Every finding on record at Country Manor Extended Services

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 10/23/23, through 10/25/23, during a recertification survey. The agency is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 10/23/23 to 10/25/23, a recertification survey was conducted. This resulted in a partial extended survey at Country Manor Extended 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. Unduplicated census previous 12 months: 129 Total home visits conducted: 3 Parent location visited, including the addresses as verified while on site: Country Manor Extended Services 520 First Street Northeast Sartell, MN 56377 Branch offices for this agency: None List Hours of Operation: 8:00 a.m. to 4:30 p.m. List total number of records reviewed: 7

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 within 5 calendar days of the registered nurse start of care visit as required for 1 of 7 patients (P7) receiving skilled care services. P7's plan of care (POC) 8/15/23 to 10/13/23, identified a start of care (SOC) date 8/15/23. Diagnoses included cerebral infarction (stroke), dysphagia (swallow disorder), diabetes, anxiety and depression. Ordered services included skilled nurse visits (SNV) one time per week for five weeks for various assessments and education, physical therapy (PT) visits two times per week for four weeks and occupational therapy (OT) two times per week for six weeks. P7's medical record identified a SOC home visit was completed by a registered nurse (RN) on 8/15/23, which included an initial assessment and evaluation of body systems, medications, vital signs, equipment and service needs. The comprehensive assessment documentation was not fully completed and signed by the assessing RN until 8/22/23, seven days after the initial assessment visit was made. During interview on 10/25/23, at 1:15 p.m. the director of nursing (DON) stated she was not sure why P7's assessment had not been completed by the five days required after the visit. It was the agency's practice to complete all SOC assessments in the required time frame. An admission policy was requested, however, none was received.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 1 of 3 patients (P5) whose medications were reviewed during home visits and record review. P5's plan of care (POC) for certification period 8/31/23 through 10/29/23, identified a start of care (SOC) date 8/13/15. Diagnoses included Turner's syndrome (a genetic disorder when one x chromosome is missing), mild cognitive impairment, diabetes, and hypothyroidism. Services included skilled nursing visits (SNV) every two weeks for eight weeks for various assessments and education, including medication set up. P5's POC listed the following medications: aspirin 81 milligrams (mg) by mouth (po) daily, atorvastatin 40 mg po daily, calcium citrate 600-400 mg po two times per day, (client manages herself), clopidogrel 75 mg po daily in am, Dulcolax laxative 5 mg po daily as needed (prn), fish oil 1000 mg po two times per day, Lisinopril (for blood pressure) 40 mg po daily, multivitamin po daily, pantoprazole (for stomach acid) 20 mg po at bedtime, and Synthroid (to treat thyroid) 112 micrograms po daily. P5's Medication Profile form listed the following medications: aspirin 81 mg po daily, atorvastatin 40 mg po daily, calcium citrate 600-400 mg po two times per day, (client manages herself), multivitamin po daily, Synthroid 112 micrograms po daily, Lisinopril 40 mg po daily, fish oil 1000 mg po two times per day, clopidogrel 75 mg po daily in am, pantoprazole 20 mg po at bedtime, Colace (a laxative) 100 mg po daily and Mira lax powder (a laxative) 17 grams daily. During a home visit conducted on 10/25/23, at 9:30 a.m. registered nurse (RN)-A greeted P5 and reviewed general condition, obtained vital signs and performed various assessments. P5 was anxious to have RN-A check her medication set up, as she wanted to be sure she had enough medications set up until her next scheduled skilled nurse visit. RN-A opened P5 automatic pill dispenser box and noted her medications had been set up for an additional seven days. P7's morning medication boxes contained 5 medications. RN-A confirmed the medications as follows: Fish Oil 1000 mg capsule, Synthroid 112 mcg, clopidogrel 75 mg, lisinopril 40 mg and pantoprazole 40 mg tablets. P7's evening medication boxes contained two medications, an atorvastatin 40mg tablet and fish oil 1000mg capsule. Colace and multivitamin were not set up in the medication set. P7 stated she took the multivitamin daily and the Colace almost every other day herself. P7's pantoprazole medication bottle label read pantoprazole 40 mg take one tablet once daily at bedtime. The 40 mg pantoprazole tablet was loaded in P7's morning medication boxes and not her evening boxes and the dosage was 40 mg instead of 20 mg as was ordered. RN-A stated the order for pantoprazole 20 mg was listed as start date 7/12/23 and she was unable to locate a physician order that would indicate the medication had been increased. The medication profile did not list times to setup most of P7's medications and so she was not sure how the nurse would know what times each medication was to be administered and she was not sure why the Colace was not setup as ordered. She did not set up P7's medications, that was done by another nurse. She only visited P7 to complete her comprehensive assessments. RN-A indicated she would verify the correct dose of pantoprazole and update the medication profile for medication setup times as well as dosages to be set. During interview on 10/25/23, at 1:30 p.m. the director of nursing (DON) stated it was the agency's practice to review a patient's medication profile in the electronic medical record. The medication profile should indicate the time each medication was to be set up and the nurse was to set the medications according to the profile. It would be difficult to know what time to set up a medication if the times were not indicated on the medication profile. RN-A was in the process of contacting P5's primary physician to verify what dose P5's omeprazole should be and they were treating the discrepancy in doses of the medication as a medication error. Agency policy, Reconciliation and Drug Regimen Review with review date 6/28/23, indicated the registered nurse (RN) would generate a list of the patient's current medications. The information would include at least the following information: name of the medication, indication, date initially prescribed for the patient, refills, whether medication was new or changed, classification and dosage route and frequency of administration of the medication. The medication profile would be completed including dosage, frequency and administration routes. A patient's medications would be reviewed and assessed during each skilled nurse visit and the medication profile would be reviewed and updated as necessary. The agency policy Medication Management-Dosage Box Set Up with review date 6/28/23, indicated a nurse would ensure the medication orders were transcribed onto the medication record. The profile would include the date of medication set up, medication name, dose, time and route of administration. The nurse would transcribe the medication order onto the medication record for all medications included in the dosage box. Dosages that could not be set up would be recorded on the medication record to include any special instructions.

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 ensure the plan of care (POC) included rehabilitation potential and discharge plan for 3 of 7 patients (P3, P4, P5) whose records were reviewed. P3's plan of care (POC) 9/25/23 to 11/23/23, identified a start of care date 6/7/21. Diagnoses included Alzheimer's disease, secondary parkinsonism, and osteoarthritis. Ordered services included skilled nurse visits for various assessments and education one time per week for nine weeks, and home health aide (HHA) visits to assist with personal care five times per week for eight weeks then four times per week for one week. P3's POC failed to identify his rehabilitation potential or discharge plan. P4's plan of care (POC) 9/5/23 to 11/3/23, identified a start of care date 3/9/23. Diagnoses included heart failure, diabetes, kidney disease and arthritis. Ordered services included skilled nurse visits for various assessments and education two times per week for nine weeks, and home health aide (HHA) visits to assist with personal care one time per week for nine weeks. P4's POC failed to identify her rehabilitation potential or discharge plan. P5's plan of care (POC) 8/31/23 to 10/29/23, identified a start of care date 8/13/15. Diagnoses included Turner's syndrome (a genetic disorder) and diabetes. Ordered services included skilled nurse visits for various assessments and education every two weeks for eight weeks. P5's POC listed durable medical supplies as none, despite P5's use of a glucometer machine and strips to measure her blood glucose levels and automatic medication dispenser in use to remind P5 to take her medications. P5's POC also failed to identify her rehabilitation potential or discharge plan. When interviewed on 10/25/23, at 1:15 p.m. the director of nursing stated she did not think the rehabilitation potential or discharge plan was needed on maintenance only patients. P3, P4 and P5 were receiving skilled nurse and HHA visits but no therapies and so she did not think the rehabilitation components or discharge plan would be required. The agency policy Care Plan Implementation with review date 6/28/23, identified the care plans purpose was to ensure the agency provided care, treatment and/or services for each patient according to the established plan of care for treatment and/or services. A policy for completion of the care plan was requested, however, none were received.