Every finding on record at Alliance HHC & Nursing Service

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 4/6/26 to 4/8/26 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 4/6/26 to 4/8/26 a recertification survey was conducted. This resulted in a partial extended survey at Alliance HHC & Nursing Services. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 423 Total home visits conducted: 4 List Parent Location visit. 6th Ave N Ste 105, Plymouth, MN 55441 Hours of Operation: 8 am - 4:30 pm Total number of records reviewed: 9

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to timely encode and submit Outcome and Assessment Information Set (OASIS) in accordance with Center for Medicare (CMS) requirement. Findings include: On the HHA Error Summary by Agency report with run date 3/18/26, the agency had an error code 0f -3330: record submitted late. The description included the submission was more than 30 days after M0090 on the new record. The report included the number of assessments with this error code was 489, which equaled 20.80% of the submissions submitted. During interview on 4/7/26 at 2:30 p.m., director of nursing (DON) stated she was the one who completed the OASIS submissions. DON stated up until recently, the completed OASIS assessments were sent out to a company to complete the quality assurance process, however, due to the company not getting the assessments back in a timely manner, the agency has started to complete their own quality assurance in house. The DON stated she felt a high number of the late submissions was from previously used company taking a long time to return completed assessments. The DON stated there had also been times when a clinician would get behind on documentation, which would lead to late submission. During interview on 4/8/26 at 3:00 p.m., director of therapy (DOT) stated she reviewed a few select late submissions and found some were submitted late because they were waiting for signed 485 orders to be returned from the physician prior to submitting. DOT stated they would be revising the process to ensure more timely submission of data. Facility policy for encoding and reporting OASIS data, undated, included the agency will encode client assessment data within 30 days of the comprehensive assessment and transmit it to the State OASIS system.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to complete a comprehensive assessment in a timely manner for 1 of 3 patients (P2) reviewed for active client's start of care (SOC). Findings include: P2’s POC for certification period 2/7/26 to 4/7/26, indicated a SOC date of 2/7/26. P2’s electronic medical record (EMR) lacked indication a SOC assessment was completed. During interview on 4/7/26 at 2:30 p.m., director of nursing (DON) confirmed she completed the visit for SOC on 2/7/26 for P2. The DON confirmed she had not closed the SOC assessment yet. The DON further verified the SOC assessment should have been completed within 5 days. A provider policy for plan of care, undated, directed the POC should be based on the comprehensive assessment and completed within 5 business days.

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 medication reconciliation to include all over the counter (OTC) medications for 1 of 1 patient (P5) reviewed for resumption of care. Findings include: P5’s plan of care (POC) or certification period of 3/18/26 – 5/16/26, included a start of care date of 11/18/25. During observation on 4/7/26 at 10:00 a.m., registered nurse (RN)-C confirmed the assisted living continued to manage P5’s medications and that there were no medications changes with hospitalization. During visit, a box of AZO (an OTC medication used for urinary tract infection prevention), Refresh eye drops (an OTC eye drop), and a nasal spray were observed on P5’s coffee table in her living room. RN-C did not inquire about medications on coffee table. P5 did not have AZO or eye drops on her current medication list. During interview on 4/7/26 at 10:30 a.m., RN-C stated she does complete a medication reconciliation with every resumption of care. She completes this by asking the patient if there were any medication changes and by comparing the medication list provided by the assisted living facility with the medication list on the patient’s 485 orders. RN-C stated she did not notice the medications sitting on P5’s coffee table. RN-C returned to P5’s apartment and confirmed with P5 that she was independently managing the AZO, eye drops and fluticasone nasal spray. P5 stated the assisted living does sometimes bring her the nasal spray, but sometimes the forget, so she keeps a bottle in her apartment for when she needs it. During interview on 4/7/26 at 2:30 p.m., director of nursing (DON) stated a medication reconciliation should be completed with every start of care, resumption of care and every recertification visit at a minimum. The nurse should review the physical bottles if they are able and include all OTC medications in their review. The DON stated this was important to check for interactions between medications and OTC medications and to provide education as needed. Agency policy for medication reconciliation, undated, included the admitting professional will document all medications including over the counter, prescribed and as needed medications on the physician plan of care.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to include all required items on 1 of 3 patient’s (P2) plan of care (POC) reviewed for active clients. Findings include: P2’s POC for certification period 2/7/26 to 4/7/26, indicated a start of care (SOC) date of 2/7/26. P2’s POC failed to include information for durable medical equipment (DME) and supplies, safety measures, nutritional requirements, functional limitations, activities permitted, mental status, treatments and order frequency, rehabilitation potential/discharge plans/goals. During interview on 4/7/26 at 2:30 p.m., director of nursing (DON) confirmed she completed the visit for SOC on 2/7/26 for P2. The DON confirmed she had not closed the SOC assessment and therefore the POC did not have all areas completed. The DON stated the SOC assessment should have been completed within 5 days and the POC be sent to the physician for signature. Provider policy for plan of care, undated, indicated the POC should be based on the comprehensive assessment and should be completed within 5 business days.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to include all required items on 1 of 3 patient’s (P2) plan of care (POC) reviewed for active clients. Findings include: P2’s POC for certification period 2/7/26 to 4/7/26 indicated a start of care (SOC) date of 2/7/26. P2’s POC failed to include physician review and signature. During interview on 4/7/26 at 2:30 p.m., director of nursing (DON) confirmed she completed the visit for SOC on 2/7/26 for P2. The DON confirmed she had not closed the SOC assessment and therefore the POC was not sent to the physician for review and signature. The DON stated the SOC assessment should have been completed within 5 days and the POC be sent to the physician for signature. Provider policy for plan of care, undated, included it should be based on the comprehensive assessment and should be completed within 5 business days.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure 2 of 3 home health aides (HHA-A, HHA-B) and 2 of 3 professional staff [registered nurse (RN)-B, licensed practical nurse (LPN)-A] completed required annual training. Findings Include: An agency provided staff list titled Caregiver List no date, included a start date for HHA-A of 10/15/24, HHA-B of 1/23/23, RN-B of 1/24/24, and LPN-A of 12/5/23. HHA-A's education transcript undated, indicated no education was completed in 2025 and no education was completed prior to start of survey on 4/6/26. HHA-B's education transcript was requested and not provided. RN-B's education transcript undated, indicated no education was completed in 2025 and 10 courses completed 4/6/26, with “Test Only” included on the course name with a total credit hour of 2.5 hours for 2026. LPN-A's education transcript undated, indicated no education was completed in 2024, 2 courses (Abuse Prevention and Medicare – Fraud, Waste and Abuse) totaling 1.25 credit hours in 2025, and no education completed in so far in 2026. During interview on 4/8/26 at 12:30 p.m., human resources administrative support (HR)-A stated previously annual education was assigned at the anniversary date of an employee, but the process was going to be changed to be assigned to all staff at the same time yearly. HR-A stated it was the responsibility of human resources to assign and track education, however she took over the role about 2 months ago so could not state why the education was not completed and tracked. HR-A confirmed the online courses on the transcript were the only annual education on file for HHA-A, HHA-B, RN-B and LPN-A. A agency policy for annual education and staff development undated, included home health aide would be required to complete 12 hours per year of annual education provided by or under direction of a RN.

On 10/10/24 - 10/11/24 a complaint survey was conducted. This resulted in a partial extended survey at Alliance Home Health Care and Nursing Services. 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 following complaints were reviewed: H81139457C Intake 110360 & H81139468C Intake 105508

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to report allegations of abuse immediately for 1 of 1 patient (P1). P1 reported allegations of sexual abuse to the HHA and the HHA failed to report the allegations to the state agency (SA) for four days following the allegations. Findings include: P1’s Home Health Certification and Plan of care dated 10/8/24 – 12/6/24 indicated P1 received skilled nursing visits twice weekly for medication management and range of motion exercises. P1’s diagnosis was muscle wasting and atrophy (decrease in size or wasting away of a body apart or tissue). P1 had pain and suicidal ideation. Upon interview on 10/10/24 at 12:23 p.m. the Director of Human Resources (HR) stated that he became aware of the sexual abuse allegations on 10/4/24 when licensed practical nurse (RN)-A began texting him, followed-up by a phone call reporting the allegations to him. He stated the agency started their internal investigation immediately, however stated the agency was unable to substantiate the allegations until 10/8/24 following an interdisciplinary team (IDT) and that was when the decision was made to report the allegations to the SA. Upon interview on 10/10/24 at 1:39 p.m. LPN-A, also the HHA’s scheduling coordinator stated she received a call on 10/4/24 at around noon from P1 stating one of his nurses, registered nurse (RN)-A made inappropriate sexual advances to him. LPN-A stated she did not receive any more information from P1 during the time of the call. She immediately reached out to the director of nursing (DON) and the director of HR informing them she received a call about sexual abuse allegation. LPN-A stated she was aware the agency reported the allegations to the SA on 10/8/24 but was not certain why it was reported on that date. Upon interview on 10/10/24 at 1:51 p.m. P1 stated he called the HHA on 10/4/24 around noon with the sexual abuse allegations. The HHA returned his call and P1 reported to the facility that RN-A had physically touched him and P1 and RN-A had a sexual relationship. Upon interview on 10/10/24 at 3:01 p.m. the director of nursing (DON) stated on 10/4/24 at around noon LPN-A called her and stated P1 called the HHA office and reported sexual allegations on RN-A. The DON stated the HHA started their internal investigation immediately. On 10/7/24 RN-A solidified a sexual relationship between herself and P1. Following the RN-A’s interview and a detailed e-mail regarding the events of the relationship with P1 the HHA reported the allegations to the SA the following day 10/8/24. Upon interview on 10/10/24 at 4:06 p.m. the Administrator stated he was aware there was a complaint made to the HHA on 10/4/24. He knew the DON and the Director of HR had initiated an investigation. He was not aware on the specific details until 10/7/24 from the HHA’s internal investigation. The Administrator stated he was not aware all allegations of abuse needed to be reported immediately without proof the allegations had happened. An HHA policy from the Department of Human Services titled Maltreatment of Vulnerable Adults mandated reporting undated indicated, if you are a mandated reported, and you know or suspect maltreatment of a vulnerable adult, you must report it immediately (within 24 hours).

A survey with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 6/26/23 through 6/29/23, during a recertification survey. The agency is NOT in compliance with the Appendix Z Emergency Preparedness Requirements.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and policy review, the facility failed to ensure their emergency preparedness policies and procedures included a risk assessment using an "all-hazards" approach. This had the potential to affect all staff and patients. The facility's Emergency Preparedness (EP) plan, dated 7/1/19, updated 9/9/22, lacked documentation of planning for staffing emergencies. During an interview on 6/26/23, at 1:20 p.m. the human resource director indicated the agency had difficulty staffing home health aides, PCA's and nurses. During an interview on 6/28/23, at 3:00 p.m. the human resource director indicated the emergency plan did not address staffing emergencies as a possible agency risk.

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), §485.542(b)(6), §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 policy review, the agency failed to ensure emergency preparedness policies and procedures addressed 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 patient surge needs during an emergency. This had the potential to affect all patients and staff of the agency. The facility's Emergency Preparedness (EP) plan, dated 7/1/19, updated 9/9/22, lacked a written plan that included 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. During an interview on 6/28/23, at 3:00 p.m. the human resource director indicated the emergency plan did not address the use of volunteers or other emergency staffing during an emergency.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to develop a written emergency communication plan that identified primary and alternate means of communicating with staff, Federal, State, tribal, regional, and local emergency management agencies. This had the potential to affect all patients and staff. The facility's Emergency Preparedness (EP) plan, dated 7/1/19, updated 9/9/22, lacked documentation of a system for primary and alternate communication plan in order to communicate with staff, Federal, State, tribal, regional and local emergency management agencies. During an interview on 6/28/23, at 3:00 p.m. the human resource director indicated the emergency plan did not address alternate means of communication other than the call down tree. He stated the plan did not address use of tribal agencies.

On 6/26/23 to 6/29/23 a recertification survey was conducted. This resulted in a partial extended survey at Alliance HHC and Nursing Service. 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. Unduplicated census: 22 Total home visits conducted: 2 Number of records reviewed: 7 Hours of Operation: 8:00 a.m. to 4:30 p.m. No branch offices.

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 document review and interview, the agency failed to obtain physician orders for 1 of 7 patients (P3) receiving skilled nurse visits (SNV). P3's plan of care (POC) for the certification period 3/22/23 to 5/20/23, indicated P3's start of care (SOC) was 3/22/23, and included diagnoses type two diabetes mellitus, hypertension, atherosclerotic heart disease and Parkinson's disease. The POC indicated P3 received 10 hours daily of personal care assistance (PCA) to assist with personal cares and activities of daily living (ADL). The POC indicated management of disease process to include renal disease, hypertension, diabetes, pain management, Parkinson and medication education. P1's POC was reviewed and signed by the physician on 4/14/23 however, the POC lacked physician orders for amount, frequency and duration of the skilled nurse visits. P3 received SNV's on 3/22/23, 5/3/23, 5/10/23 and 5/17/23 without physician orders. Agency's Plan of Care policy, undated, indicated POC must include type, frequency and duration for all visits/services and signed by the physician. When interviewed on 6/29/23 at 4:30 p.m. registered nurse (RN)-C confirmed the POC lacked physician orders for SNV.