Every finding on record at Benedictine Health Center Duluth

A survey with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 4/10/23, through 4/12/23 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 4/10/23 through 4/12/23, a recertification survey was conducted. This resulted in a partial extended survey at Benedictine Home Health. 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 previous 12 months: 369 Total home visits conducted: 04 Benedictine Home Health Agency/Hearthstone 935 Kenwood Avenue Duluth MN 55811 No Branches List Hours of Operation: 8:00 a.m. to 4:30 p.m. List total number of records reviewed: 10

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 initial assessment visit within 48 hours of the referral date for 5 of 10 patients (P2, P4, P5, P8, P10) reviewed in the sample P4's plan of care (POC), dated 2/19/23 to 4/19/23, indicated P4's start of care (SOC) was 2/19/23. Diagnoses included encephalitis (inflammation of the brain), epilepsy (brain disorders with seizures), degenerative joint disease, depression, osteoarthritis, open wounds, and neurogenic (caused by the nervous system) bowel. The POC further indicated P4 required skilled nurse visits for various assessments and education, as well as catheter management. SNV were ordered every three weeks plus three as needed (prn). P4's referral order dated 1/27/23, indicated a home care evaluation every three weeks and prn for foley catheter exchanges was ordered. The clinical record failed to identify any reason why P4 had not been assessed within 48 hours of the referral date of 1/27/23, and lacked evidence P4's physician was notified of the delay in the SOC date. P8's POC dated 9/9/22 to 11/7/22, indicated P8's SOC was 9/9/22. Diagnoses included pressure ulcer, difficulty walking, peripheral vascular disease, chronic obstructive pulmonary disease and emphysema. The POC indicated SNV were required for various assessments and education, as well as decubiti wound care, SNV were ordered one time a week for one week then two times per week for eight weeks with three prn visits. P8's referral with faxed stamp of 9/6/22, indicated SNV were ordered as soon as possible for wound management. The clinical record failed to identify any reason why P8 had not been assessed within 48 hours of the referral date of 9/6/22, and lacked evidence P8's physician was notified of the delay in the SOC date. P10's POC dated 10/31/22 to 12/28/22, identified P10's SOC 10/31/22. Diagnoses included acute cystitis, diabetes, chronic pain, heart failure, morbid obesity, chronic respiratory failure, and methicillin resistant staph aureus infection. Skilled nurse visits were required to perform the admission and discharge visits. Physical therapy (PT) was required with visits two times per week for one week, three times per week for two weeks and two times per week for two weeks. PT ordered for therapeutic exercises, education and gait training. Occupational therapy was required with visits one time per week for one week and two times per week for four weeks with four visits prn if needed. OT was required for training in equipment and activities of daily living, therapeutic exercises and education. P10's referral dated 10/24/23, indicated P10 was being discharged from the hospital on 10/24/23, to her home and an interagency referral had been made for home health care, nursing, PT, and OT. During telephone interview on 4/12/23, at 11:00 a.m. licensed social worker (LSW)-A, employee of Essentia Health St. Mary's Medical Center, stated she typically would reach out to the home care agency with the referral during discharge planning. Referrals were sent out the day the patient discharged, either by inter agency, fax or email. There would not be a delaying with sending discharge orders to referred agencies, even if the patient discharged on the weekend, the weekend LSW would have taken care of it. P10 had been a prior home care patient of the agency. The agency was called regarding P10's potential discharge from hospital on 10/21/22, and the agency was faxed referral orders and the face to face documentation on 10/24/22. The clinical record failed to identify any reason why P10 had not been assessed within 48 hours of the referral date of 10/24/22, and lacked evidence P10's physician was notified of the delay in the SOC date. When interviewed on 4/12/23, at 9:20 a.m. the director of nursing (DON) stated it was the agency's policy to admit patients within 48 hours of receiving their referral. Sometimes there could be a delay with the agency receiving the referrals in a timely fashion, such as if it was sent to an assisted living or board and care. With hospital referrals, they were typically received on day of patient discharge. During interview with administrative assistant (AA)-A on 4/12/23, at 10:00 a.m. AA-A stated she received and processed the agency referrals. Hospitals and transitional care units typically faxed their referrals to the agency. She also had access to the health care EPIC computer system and was able to look up if patients had discharged to home. When she knew someone was going to discharge, she would tentatively schedule them for a start of care, because she knew they only had the two days. If the agency could not do the SOC timely she would have a nurse obtain a physician order for the later date. The agency's undated Comprehensive Patient Assessment policy indicated the initial patient assessment must be conducted by a registered nurse (RN) within 48 hours of referral and/or within 48 hours of the patients return home, unless the physician specifies a specific time to conduct the assessment. P2's plan of care (POC), dated 4/8/22 to 6/6/23, indicated P2's start of care (SOC) was 12/9/22. Diagnoses included NASH cirrhosis, generalized weakness, hepatic encephalopathy, hypertension and diabetic nephropathy. The POC further indicated P2 required skilled nurse visits for international normalised ratio (INR) blood tests . SNV were ordered weekly for nine weeks. P2's referral order fax stamped 12/2/22, indicated a home care evaluation for INR blood draws and Physical therapy evaluation. The referral order also indicated P2 was discharged from the hospital on 12/6/22 The clinical record failed to identify any reason why P2 had not been assessed within 48 hours of the discharge date of 12/6/22,and lacked evidence P2's physician was notified of the delay in the SOC date. P5's POC dated 3/28/23 to 5/26/23, indicated P5's SOC was 3/28/23. Diagnoses included unspecified dementia, weakness, vascular parkinsonism, heart failure and psychoactive substance abuse. SNV were ordered for admission/discharge, physical therapy (PT)one time weekly for 1 week and two times weekly for two weeks. occupational visits (OT) two times a week for three weeks. P5's referral with dated of 3/21/23, indicated PT for strengthening. The clinical record failed to identify any reason why P5 had not been assessed within 48 hours of the referral date of 3/21/23, and lacked evidence P5's physician was notified of the delay in the SOC date. When interviewed on 4/12/23, at 9:20 a.m. the director of nursing (DON) stated it was the agency's policy to admit patients within 48 hours of receiving their referral. Sometimes there could be a delay with the agency receiving the referrals in a timely fashion, such as if it was sent to an assisted living or board and care. With hospital referrals, they were typically received on day of patient discharge. During interview with administrative assistant (AA)-A on 4/12/23, at 10:00 a.m. AA-A stated she received and processed the agency referrals. Hospitals and transitional care units typically faxed their referrals to the agency. She also had access to the health care EPIC computer system and was able to look up if patients had discharged to home. When she knew someone was going to discharge, she would tentatively schedule them for a start of care, because she knew they only had the two days. If the agency could not do the SOC timely she would have a nurse obtain a physician order for the later date. The agency's undated Comprehensive Patient Assessment policy indicated the initial patient assessment must be conducted by a registered nurse (RN) within 48 hours of referral and/or within 48 hours of the patients return home, unless the physician specifies a specific time to conduct the assessment.

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 the physician orders were followed for 1 of 10 patients (P7) who had a home health aide (HHA) ordered but the service had not been provided and the physician had not been notified the service was not provided. P7's plan of care (POC) 4/26/22 to 8/24/22, indicated a start of care (SOC) date 4/26/22. Diagnoses included neuromuscular dysfunction of bladder, C7 level cervical injury, acquired absence of left and right leg above the knee, and quadriplegia. The POC indicated P7 required skilled nurse visits (SNV) for various assessments, education and management of Foley catheter. SNV were ordered every two weeks for five weeks, one time a month for two months for catheter changes and five visits as needed (PRN). Occupational therapy (OT) was ordered one time per week for one week and three visits PRN to provide recommendations and information for home modifications to increase patient safety. P7's referral order dated 4/19/22, indicated P7 would discharge to his home on 4/25/22. The referral indicated P7 would require assistance with catheter changes, medication management, monitor vital signs, assist with showers and new adaptive equipment. Orders included home health nurse, home health aide and in home OT. P7's clinical record failed to identify the initiation of a home health aide to assist with showering or a reason the service had not been attempted. The record lacked documentation P7's physician had been notified home health aide visits had not been initiated and an order to discontinue home health aide services was not found. During a home visit on 4/12/23, at 11:00 a.m. P7 was observed lying in bed. P7 stated he had friends who came a couple times of week and assisted him when he showered. P7 stated he needed assistance to switch the cushion in his wheelchair to his shower cushion so he could shower while in the wheelchair. Once the cushion was switched out, he was usually able to shower independently, although he had difficulty monitoring for skin issues. He had friends assist him when they visited and was usually able to shower one to two times per week when they came. During interview on 4/12/23, at 8:15 a.m. the director of nursing (DON) stated she was unable to find physician notification or an order to discontinue home health aide services for P7 but she knew P7's physician had been verbally notified a home health aide would not be provided to P7 as the agency did not staff home health aides. She did not feel an order would be necessary as the service was not included on the agency's initial POC and the physician's knew the agency did not provide home health aide services. The agency's undated policy Unmet Needs indicated the prescribing physician would be notified within five business days if a service order could not be provided.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to implement an infection control program that included tracking, trending and analysis of client infections as required. During an interview on 4/12/23, at 8:15 a.m. the director of nursing (DON) stated she had not implemented an infection control surveillance program to track client infections. She was not aware of the requirement and did not have a policy.