indicated any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or NPPs issuing orders for the HHA plan of care.