Every finding on record at Accord

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 10/16/23-10/17/23 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

The 2567 for federal deficiencies has been revised as a result of an informal dispute resolution (IDR) completed on January 3, 2023. On 10/16/23 - 10/17/23 a recertification and a complaint survey was conducted. This resulted in a partial extended survey at Accord Home Health. The agency was found to have met the requirements at 42 CFR. Part 484 for Home Health Agencies. The following complaint was reviewed H72716482C. Unduplicated census previous 12 months: 0 Total home visits conducted: 0 List Parent Location visited, including the addresses as verified while on site: Accord 1515 ENERGY PARK DRIVE SAINT PAUL, MN 55108 List all other branch offices for this agency and identify which of these were visited during this survey and which you pulled records from: N/A - No Branches. List Hours of Operation: 9:00 a.m.- 5:00 p.m. List total number of records reviewed: 2

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and document review, the agency failed to meet the Conditions of Participation (CoP) for Organization and administration of services, 42 CFR § 484.105 at G0940. The agency failed to ensure skilled nursing services and at least one other therapeutic service was made available for patients. See G982 A facility patient list was requested however was not received. A facility employee list was requested however was not received. When interviewed on 10/16/23 at 10:10 a.m., the chief executive officer (CEO) stated the agency had discharged the last home care patient in 12/2022, due to staffing challenges. Furthermore, the agency currently had no staff hired to provide home care services. The CEO stated the agency had been working with a consultant to determine what staffing would be needed to bring back home care services and was hoping to determine their ability to restart home care services or work towards decertification in the next 60 days.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure skilled nursing services and at least one other therapeutic service was made available for patients. Finding include: A facility patient list was requested however was not received. A facility employee list was requested however was not received. When interviewed on 10/16/23 at 10:10 a.m., the chief executive officer (CEO) stated the agency had discharged the last home care patient in 12/2022, due to staffing challenges. Furthermore, the agency currently had no staff hired to provide home care services. The CEO stated the agency had been working with a consultant to determine what staffing would be needed to bring back home care services and was hoping to determine their ability to restart home care services or work towards decertification in the next 60 days.

On 10/5/22 through 10/7/22, a complaint survey was conducted. This resulted in a partial extended survey at Accord. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. H72714902C/71991 was unsubstantiated, however a related deficiency was issued at G464 as a result of the complaint investigation.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to arrange a safe and appropriate discharge when the provider was not aware of the discharge, therefor measurable goals and outcomes were not set forth for 1 of 3 patients (P3) reviewed for inappropriate discharge. P3 was transferred to the hospital to have a scheduled C-section and was discharged by the agency without a safe plan in place. P3’s Home Health Certification and Plan of Care dated 7/17/22, indicated P3 was admitted to the agency on 3/22/2010, with diagnosis’ including major depressive disorder, recurrent, moderate, and type I diabetes mellitus. In addition, the 485-form indicated P3’s mental status was oriented, but forgetful and psychosocially P3 had impaired decision making, poor coping skills and a poor home environment. The patient's physician orders on the 485-form indicated P3 was to have skilled nursing visits every other week for: 1. Assess mental health. 2. Assess medication side effects, medication efficacy and compliance. 3. Assess level of function for early decompensation. 4. Assess vital signs. 5. Medication management to include education on indications, side effects, maintenance of currently medication list in the home, correct administration, and maintenance of adequate medication supply. 6. Assess for vulnerabilities, provide interventions and report to providers as needed. 7. Assist in obtaining community support to maintain independent living as needed. 8. Provide education focused on disease process, stress management, problem- solving, recognizing, and coping with decompensation symptoms, Covid-19 exposure risk, mitigation, and crisis management as needed. P3’s skilled nursing note dated 9/7/22, indicated P3 demonstrated/expressed anxiety and impaired decision making. A pain intensity of 6/10 was documented. Plans for the next visit was scheduled for 9/21/22 for mental health assessment, blood glucose monitoring, vital signs, medication set-up and medication efficacy. The comment section indicated RN-A verbally stated the agency would be discharging all patients by 11/1/22, as they would not be providing services they provide anymore and P3 would be receiving a notice in the mail. P3’s discharge summary dated 9/30/22, indicated P3 had been discharged from facility on 9/15/22, for the reason of hospitalization to have a baby. The summary had a listing of predefined discharge information including: 1. Discharge instruction provided? 2. Medically necessary/appropriate follow-up advised? 3. Medical necessary/appropriate follow-up advised? 4. Understanding of need for medical follow-up advised? 5. Medications reviewed at discharge visit? 6. Able to comprehend discharge instructions? 7. Instructed to call agency of choice for future homecare needs? 8. Informed of discharge prior to discharge date, per agency policy and timeline? RN-A failed to answer the above questions on the discharge summary. The discharge summary indicated P3 was informed she would continue to receive medications from pharmacy every 28 days. The discharge summary was not signed by the provider. P3’s patients notes/messages dated 9/30/22 indicated RN-A placed a call to P3’s physician and informed her that P3 had been discharged from the agency as of 9/15/22 as she was transferred to the hospital delivered her baby. During an interview on 10/6/22, at 11:30 a.m. P3 reported a few days before she had her C-section her nurse, registered nurse (RN)-A, visited her on 9/7/22 and told that over the next few months the company was going to close. On 9/15/22, P3 stated she called RN-A and told her she was in the hospital and had her baby. RN-A called P3 back later that day and told her that she was immediately discharged because of the hospital admission. P3 was unaware if the facility spoke with her psychiatrist. P3 stated she didn’t know what to do, so found the phone number to her pharmacy on her medication bottles and called her pharmacy to make sure her meds would be sent to her. She also indicated the facility did more than her medication management, they worked on coping techniques and mental health concerns. She stated, “I need them more than ever now, having this baby is difficult and I am struggling with my mental health.” P3 reported she didn’t understand that she would lose her services for having a baby. During an interview on 10/6/22, at 12:30 p.m., RN-A stated she was told by administration that nursing can has to discharge for any hospitalization reason and cannot see the patient again. She reported she completed the dismissal form without see the patient and no education was completed. RN-A reported being worried about P3 as she had multiple medication change at the time of the discharge. She stated our agency is trying to find new agencies for all our patients are discharging but reported she doesn’t feel like she is doing discharges the correct way by not having any follow-up when patients are admitted to the hospital. During an interview on 10/6/22, at 2:10 p.m. the Chief Executive Officer (CEO) verified that the agency nurses have been directed to discharge any client who is admitted to the hospital and these clients are not eligible for re-admission. She reported there is a plan in and place and the administrator is in charge of the plan. During an interview on 10/6/22, at 2:32 p.m. the Administrator verified that all clients are to be discharged if they are admitted to the hospital for any reason. She stated the agency sent out a letter dated 9/20/22, to all the clients indicating the facility will not be able to provide for cares for them past 11/1/22, however verified P3 would not have received the letter prior to discharge on 9/15/22. She reported the staff has many processes for discharges, they try to coordinate transfer with other agencies, their provider, and their case worker. She stated a formal letter has not gone out to the provider or the case managers because the agency could not pull all the physicians and case workers data out of the agencies systems software to have an address or fax number. The Administrator believed the hospital would be responsible for the discharge and ongoing care for the patient and stated "When clients are sent to the hospital, isn’t the hospital discharge planning at that point, responsible for the ongoing care of the client?" During an interview on 10/7/22, at 4:05 p.m. a registered nurse from the providers office reported the psychiatric team was unaware of the discharge until 10/5/22, when the agency discharge summary fax was received. She denied any other notifications regarding discharge from the agency. The providers nurse made a call to P3 on 10/7/22, regarding the agency discharge. She stated P3 needed continued home care services and the providers team has reached out to another agency and hopefully will provided soon for P3. An agency policy, titled Care Coordination dated 7/24/22, indicated if a transfer or discharge is necessary for the patient’s welfare because the agency and the physician who is responsible for the home health plan of care agree that the agency can no longer meet the patient’s needs, the agency will arrange a safe and appropriate transfer to other entities. If the service plan/agreement with a patient is terminated by the agency, the organization shall provide the patient and the legal representative with the following information. 1. The effective date of termination. 2. Reason for termination. 3. A list of known licensed home care providers and/or other providers who can meet the patients’ needs in the geographic area of the patient. 4. A statement that the agency will participate in a coordinated transfer of care for the patient to another home care provider, health care provider or caregiver. 5. Name and contact information for a representative employed by the agency with whom the patient may discuss the termination. 6. A copy of the Home Care Bill of Rights with contact information for advocacy agencies. An agency policy, titled Discharge/Transfer policy dated 7/13/22, indicated that the agency would assist clients and their family caregivers in selecting a post-acute care provider (e.g., home Health agency, Skilled Nursing Facility, Inpatient Rehabilitation Facility, or Long-Term Care Hospitals). The physician/allowed non-physician practitioner (NPP) will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan. The impending discharge will be reviewed with other members of the home care team to assure coordination and continuity with the client and family/caregivers. Upon discharge to self-care, the client will receive verbal/written information regarding community resources, medication use, any procedures/treatments to be performed, and follow-up visits for physician cares. To avoid charges of “abandonment” at the time of discharge the agency will document evidence that the decision was not made unilaterally. The client, family and physician participated in the decision to discharge the client from the agency. A completed discharge will be sent to the primary provider with 5 business days of the client’s discharge.

On 6/30/22 through 7/1/22, a survey for compliance with Appendix Z, Emergency Preparedness Requirements, §483.73(b)(6) was conducted during a complaint survey. The facility was NOT in compliance. The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. Because you are enrolled in ePOC, your signature is not required at the bottom of the first page of the CMS-2567 form. Upon receipt of an acceptable electronic POC, an onsite revisit of your facility may be conducted to validate substantial compliance with the regulation has been attained.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure it developed policies and procedure on staffing strategies and surge planning surrounding natural disasters and failed to develop a policy on the use of volunteers in an emergency and other emergency staffing strategies to address surge needs. This had the potential to affect all current 79 patients who were receiving services from the agency. A review of the agency Emergency Preparedness Policy and Procedure revised 2/16/22, revealed the written plan for emergency lacked policies and procedures to facilitate volunteer support for individuals with varying levels of skills and training, the use of volunteers and other staffing strategies and surge planning surrounding natural disasters in its emergency plan. During an interview on 6/30/22, at 12:15 p.m. with the consultant RN and the agency chief executive officer (CEO), the consultant RN stated when asked about other emergency staffing strategies the agency had in plan to address staffing problems during a pandemic, and post pandemic, the consultant stated there was no requirement for home health care agencies to have this in place as this was a only long term care facility requirement. Surveyor reviewed the Home Health Agency Requirements Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Final Rule updated March 26, 2021.

On 6/30/22 through 7/1/22, a complaint survey was conducted. This resulted in a partial extended survey at Accord. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. H72712897C/71006 was substantiated, and related deficiencies were issued at G458, G464, & G962 as a result of the complaint investigation.

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 home health agency (HHA) failed to ensure discharges were appropriate and allowed by the practitioner/physician who was responsible for the home health plan of care for 3 of 3 patients (P1, P5, P8). In addition, failed to ensure the physician/practitioner agreed that the measurable outcomes and goals set forth in the plan of care in accordance had been achieved that the patient no longer needed the HHA's services. This had the potential to affect all 79 patients who currently receiving services from the agency and 31 patients who were abruptly discharged from the agency. P1’s plan of care (POC) for certification period 5/18/22 to 7/16/22, identified diagnoses of Major depressive disorder, recurrent severe without psych features, Anorexia nervosa, restricting type, post-traumatic stress disorder, borderline personality disorder and patient's noncompliance with other medical treatment and regimen. P1's POC included orders for skilled nurse visits (SNV) 5/24/22 to 7/16/22, one visit per week for 8 weeks and the nurse was to order, deliver, and set-up medications in med-minder every other week; administer injectable medication every month; assess medication compliance, efficacy and side effects; assess vital signs as needed; assess mental status, level of functioning and observe for early decompensation symptoms. Also, the nurse was to facilitate medical/psych providers appointments as needed; assist in obtaining community supports to maintain independent living as client accepts; provide psychoeducation focused on disease process, medication compliance, stress avoidance, problem solving abilities, identification of decompensation symptoms, and crisis management as needed. In addition, the POC identified P1 had vision impairment (right side blindness), nutrition impairment (anorexia), had difficulty taking meds correctly, history/potential for suicidal behaviors, potential for self-inflicted injuries, potential for psychotic behaviors and poor impulse control and nurse was to monitor for vulnerabilities at each nursing visit, educate, and report to providers as needed. A report dated 6/27/22, indicated the agency had dropped home care services for in home mental health medication monitoring and administration with little notice to patients and other providers/care team responsible parties. The report indicated P1 was utilizing services due to suicidal plans to take all the medications to overdose. In addition, the agency nurse had set up medications for the last time and scheduled to have pill packs mailed directly to P1 which would allow P1 to have full possession of medication bottles which P1 had verbalized urges to take them in attempts to commit suicide. The report further indicated due to the short notice of ending services P1 was not well prepared for successful transition/discharge which put P1 at risk. During review of the medical record the following was revealed: -Skilled nursing visit (SNV) note dated 6/14/22 indicated P1 had reported feeling anxious and overwhelmed during the visit due to the news of being discharged. The SNV note also indicated the nurse had explained to P1 that she will be discharged due to staffing and the last SNV would be 6/21/22 and P1 would receive monthly injections at the pharmacy and medications would be mailed to P1 in multi-dose medication packs rather in bottles one week at a time. -A Patient Communication dated 6/18/22, sent to the physician indicated “Patient is discharged from home care services due to inadequate staff. A 10-day notice and list of other home care providers was provided to patient and the Washington county case manager.” -SNV note dated 6/21/22 which was 3 days after P1’s physician was notified of the discharge indicated P1 had reported feeling overwhelmed and anxious as she was nervous about being discharged and the nurse had provided reflective listening as P1 spoke about the feelings and concerns. The nurse documented one week of dispills would be mailed to P1 at a time as P1 felt unsafe with having more than one week supply of medications. At the time of the visit the nurse had reminded P1 to take Hydroxyzine is as needed for anxiety and P1 had stated to the nurse “Can I take all 4 capsules at once if I feel like I need to forget about the day, sometimes I just want to sleep and forget about the day when I have a lot of anxiety and feeling overwhelmed.” The nurse had then explained Hydroxyzine was used to help control anxiety and tension caused by nervous and emotional conditions and P1 was to medicine only as directed by your doctor. At the end of the visit the nurse had removed the locked box from P1’s home which contained several bottles of laxative that P1 agreed to let nurse remove with medications from her home. The note further indicated P1’s case manager was aware of the lock box being taken out of the home. -Discharge Summary dated 6/25/22, indicated P1 was discharged from the agency on 6/24/22, due to inadequate nursing staff and a 10-day notice with list of other homecare providers was provided to the patient/caregiver. During further review of the medical record, it was revealed the medical record lacked documentation of the provider/physician response and signed orders about P1 being discharged. In addition, the medical record lacked documentation of the facility coordinating with the patient/caregiver, provider/physician, and other care team members to discuss safe discharge for P1 to include other services aligned for the patient to ensure a smooth transition. P5’s POC for certification period ending 6/6/22, identified diagnoses of Major depressive disorder, anxiety, insomnia, diabetes mellitus and hypertension. P5's POC included orders for weekly SNV, and the nurse was to order, deliver, and set-up medications in med-minder every other week; assess medication compliance, efficacy and side effects; assess vital signs as needed; assess mental status, level of functioning and observe for early decompensation symptoms. During review of the medical record the following was revealed: -SNV dated 5/23/22, indicated P5 had reported to the nurse she was anxious related to discharge from agency and was unable to find housing “[P5] does not have family to assist with medication management.” The note further indicated the discharge date was 5/31/22, and it had been noted P5 had picked on the scab on the left breast which she picked due to increased anxiety. -SNV dated 5/31/22, indicated P5 had reported feeling anxious due to changes going on-finding housing, discharge from this agency and was having trouble falling asleep and this was the last visit by the nurse from the agency due to lack of nursing staff available to provide services. The note further indicated, the locked box for medication storage with key was given to P5’s roommate who stated would keep it secure and P5’s roommate agreed to not give key to P5 “This nurse will call case manager [CM] to report that [roommate] has key.” -Patient Communication note dated 5/19/22, indicated a voice message was left for the county case manager to inform her that P5 will be discharged from agency on 6/2 due to lack of nursing staff. -10 Day Discharge Notice dated 5/19/22, the agency no longer would be able to provide staff to fulfill your home health nursing plan of care effective date of discharge will be 6/2/2022. The notice indicated P5’s physician that ordered home care services had been notified and will be able to provide a referral to another provider that can meet the patient needs. The notice further indicated the agency had been in been in contact with the case manager to further assist in the referral process. -Patient Communication note dated 6/2/22, indicated a phone call was made to the county case manager to inform her that P5’s roommate had key to locked box and the case manager requested current medication list, to be e-mailed to her. The medical record lacked documentation of the agency coordinating with the providers/physician responsible for the patients care and other care team members including the county case managers being involved in the discharge planning to ensure it was safe and smooth to avoid stress for the patient. P8’s POC for certification period ending 6/9/22, identified diagnoses of anxiety, and Attention-deficit hyperactivity disorder, predominantly hyperactive type. The POC identified P8 for Psychosocial status he had demonstrated/expressed anxiety, depressed mood, poor Coping Skills and was forgetful. In addition, the POC indicated P8 received SNV twice monthly from 5/5/22 through 5/31/22 for one month then once monthly from 6/7/22, through 6/9/22. The POC indicated P8 had a decline in mental, emotional, or behavioral status in the past 3 months and nurses were to do collaboration with (case manager, providers, support people) to provide accurate information as needed and the nurse was to assess mental health status, medication side effects and medication efficacy, monitor medication compliance, maintenance of adequate medication supply order refills, deliver and set up medications in med minder or machine. During a review of the medical record the following was revealed: -SNV dated 5/18/22, indicated P8 reported to the nurse he felt anxious, mostly due to being discharged from the agency and felt down because of getting diagnosed with skin cancer. The medical record lacked documentation of the agency communication and coordination with the providers/physician responsible for the patients in the discharge planning to ensure it was smooth to avoid stress for the patient. In addition, the medical record lacked documentation the patient had been provided a notice for being discharged from the agency as resident was informed of the discharge on 5/18/22, visit and was discharged the next day. During interview on 6/30/22, at 12:00 p.m. registered nurse (RN)-A stated “basically we don’t have the staff. I have had to discharge people basically because we don’t have the staff. We are required to send a 10-day notice and that was mailed to [P1] and was about a couple weeks ago.” RN stated licensed practical nurse (LPN)-A had met with P1 and discussed the staffing issue. RN-A stated usually when discharging a patient, the agency nurses/staff would look at the individual and diagnoses and would not discharge a patient unless they felt it was safe to do so. RN-A then stated “we have been dealing with staffing issues for a long time and the nurses are stressed. We don’t have a choice and she probably needed to have a nurse but, in her case, we contacted the case manager and the physician a couple of weeks ago.” RN-A then stated after the previous RN quit who was assigned to P1, she had been assigned to P1 but had told management due to going part time and the distance to P1’s home she was not able to keep P1 in her caseload and had asked management to find a solution to the issue. During interview on 6/30/22, at 3:24 p.m. RN-B stated in the last months since December 2021, the agency had struggled with staffing as a result a lot of staff resigning from their positions or cutting back to part-time. RN-B stated the agency had to discharge a lot of the patients because of not having enough help “the population we serve need the services, but we are short of staff.” RN-B stated she was not involved in the discharge process and discussions for the patients who the agency had discharged due to lack of staff. RN-B stated she had discharged patients from her caseload, but this were patients who had met their goals. RN-B stated she did not have to give any of the patients the 10-day notices and felt the nurses who were managing them all along should have been able to review the patients and would have discharged them appropriately if they had met their goals and each time she was going to discharge a patient she always updated the physician ahead of time, got an order prior to discharging the patient from the agency. During an interview on 6/30/22, at 12:15 p.m. with the consultant RN and the agency chief executive officer (CEO), the consultant stated at the time the large patient number discharges began, she was not working for the agency. She then stated the RN case manager with the agency administrator who was doing clinical management duties was working with people on evaluating the case load looking into the medical necessities. The consultant RN stated who was involved and notified was all supposed to be documented in the patient medical record. The CEO stated there had been a lot of discharges in May and a lot of calls had been made. The consultant RN stated it was the responsibility of the agency to ensure it was communicated to the physician/providers of the patient discharges and it was the goal of the agency to ensure the discharges were safe. The CEO and the consultant acknowledged the patients’ medical records should have had documentation of the communication which was completed with the providers/physician The consultant RN stated her understanding was all the discharged patient cases were reviewed for medical necessity and if they were on Medicare. She then stated most of the discharged patients had mental health diagnoses, had been on case load for a long time which made it hard to determine what services the nurse was doing in the home and thus they were discharged because they had other mental health resources it was thought to be safe to discharge them. During interview on 7/1/22, at 1:51 p.m. P1’s physician stated she was not aware P1 was being discharged from the HHA until P1 had come for an appointment on 6/14/22 and had indicated to the provider she thought the nurse was coming on some intervals and was not going to be completely discharged from the agency. The MD stated the clinic, nor the staff had not received anything from the agency regarding discontinuing P1’s services. P1’s physician stated P1 would benefit with homecare services as P1 had indicated she would overdose with managing her medications. P1’s physician also stated P1 needed some sought of oversight on medications as P1 should not have access to medications more than a week at a time related to suicidal ideation and overdose history and verbalizations “She needs oversight on meds as she would take more than she needs and try to hurt herself.” The agency Discharge policy updated 5/28/21, indicated the following: "3. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan. 4. The impending discharge will be reviewed with other members of the home care team to assure coordination and continuity with the client and family/caregivers..."

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to notify identified other health care professionals who may be involved in the patient's care when discharge becomes imminent for 3 of 3 patients (P1, P5, P8). This had the potential to affect all 79 patients who currently receive services from the agency and 31 patients who were discharged from the agency abruptly. P1’s plan of care (POC) for certification period 5/18/22 to 7/16/22, identified diagnoses of Major depressive disorder, recurrent severe without psych features, Anorexia nervosa, restricting type, post-traumatic stress disorder, borderline personality disorder and patient's noncompliance with other medical treatment and regimen. P1's POC included orders for skilled nurse visits (SNV) 5/24/22 to 7/16/22, one visit per week for 8 weeks and the nurse was to order, deliver, and set-up medications in med-minder every other week; administer injectable medication every month; assess medication compliance, efficacy and side effects; assess vital signs as needed; assess mental status, level of functioning and observe for early decompensation symptoms. Also, the nurse was to facilitate medical/psych providers appointments as needed; assist in obtaining community supports to maintain independent living as client accepts; provide psychoeducation focused on disease process, medication compliance, stress avoidance, problem solving abilities, identification of decompensation symptoms, and crisis management as needed. In addition, the POC identified P1 had vision impairment (right side blindness), nutrition impairment (anorexia), had difficulty taking meds correctly, history/potential for suicidal behaviors, potential for self-inflicted injuries, potential for psychotic behaviors and poor impulse control and nurse was to monitor for vulnerabilities at each nursing visit, educate, and report to providers as needed. A report dated 6/27/22, indicated the agency had dropped home care services for in home mental health medication monitoring and administration with little notice to patients and other providers/care team responsible parties. The report indicated P1 was utilizing services due to suicidal plans to take all the medications to overdose. In addition, the agency nurse had set up medications for the last time and scheduled to have pill packs mailed directly to P1 which would allow P1 to have full possession of medication bottles which P1 had verbalized urges to take them in attempts to commit suicide. The report further indicated due to the short notice of ending services P1 was not well prepared for successful transition/discharge which put P1 at risk. During review of the medical record the following was revealed: -Skilled nursing visit (SNV) note dated 6/14/22 indicated P1 had reported feeling anxious and overwhelmed during the visit due to the news of being discharged. The SNV note also indicated the nurse had explained to P1 that she will be discharged due to staffing and the last SNV would be 6/21/22 and P1 would receive monthly injections at the pharmacy and medications would be mailed to P1 in multi-dose medication pack rather in bottles one week at a time. -A Patient Communication dated 6/18/22, sent to the physician indicated “Patient is discharged from home care services due to inadequate staff. A 10-day notice and list of other home care providers was provided to patient and the Washington county case manager.” -SNV note dated 6/21/22 which was 3 days after P1’s physician was notified of the discharge indicated P1 had reported feeling overwhelmed and anxious as she was nervous about being discharged and the nurse had provided reflective listening as P1 spoke about the feelings and concerns. The nurse documented one week of dispills would be mailed to P1 at a time as P1 felt unsafe with having more than one week supply of medications. At the time of the visit the nurse had reminded P1 to take Hydroxyzine is as needed for anxiety and P1 had stated to the nurse “Can I take all 4 capsules at once if I feel like I need to forget about the day, sometimes I just want to sleep and forget about the day when I have a lot of anxiety and feeling overwhelmed.” The nurse had then explained Hydroxyzine was used to help control anxiety and tension caused by nervous and emotional conditions and P1 was to medicine only as directed by your doctor. At the end of the visit the nurse had removed the locked box from P1’s home which contained several bottles of laxative that P1 agreed to let nurse remove with medications from her home. The note further indicated P1’s case manager was aware of the lock box being taken out of the home. -Discharge Summary dated 6/25/22, indicated P1 was discharged from the agency on 6/24/22, due to inadequate nursing staff and a 10-day notice with list of other homecare providers was provided to the patient/caregiver. During further review of the medical record, it was revealed the medical record lacked documentation of the agency notifying other care team members to discuss safe discharge for P1 to ensure other services were aligned for the patient to ensure a smooth transition. P5’s POC for certification period ending 6/6/22, identified diagnoses of Major depressive disorder, anxiety, insomnia, diabetes mellitus and hypertension. P5's POC included orders for weekly SNV, and the nurse was to order, deliver, and set-up medications in med-minder every other week; assess medication compliance, efficacy and side effects; assess vital signs as needed; assess mental status, level of functioning and observe for early decompensation symptoms. During review of the medical record the following was revealed: -SNV dated 5/23/22, indicated P5 had reported to the nurse she was anxious related to discharge from agency and was unable to find housing “[P5] does not have family to assist with medication management.” The note further indicated the discharge date was 5/31/22, and it had been noted P5 had picked on the scab on the left breast which she picked due to increased anxiety. -SNV dated 5/31/22, indicated P5 had reported feeling anxious due to changes going on-finding housing, discharge from this agency and was having trouble falling asleep and this was the last visit by the nurse from the agency due to lack of nursing staff available to provide services. The note further indicated, the locked box for medication storage with key was given to P5’s roommate who stated would keep it secure and P5’s roommate agreed to not give key to P5 “This nurse will call case manager [CM] to report that [roommate] has key.” -Patient Communication note dated 5/19/22, indicated a voice message was left for the county case manager to inform her that P5 will be discharged from agency on 6/2 due to lack of nursing staff. -10 Day Discharge Notice dated 5/19/22, the agency no longer would be able to provide staff to fulfill your home health nursing plan of care effective date of discharge will be 6/2/2022. The notice indicated P5’s physician that ordered home care services had been notified and will be able to provide a referral to another provider that can meet the patient needs. The notice further indicated the agency had been in been in contact with the case manager to further assist in the referral process. -Patient Communication note dated 6/2/22, indicated a phone call was made to the county case manager to inform her that P5’s roommate had key to locked box and the case manager requested current medication list, to be e-mailed to her. P8’s POC for certification period ending 6/9/22, identified diagnoses of anxiety, and Attention-deficit hyperactivity disorder, predominantly hyperactive type. The POC identified P8 for Psychosocial status he had demonstrated/expressed anxiety, depressed mood, poor Coping Skills and was forgetful. In addition, the POC indicated P8 received SNV twice monthly from 5/5/22 through 5/31/22 for one month then once monthly from 6/7/22, through 6/9/22. The POC indicated P8 had a decline in mental, emotional, or behavioral status in the past 3 months and nurses were to do collaboration with (case manager, providers, support people) to provide accurate information as needed and the nurse was to assess mental health status, medication side effects and medication efficacy, monitor medication compliance, maintenance of adequate medication supply order refills, deliver and set up medications in med minder or machine. During a review of the medical record the following was revealed: -SNV dated 5/18/22, indicated P8 reported to the nurse he felt anxious, mostly due to being discharged from the agency and felt down because of getting diagnosed with skin cancer. The medical record lacked documentation of the agency notifying timely other care team members including the county case managers being involved in the discharge planning to ensure it was safe and smooth to avoid stress for the patient. During an interview on 6/30/22, at 12:15 p.m. with the consultant RN and the agency chief executive officer (CEO), the consultant RN acknowledged the agency had challenges with staffing post pandemic and there was instability in staffing of the field staff clinicians and management. The consultant stated at the time the large patient number discharges began, she was not working for the agency. She then stated the RN case manager with the agency administrator who was doing clinical management duties was working with people on evaluating the case load looking into the medical necessities. She then also stated the staff was having conversations with the county case managers on the discharges. The CEO then stated there was conversations with pharmacies to make sure the medications were being delivered, families and other providers involved in the cases were notified within 10 days of the discharges or they were called which was on an individual case. The consultant RN stated who was involved and notified was all supposed to be documented in the patient medical record. The CEO stated there had been a lot of discharges in May and a lot of calls had been made. The consultant RN stated patients had been given the discharge plan and resources including the list of providers who provided services and she thought it was the responsibility of the county case manager to assist the patients with coordinating the services and not the agency responsibility as the patients had Waiver program services (services that help people with disabilities live in the community rather than in an institution) “That is what is in the policy and it’s not required the agency to do coordination.” They both acknowledged the agency had not made any efforts to transfer patients to other agencies as staffing was the agency problem as patients did not request for the discharges. The CEO and the consultant acknowledged the patients’ medical records should have had documentation of the communication which was completed with the care team for the discharged patients including the county case managers. The consultant RN stated her understanding was all the discharged patient cases were reviewed for medical necessity and if they were on Medicare. She then stated most of the discharged patients had mental health diagnoses, had been on case load for a long time which made it hard to determine what services the nurse was doing in the home and thus they were discharged because they had other mental health resources it was thought to be safe to discharge them. The CEO stated she knew the nurses and the clinical manager/administrator had met to discuss the patients however, there was no documentation of meetings, and the clinical manager was no longer working at the agency. The consultant stated she would have expected the staff was reviewing each resident as an individual when doing the discharge process. During interview on 7/8/22, at 9:19 a.m. the county case manager (CCM) stated P1 and other 11 patients who were under the funded program managed by the county and contracted to the agency had been discharged abruptly from the agency without appropriate timely discharge and lack of coordination/communication which affected the patients. The CCM stated P1 was at risk for suicidal ideation and having access to large amounts of medications was not appropriate for P1. The CCM stated on 5/9/22, the agency had a meeting with the county and had indicated to the case managers and informed them the agency was going to discharge several patients from the agency but did not give the county case manager a great reason as to why they were terminating the services. The CCM then stated at the beginning of it all, P1 was not going to be discharged but then this had changed later probably 2 weeks later and had indicated P1 was not appropriate for services. The CCM stated P1 required the SNV services because of overusing medications, was on a civil commitment, and required monthly antipsychotic injections which P1 did not want to get at the pharmacy. The CCM stated although the agency indicated all the patients were not appropriate for services, all the patients required the services because they had become stable due to getting the skilled nursing services which stabilized their mental health issues. The CCM stated the agency never communicated with her about P1’s discharge as P1 was discharge was decided two weeks to a month later after the meeting on 5/9/22, as the agency had initially indicated they were going to keep P1 on the caseload. The CCM stated the agency never coordinated prior to discharging P1 where and what to do with the laxatives and all other medications which belonged to P1 that could not be stored in the home due to P1’s misuse. The CCM stated the agency had e-mailed her supervisor who had been on vacation for 2 weeks and had received a bounced back e-mail that she was on vacation but did not act on communicating with someone else at the county to discuss about the discharge. The CCM stated she had been P1’s case manager for over two years and the agency was aware to communicate with her about any changes regarding the home care services for P1. The CCM stated when the agency was discharging P1 from the agency the RN-A had indicated they had ordered medications for one week to only be mailed in pill packs due to P1’s history of overdose and suicidal ideation but instead this never happened, and she had to address the issue with the pharmacy last week. The CCM stated other patients who were discharged from the agency inappropriately had concerns of the agency asking another patient who lived in a shared home who continued to receive services from the agency to be responsible for the discharged patient and was putting stress on the patient to remind the discharged patient to take their medications. The CCM stated the arrangement the agency had made for P1 to get injections from the pharmacy was for a limited time and nothing was long term to make sure P1 received the anti-psychotic injections to ensure she remained stable. The CCM stated the county was not aware the agency was struggling with staffing since December 2021, as the county would have not signed a contract with the agency to avoid mass discharges for patients with mental health issues who were vulnerable and needed continued services to be stable. The agency Discharge policy updated 5/28/21, indicated the following: "3. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan. 4. The impending discharge will be reviewed with other members of the home care team to assure coordination and continuity with the client and family/caregivers..." 2. Transfer Criteria b. Evidence that the client no longer qualifies for home care services or there is no payer source for ongoing services. c. If there are unmet needs and the agency is no longer able to meet those needs, documentation will demonstrate that appropriate notice was given (verbal and written) and referrals made as indicated. In this situation, the decision will be made with the physician as well as the client and their representatives. d. Documentation of all communication with the client, including the rationale for discharge will be kept in the client file. A discharge summary will be sent to the physician.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on interview and document review, the home health agency (HHA) governing body failed to ensure patient discharges were coordinated with other health care professionals who may be involved in the patient's care when multiple patients discharges become imminent. This had the potential to affect all 79 patients who currently receive services from the agency and 31 patients who were discharged from the agency abruptly. A report dated 6/27/22, indicated the agency had dropped home care services for in home mental health medication monitoring and administration with little notice to patients and other providers/care team responsible parties. The report indicated P1 was utilizing services due to suicidal plans to take all the medications to overdose. In addition, the agency nurse had set up medications for the last time and scheduled to have pill packs mailed directly to P1 which would allow P1 to have full possession of medication bottles which P1 had verbalized urges to take them in attempts to commit suicide. The report further indicated due to the short notice of ending services P1 was not well prepared for successful transition/discharge which put P1 at risk. During review of the medical record the following was revealed: -A Patient Communication dated 6/18/22, sent to the physician indicated “Patient is discharged from home care services due to inadequate staff. A 10-day notice and list of other home care providers was provided to patient and the Washington county case manager.” -Discharge Summary dated 6/25/22, indicated P1 was discharged from the agency on 6/24/22, due to inadequate nursing staff and a 10-day notice with list of other homecare providers was provided to the patient/caregiver. During further review of the medical record, it was revealed the medical record lacked documentation of the agency coordinating with the patient/caregiver, provider/physician, and other care team members to discuss safe discharge for P1 to ensure other services were aligned for the patient to ensure a smooth transition. P5’s POC for certification period ending 6/6/22, identified diagnoses of Major depressive disorder, anxiety, insomnia, diabetes mellitus and hypertension. P5's POC included orders for weekly SNV, and the nurse was to order, deliver, and set-up medications in med-minder every other week; assess medication compliance, efficacy and side effects; assess vital signs as needed; assess mental status, level of functioning and observe for early decompensation symptoms. During review of the medical record the following was revealed: -SNV dated 5/23/22, indicated P5 had reported to the nurse she was anxious related to discharge from agency and was unable to find housing “[P5] does not have family to assist with medication management.” The note further indicated the discharge date was 5/31/22, and it had been noted P5 had picked on the scab on the left breast which she picked due to increased anxiety. -SNV dated 5/31/22, indicated P5 had reported feeling anxious due to changes going on-finding housing, discharge from this agency and was having trouble falling asleep and this was the last visit by the nurse from the agency due to lack of nursing staff available to provide services. The note further indicated, the locked box for medication storage with key was given to P5’s roommate who stated would keep it secure and P5’s roommate agreed to not give key to P5 “This nurse will call case manager [CM] to report that [roommate] has key.” -Patient Communication note dated 5/19/22, indicated a voice message was left for the county case manager to inform her that P5 will be discharged from agency on 6/2 due to lack of nursing staff. -10 Day Discharge Notice dated 5/19/22, the agency no longer would be able to provide staff to fulfill your home health nursing plan of care effective date of discharge will be 6/2/2022. The notice indicated P5’s physician that ordered home care services had been notified and will be able to provide a referral to another provider that can meet the patient needs. The notice further indicated the agency had been in been in contact with the case manager to further assist in the referral process. -Patient Communication note dated 6/2/22, indicated a phone call was made to the county case manager to inform her that P5’s roommate had key to locked box and the case manager requested current medication list, to be e-mailed to her. The medical record lacked documentation of the agency coordinating with the providers/physician responsible for the patients care and other care team members including the county case managers being involved in the discharge planning to ensure it was safe and smooth to avoid stress for the patient. P8’s POC for certification period ending 6/9/22, identified diagnoses of anxiety, and Attention-deficit hyperactivity disorder, predominantly hyperactive type. The POC identified P8 for Psychosocial status he had demonstrated/expressed anxiety, depressed mood, poor Coping Skills and was forgetful. In addition, the POC indicated P8 received SNV twice monthly from 5/5/22 through 5/31/22 for one month then once monthly from 6/7/22, through 6/9/22. The POC indicated P8 had a decline in mental, emotional, or behavioral status in the past 3 months and nurses were to do collaboration with (case manager, providers, support people) to provide accurate information as needed and the nurse was to assess mental health status, medication side effects and medication efficacy, monitor medication compliance, maintenance of adequate medication supply order refills, deliver and set up medications in med minder or machine. During a review of the medical record the following was revealed: -SNV dated 5/18/22, indicated P8 reported to the nurse he felt anxious, mostly due to being discharged from the agency and felt down because of getting diagnosed with skin cancer. The medical record lacked documentation of the agency communication and coordination with other care team members including the county case managers in the discharge planning to ensure it was smooth to avoid stress for the patients. During interview on 6/30/22, at 3:24 p.m. registered nurse (RN)-B stated in the last months since December 2021, the agency had struggled with staffing as a result a lot of staff resigning from their positions or cutting back to part-time. RN-B stated the agency had to discharge a lot of the patients because of not having enough help “the population we serve need the services, but we are short of staff.” RN-B stated she each time she was going to discharge a patient she always updated the physician ahead of time, got an order prior to discharging the patient from the agency and the case managers involved. During an interview on 6/30/22, at 12:15 p.m. with the consultant RN and the agency chief executive officer (CEO), the consultant RN acknowledged the agency had challenges with staffing post pandemic and there was instability in staffing of the field staff clinicians and management. The consultant stated the clinical manager had resigned in December and another one was hired in January and then that one resigned early May 2022. The consultant then stated in the time frame since the beginning of the year other staff including the administrative staff who completed quality assurance duties, intake and direct care had also resigned, then 2 full time nurses quit between April and May 2022, and one went down to part-time. The CEO then stated all along there since December 2021, to now the agency had been doing recruitment efforts and currently the agency had four nurses (two were full time RN’s, one part-time RN and one full time LPN) for the current 79 patients the agency provided in current census. The CEO stated it had been a struggle with recruiting and this continued to be an effort the agency was making through time with the focus being on getting RN’s and LPN’s. She then stated the agency had used online resources, direct hire agencies, handshake and word of mouth resources which had not brought staff. The CEO and the consultant RN both acknowledged they were aware of supplemental nursing services agencies (SNSA-pool agency) however, this was an area they had not considered to see if they could get nurses due to the cost implication and thought most are being used by hospitals. The consultant stated at the time the large patient number discharges began, she was not working for the agency. She then stated the RN case manager with the agency administrator who was doing clinical management duties was working with people on evaluating the case load looking into the medical necessities. She then also stated the staff was having conversations with the county case managers on the discharges. The CEO then stated there was conversations with pharmacies to make sure the medications were being delivered, families and other providers involved in the cases were notified within 10 days of the discharges or they were called which was on an individual case. The consultant RN stated who was involved and notified was all supposed to be documented in the patient medical record. The CEO stated there had been a lot of discharges in May and a lot of calls had been made. The consultant RN stated patients had been given the discharge plan and resources including the list of providers who provided services and she thought it was the responsibility of the county case manager to assist the patients with coordinating the services and not the agency responsibility as the patients had Waiver program services (services that help people with disabilities live in the community rather than in an institution) “That is what is in the policy and it’s not required the agency to do coordination.” They both acknowledged the agency had not made any efforts to transfer patients to other agencies as staffing was the agency problem as patients did not request for the discharges. The CEO and the consultant acknowledged the patients’ medical records should have had documentation of the communication which was completed with the providers/physician and the care team for the discharged patients including the county case managers. The consultant RN stated her understanding was all the discharged patient cases were reviewed for medical necessity and if they were on Medicare. She then stated most of the discharged patients had mental health diagnoses, had been on case load for a long time which made it hard to determine what services the nurse was doing in the home and thus they were discharged because they had other mental health resources it was thought to be safe to discharge them. The CEO stated she knew the nurses and the clinical manager/administrator had met to discuss the patients however, there was no documentation of meetings, and the clinical manager was no longer working at the agency. The consultant stated she would have expected the staff was reviewing each resident as an individual when doing the discharge process. During interview on 7/8/22, at 9:19 a.m. the county case manager (CCM) stated P1 and other 11 patients who were under the funded program managed by the county and contracted to the agency had been discharged abruptly from the agency without appropriate timely discharge and lack of coordination/communication which affected the patients. The CCM stated on 5/9/22, the agency had a meeting with the county and had indicated to the case managers and informed them the agency was going to discharge several patients from the agency but did not give the county case manager a great reason as to why they were terminating the services. The CCM stated the agency never coordinated prior to discharging P1 where and what to do with the laxatives and all other medications which belonged to P1 that could not be stored in the home due to P1’s misuse. The CCM stated she had been P1’s case manager for over two years and the agency was aware to communicate with her about any changes regarding the home care services for P1. During review of the agency QAPI Meeting Agenda notes provided by the agency for meeting dates 10/27/21, 4/14/22, 5/12/22 and 6/24/22, it was revealed the agency did not discuss anything concerning patient discharges from the agency as agency started to discharge multiple patients in May 2022.