Every finding on record at Bigfork Valley Home Care

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted 7/6/21 through 7/9//21, during a recertification survey. The facility was in full compliance and no deficiencies were issued.

A partial extended survey was conducted at Bigfork Valley Home Care on 7/6/21 through 7/9/21. . The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census: 42 (2 home visits completed). No branch offices. Hours of Operation: 8:00 a.m.- 4:30 p.m. Total number of records reviewed: 7

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 document review, the agency failed to ensure an incident of neglect was reported immediately to the State Agency (SA) for one of seven patients (P4) reviewed for patient rights. Findings include: P4's plan of care (POC) dated 5/13/21 to 7/11/21, indicated start of care (SOC) date of 5/18/20. The POC included diagnoses of age related cognitive decline, benign prostatic hyperplasia without lower urinary tract symptoms, gastro-esophageal reflux disease without esophagitis, and glaucoma. The POC further indicated skilled nursing visits one time every week for eight weeks for medication set up, fall prevention, various assessments, and education. The POC also indicated home health aide one time per week for one week, and two times per week for eight weeks to assist with partial bath, clean nails, soak feet, assist with walking, and socialization along with homemaker one time per week for one week and two times per week for eight weeks to assist with housekeeping and laundry tasks. Review of P4's clinical record revealed the recertification summary written on 5/12/21 for POC dated 5/13/21 to 7/11/21, indicated P4 was nearing the point of needing skilled nursing 24 hours per day, extremely forgetful, and falling down frequently. Further, P4 reported to registered nurse (RN)-A that he had been waking up in the middle of the night outside and not knowing how or why he was there. Upon further review of the clinical record, skilled nurse note dated 5/5/21, (RN)-A documented P4 had verbalized to her at the visit that he found himself outside of his house again in the middle of the night. He had no idea how or why he was outside, but he woke up outside at 2 AM. RN-A further documented that P4 was not safe to be at home alone and he needed 24 hour care. RN-A documented that she contemplated filing a Vulnerable Adult on P4 because of the incident and indicated it had happened multiple times. RN-A further documented P4 would best be served living in a nursing home setting and was not appropriate for an assisted living setting. During interview on 7/8/21, at 2:50 p.m. licensed practical nurse (LPN)-A read the skilled nurse noted dated 5/5/21. LPN-A stated that was a reportable event as P4 was vulnerable and unsafe. She stated she was not aware of that event. During interview on 7/9/21, at 9:00 a.m. family member (FM)-A recalled that she could have been at P4's home the morning after the incident on 5/5/21 and stated P4 had times when he was more confused than others. She stated communication with agency nurses can be difficult at times and she was not aware that RN-A's concerns were that severe. FM-A further stated she had help coming in to assist P4 at least daily now until she finds placement for him before winter comes. RN-A was no longer employed by the agency. There was no clinical manager available for interview The agency policy "Vulnerable Adults Maltreatment Prevention and Reporting-Mandated Reporter," last revised 2/2020, indicated all suspected maltreatment or any unsafe situation which may affect a vulnerable adult must be reported to Bigfork Valley administration as soon as possible (no later than 24 hours from the time the situation is known). The agency policy "Senior Services Abuse Prevention Plan," last revised 4/2021, indicated homecare staff would report any suspicions of mistreatment, neglect, abuse or misappropriation of resident property to MN Adult Abuse Reporting Center (MAARC) via website or telephone.

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: Findings include: P4's plan of care (POC) dated 5/13/21 to 7/11/21, indicated start of care (SOC) date of 5/18/20. The POC included diagnoses of age related cognitive decline, benign prostatic hyperplasia without lower urinary tract symptoms, gastro-esophageal reflux disease without esophagitis, and glaucoma. The POC further indicated skilled nursing visits one time every week for eight weeks for medication set up, fall prevention, various assessments, and education. The POC also indicated home health aide one time per week for one week, and two times per week for eight weeks to assist with partial bath, clean nails, soak feet, assist with walking, and socialization along with homemaker one time per week for one week and two times per week for eight weeks to assist with housekeeping and laundry tasks. P4's POC included the following medication: 8 hour arthritis pain reliever (acetaminophen) 650 milligrams (mg) by mouth (po) twice per day (bid); aspirin 81 mg po daily (qd); fish oil 1000 mg po qd; glucosamine-chondroitin (joint supplement) one tab po bid; donepezil (treat confusion related to dementia) HCL 10 mg po qd; finasteride (treat enlargement of prostate gland) 5 mg po qd; latanoprost (treat glaucoma) 0.005% instill one drop into right eye every evening; meclizine (treat dizziness) HCL 12.5 mg po as needed (prn), may take up to bid; omeprazole (decrease acid reflux) 20 mg po qd; sertraline (antidepressant) HCL 25 mg po qd, tamsulosin (to improve urinary flow) 0.4 mg po qd; and vitamin D3 po qd. During a home visit on 7/7/21, at 10:30 a.m. the surveyor observed licensed practical nurse (LPN)-A set up P4's medications following the electronic medical record (EMR). P4's medication bottles were compared to the POC dated 5/13/21 to 7/11/21. The following medications were found in P4's cabinet and not listed on the POC: melatonin (sleep aid) 3 mg and 5 mg tablets, ibuprofen 200 mg tablets, fiber capsules, docusate sodium (stool softener) 100 mg capsules, Tums, aspirin 325 mg tablets, and Omega Plus (fatty acid supplement) tablets. LPN-A confirmed these medications were not listed on the POC. She stated they were brought in from the daughter and that any new medications should be reconciled, and providers should be notified of any other medications that P4 may be taking. LPN-A did not set these medications up during the home visit. Clinical manager was not available for interview. Review of the agency's policy, "Medication Management-Home care and AL," last revised on 8/2018, indicated the agency required a prescription for all medications that are managed for the clients, including any over the counter medications and dietary supplements. The policy addressed home care and assisted living. A policy regarding medication management for home care clients was requested but not received. Based on observation, interview, and document review, the agency failed to complete a comprehensive drug review to ensure the accuracy of all medications/dosages for 2 of 7 patients (P4, P5) whose medications were reviewed during home visits and record review. Findings include: P5's plan of care (POC) for the certification period 6/14/21 to 8/12/21, included diagnoses of venous insufficiency, non pressure chronic ulcer lower leg, lymphedema, peripheral vascular disease, major depressive disorder, recurrent and hypertension. The POC further indicated P5 received skilled nurse visits four times per week for nine weeks for various assessments, education, and wound care. P5's POC included the following medications: calcium 600 milligram (mg) with vitamin D one tablet po (by mouth) two times (bid) qd (daily); demadex (diuretic) 20 mg po bid; diphenhydramine 25 mg q (every) 6 hours prn (as needed); ditropan (for bladder) 5 mg po bid; ferrous sulfate 325 mg po qd; lisinopril (blood pressure) 5 mg po qd; mesalamine (bowel disease) 1.2 gram (gm) 2 tablets qd; metamucil 0.52 gm 2 capsules bid; mirapex 1.5 mg po bid; multivitamin one tablet po qd; nystatin 100,000 units topical qd prn; omeprazole 40 mg po qd; pentoxifylline extended release 400 mg po bid; potassium chloride extended release 10 milliequivalents (meq) po bid; tylenol 325 mg po q 6 hours prn. During a home visit conducted on 7/7/21, at 2:00 p.m. P5's current medication bottles were compared to the medications listed on the POC, however, one of the medications in the home was not on the POC and the dosage was incorrect on another medication. P5 set up her own medications and verified the medication was not listed on her POC and the other medication had incorrect dosage. P5 stated she had been taking Citalopram (to treat depression) for quite awhile. P5 also stated the doctor had directed her to increase her demadex to two tablets twice a day instead of one tablet at her last appointment. However, she felt she got to shaky from the increase so decided to do one tablet in the morning and two in the afternoon. When interviewed on 7/7/21, at 2:45 p.m. licensed practical nurse (LPN)-A stated she did not review patient's medications during her visits. The registered nurse (RN) did it at SOC and when they made the recertification visits. LPN-A verified citalapram was not on P5's medication, and the increase in P5's demadex was not documented. LPN-A indicated she was adding the citalopram to P5's medication list now and was not sure why the medication had not been listed previously. She would also notify the RN of the increased demadex dosage P5 had reported. Registered nurse and/or clinical manager was not available for interview. Review of the agency's policy Admission and Initial/Ongoing Assessments of Clients, with review date of 10/2020, indicated the registered nurse (RN) would re-assess each client on an on-going basis and would revise the client's service plan based on the client's needs. Assessments not to exceed 60 days from the last date of the assessment. At these re-assessments, the RN would review the client's service plan and plan of care, evaluate the client's medication management services and the client's medications, and update the service plan and POC as necessary based on the client's needs.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 2 of 7 patients (P1, P3, P7), and failed to notify the physician when the visits were not conducted according to the plan of care (POC). Findings include: P1's plan of care (POC) for the certification period 6/6/21 to 8/4/21, indicated P1's start of care (SOC) was 12/8/21, and included diagnoses hypertension, tachycardia, degenerative disease of nervous system, ataxia (lack of muscle control with voluntary movements) and muscle weakness. The POC further indicated P1 received skilled nurse visits (SNV) for various assessments, education and med management. P1 also received homemaker visits to assist him with general household task, errands and cleaning. Review of P1's clinical record indicated a SNV was completed 6/1/21, for recertification and a comprehensive assessment was completed. A supplemental order was obtained on 6/3/21, for SNV three times per month for three months. Review of P1's SNV for certification period 6/6/21 to 8/4/21 revealed P1 received SNV on 6/1/21, with no further SNV for the month of June. SNV were performed one time per month in June and not the three times per month as ordered by the physician. There was no indication the provider was notified when the SNV were not conducted according to the POC. During an interview on 7/7/21, at 11:30 a.m. care coordinator (CC)-A indicated the supplemental order obtained on 6/6/21 was a mistake as P1 was only seen by the nurse one time per month. P3's POC with certification period 6/10/21 to 8/8/21, indicated P3's SOC was 2/10/21, and included diagnoses of hemiplegia, depressive disorder, emphysema, diabetes mellitus, and sleep apnea. P3's orders indicated SNV one time per month for three months for various assessments, education and supervision of the home health aide (HHA) and HHA visits eight hours per week for nine weeks for personal cares and montoring and homemaker two hours per week for nine weeks for general housekeeping, errands, and cleaning. P3's clinical record lacked documentation that HHA visits were completed eight hours weekly and only documented two hours per week for the month of June 2021, and the first week in July 2021. The clinical manager was unavailable for interview. P7's POC with certification period 11/30/20 to 1/28/21, indicated P7's SOC was 10/17/12, and included diagnoses of congestive heart failure, heart disease, sleep apnea, monoplegia of lower limb, and hypertension. P7's orders were for SNV every week for nine weeks for various assessments, education and supervision of the HHA and HHA visits one time per week for nine weeks for personal cares and monitoring. P7's clinical record lacked documentation that SNV were completed for the weeks 12/13/20, 1/3/21, and 1/17/21. There was no indication the provider was notified when the SNV were not conducted according to the POC. The clinical manager was unavailable for interview. Review of the agency's policy Missed Visits, with review date of 3/2020, indicated when a visit is canceled it would be placed on a missed visit note under charting in the electronic medical record (EMR) and sent to the physician for notification. All staff were trained and made aware of importance of notification of any visit cancellation.

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: P4's plan of care (POC) indicated start of care (SOC) date of 5/18/20. The POC dated 5/13/21 to 7/11/21 included diagnoses of aged related cognitive decline, benign prostatic hyperplasia without lower urinary tract symptoms, gastro-esophageal reflux disease without esophagitis, and glaucoma. The POC further indicated skilled nursing visits one time every week for eight weeks for medication set up, fall prevention, various assessments, and education. The POC also indicated home health aide one time per week for one week, and two times per week for eight weeks to assist with partial bath, clean nails, soak feet, assist with walking, and socialization along with homemaker one time per week for one week and two times per week for eight weeks to assist with housekeeping and laundry tasks. Review of P4's clinical record revealed the POC dated 9/15/20 to 11/13/20 lacked orders for frequency and duration of services provided to P4 during that certification period, however P4 continued to receive weekly SNV, two times per week HHA and homemaking services without provider orders. P6's plan of care (POC) indicated start of care (SOC) date of 11/20/18. The POC's dated 10/30/20 to 12/28/20 and 2/27/21 to 4/27/21 included diagnoses of atherosclerotic heart disease, hypertensive heart disease with heart failure, hyperlipidemia, and atherosclerosis of aorta. The POC's further indicated skilled nursing visits (SNV) for medication set up, various assessments and education; home health visits (HHA) to assist with shower, skin care, fingernail care, obtain pulse and blood pressure; and homemaker to assist with meal preparation housekeeping and laundry tasks. Review of P6's clinical record revealed the POC dated 10/30/20 to 12/28/20 was not signed by a provider until 11/8/20, yet P6 received a SNV and HHA on 11/4/20. Further, POC dated 2/27/21 to 4/27/21 was not signed by a provider until 3/4/21, yet P6 received HHA on 3/2/21 and SNV on 3/3/21. The clinical record lacked verbal orders to continue with the plan of care. There was no clinical manager available to interview. A policy regarding plan of care was requested, but not received. Based on interview and document review, the agency failed to have the total plan of care (POC) reviewed every 60 days for 2 of 7 patients (P5, P6) who were receiving home care services. In addition, the agency failed to ensure physician orders were obtained when the home health services were continued into another certification period for 4 of 7 patients (P1, P4, P5, P6), reviewed in the sample. Finding Include: P1's plan of care (POC) for the certification period 2/6/21 to 4/6/21, indicated P1's start of care (SOC) was 12/8/21, and included diagnoses hypertension, tachycardia, degenerative disease of nervous system, ataxia (lack of muscle control with voluntary movements) and muscle weakness. The POC further indicated P1 received skilled nurse visits (SNV) for various assessments, education and med management. P1 also received homemaker visits to assist him with general household task, errands and cleaning. Review of P1's clinical record indicated a SNV was completed 2/2/21, for recertification and a comprehensive assessment was completed. P1's clinical record was reviewed and signed by the physician on 2/17/21, however, the POC lacked physician orders for amount, frequency and duration of the skilled nurse visits. P1 continued to receive SNV one time per month through Febuary, March and April without physician orders. During an interview on 7/7/21, at 11:30 a.m. care coordinator (CC)-A stated the frequency and duration orders for visits should be on the POC and verified it was not on P1's POC. CC-A indicated the supplemental order obtained on 6/6/21 was a mistake as P1 was only seen by the nurse one time per month. P5's POC for the certification period 6/14/21 to 8/12/21, indicated P5's SOC was 11/2/20, and included diagnoses venous insufficiency, non pressure chronic ulcer lower leg, lymphedema, peripheral vascular disease, major depressive disorder, recurrent and hypertension. The POC further indicated P5 received skilled nurse visits (SNV) four times per week for nine weeks for various assessments, education, and wound care. Review of P5's clinical record indicated a SNV was completed 6/11/21, for recertification and a comprehensive assessment was completed. P5's clinical record lacked a current POC that was reviewed and signed by the physician, after the certification date of 6/14/21, however, continued to receive SNV four times per week on 6/14/21, 6/15/21, 6/16/21, 6/21/21, 6/23/21, 6/25/21, 6/28/21, 6/29/21, 6/30/21, 7/1/21, 7/2/21, 7/5/21, 7/6/21, and 7/7/21. The clinical record also lacked a supplemental order for continuing SNV on and after 6/14/21. During an interview on 7/7/21, at 2:45 p.m. licensed practical nurse (LPN)-A stated it was not the agency's practice to obtain verbal orders for recertification. The POC was sent to the physician for his signature and they must not have gotten it back from him yet. The clinical manager was unavailable for interview. A policy was requested on patient recertification, however, none was received.