Every finding on record at Deer River Healthcare Center, Inc.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 1/27/2025-1/28/2025 during a recertification survey. The facility is not in compliance with the Appendix Z Emergency Preparedness Requirements

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: Emergency Preparedness, 42 CFR § 484.102 at E0001. The agency failed to have an Emergency Preparedness program. This had the potential to affect all patients served by the agency. The cumulative effect of the systemic problem resulted in the provider's inability to ensure the provision of quality health care in a safe environment. See E0004, E0013 and E0036. When interviewed on 1/28/25 at 1:20 p.m., the interim home care manager confirmed there was not an EP program for the Deer River home health care agency. On 1/28/25 at 1:20 p.m., the administrator confirmed the EP program excluded the home care department. Refer to: E0004: Based on interview and document review, the facility failed to ensure compliance with all applicable Federal, State and local emergency preparedness requirements. The facility failed to develop, establish and maintain, a comprehensive emergency preparedness program that meets the requirements of this section. The facility failed to develop an Emergency Plan and failed to review and update the plan as required. This had the possibility to affect all staff and patients that received care from the agency. E0013: Based on interview and document review, the home health agency (HHA) failed to conduct a comprehensive all-hazards community-based risk assessment to determine potential disasters which could impact the HHA and develop corresponding policies and procedures to ensure patient safety and quality care during a disaster. This had the possibility to affect all staff and patients that received care from the agency. E0036: Based on interview and document review, the home health agency (HHA) failed to conduct a comprehensive all-hazards community-based risk assessment to determine potential disasters which could impact the HHA and develop corresponding policies and procedures to ensure patient safety and quality care during a disaster. This had the possibility to affect all staff and patients that received care from the agency.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure compliance with all applicable Federal, State and local emergency preparedness requirements. The facility failed to develop, establish and maintain, a comprehensive emergency preparedness program that meets the requirements of this section. The facility failed to develop an Emergency Plan and failed to review and update the plan as required. This had the possibility to affect all staff and patients that received care from the agency. A review of the facility policy Essentia Health Deer River Emergency Operation Plan dated 1/1/25, indicated plans for the following facilities: Deer River Hospital, Deer River Swing Bed, Deer River Clinic. Deer River Pharmacy, Deer River Hospice and Deer River Homestead. The plan did not address home health care patients and staff. The facility failed to ensure the following emergency preparedness program for home health care patients and staff: -§484.102(a)(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. -§484.102(a)(2) Include strategies for addressing emergency events identified by the risk assessment. -§484.102(a)(3) Address patient population, including, but not limited to, the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. -§484.102(a)(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the HHA’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. During an interview on 1/28/25 at 1:20p.m., the interim home care manager confirmed there was not an EP plan for the Deer River home health care agency.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to conduct a comprehensive all-hazards community-based risk assessment to determine potential disasters which could impact the HHA and develop corresponding policies and procedures to ensure patient safety and quality care during a disaster. This had the possibility to affect all staff and patienrs that received care from the agency. A review of the facility policy Essentia Health Deer River Emergency Operation Plan dated 1/1/25, indicated plans for the following facilities: Deer River Hospital, Deer River Swing Bed, Deer River Clinic. Deer River Pharmacy, Deer River Hospice and Deer River Homestead. The plan did not address home health care patients and staff. The facility failed to ensure the following emergency preparedness program for home health care patients and staff: -§484.102(b) Policies and procedures. The HHA 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 annually. -§484.102(b)(1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. -§484.102(b)(2) The procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. -§484.102(b)(3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. -§484.102(b)(4) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. -§484.102(b)(5) The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency. During an interview on 1/28/25 at 1:20p.m., the interim home care manager confirmed there was not an EP plan in place for the Deer River home health care agency

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures and an appropriate communication plan. This had the possibility to affect all staff and patients that received care from the agency. A review of the facility policy Essentia Health Deer River Emergency Operation Plan dated 1/1/25, indicated plans for the following facilities: Deer River Hospital, Deer River Swing Bed, Deer River Clinic. Deer River Pharmacy, Deer River Hospice and Deer River Homestead. The plan did not address home health care patients and staff. The facility failed to ensure training and testing policies had been developed and implemented and included the following: -§484.102(d) Training and testing. The HHA must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. -§484.102(d)(1) Training program. The HHA must do all of the following: Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. Provide emergency preparedness training at least annually. Maintain documentation of the training. Demonstrate staff knowledge of emergency procedures. -§484.102(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event. Complete a second full-scale that is community-based or individual, facility-based. Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. During an interview on 1/28/25 at 1:20p.m., the interim home care manager confirmed there was no testing or training policies and procedures for the Deer River home health care agency.

On 1/27/2025-1/ 28/2025 a recertification survey was conducted. This resulted in a partial extended survey at Essentia Health Deer River Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: 42 CFR § 484.105 at G0940. 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: 1 Total home visits conducted: 1 Parent location: 115 10th Avenue NE, Deer River, MN 56636 No branch offices Hours of Operation: 8 a.m. to 4:30 p.m. 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 the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Organization and administration of services, 42 CFR § 484.105 at G0940. The agency had skilled nursing services available and lacked at least one additional therapeutic service available for current and future patients the agency may admit. See G982. Refer to G0982: Based on interview and document review, the agency failed to provide skilled nursing services and at least one other therapeutic at time of survey affecting one of one patient (P1) and any future admissions.

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 agency failed to provide skilled nursing services and at least one other therapeutic at time of survey affecting one of one patient (P1) and any future admissions. During entrance interview on 1/28/25, at 9:00 a.m. the administrator indicated the agency had not served any home care clients for the majority of 2024. She stated the agency has had a difficult time filling vacant positions but would like to continue to provide services in the area. She further indicated the agency had no home health aides (HHA), occupational therapists (OT) or physical therapists (PT) employed so was unable to provide these services. When interviewed on 1/28/25 at 9:00 a.m. the interim home care manager indicated if the agency received a referral who required HHA, PT or OT, they would have to decline it. She further indicated the agency could utilize an HHA from the hospice department and provide home care training, which could take one to two weeks. Documents reviewed revealed the agency had one active patient that received skilled nursing services, with a start of care (SOC) of 1/2/25. The previous patient served indicated SOC date of 12/1/23, discharge (DC) date of 1/9/24. The organization chart provided indicated "PT/OT/SLP/MSW (Currently looking at realigning services) Not available currently." Further, "HHA (home health aide) (Currently looking at realigning services) Not available currently."

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 5/09/22-5/12/22 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 5/9/22-5/12/22, a recertification survey was conducted at Deer River Home Care. This resulted in a partial extended survey. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 51 Total home visits conducted: 3 Branch offices: None Hours of Operation: 8:00 a.m. - 4:30 p.m. Total number of records reviewed: 7

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure 1 of 7 patients (P4) was informed and consented to services or care being provided, including any ongoing changes in services. P4's plan of care (POC) for certification period 4/17/22 to 6/15/22, indicated his start of care (SOC) was 6/21/21. Diagnoses included osteoarthritis, diabetes, heart disease, kidney disease, chronic obstructive pulmonary disease and bipolar disorder. The POC indicated P4 received skilled nurse visits (SNV) weekly and as needed (prn) for various assessments, monitoring and medication setup. Home health aide (HHA) services two times per week to assist with personal cares. Review of P4's medical record lacked evidence P4 was informed of and agreed to the initiation of services at the start of care as well as how the planned services and care would be billed. When interviewed on 5/12/22, at 4:00 p.m. clinical manager (CM)-A stated services agreement forms were included in the admission packet, however, she was unable to find one for P4 from his admission. She was unsure if the document had been scanned in to a wrong chart or misplaced. The agency's policy Home Health Notice of Rights dated 1/7/16, indicated the professional would explain the services the client should receive regardless of financial implications. The home health professional would be responsible to receive feedback from the client on the plan of care provided and explain to the client client the coverage of care of each insurance payer. The home health professional would receive a signed notice by the client or representative acknowledging they understood their Bill of Rights and Responsibilities. The agency's policy Home Health Patient Admission Process dated 2/12/28, indicated the registered nurse completing the admission would be responsible for obtaining the patient's signature on the Admission Agreement, Service Agreement, and Home Care Bill of Rights.

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 1 of 7 patients (P7) reviewed, in the sample. P7's plan of care (POC), with certification date 10/25/21 to 12/23/21, indicated a start of care (SOC) date 10/25/21. The POC included diagnoses for orthopedic aftercare following surgical amputation, acquired absence of right foot, diabetes, non pressure chronic ulcer of left foot and venous insufficiency. Review of P7's medical record identified a referral for home care services from P7's physician dated 10/4/21, for skilled nursing services. The SOC assessment visit was not completed until 10/25/21. The clinical record failed to identify any reason why P7 had not been assessed within 48 hours of the referral date of 10/4/21, and lacked evidence P7's physician was notified of the delay in the SOC date. During an interview on 5/12/22, at 3:00 p.m. the clinical manager (CM)-A verified the record lacked physician notification and orders for the delayed SOC to home care services. CM-A indicated nurses were suppose to send an order to the primary physician for approval for delay of SOC or to refer to another agency. Review of the agency's policy Home Care Certified Program Comprehensive Assessment dated 3/10/20, indicated when a valid referral was received by the agency, the initial assessment visit would be completed within 48 hours of the referral. If the client refuses the visit within the time frame, the request must be documented in the medical record, as well as a notation the physician was notified and approved the delayed start of care.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure that a comprehensive assessment was updated and revised, including the Outcome and Assessment Information Set (OASIS) data within 48 hours of return from a hospital for 1 of 7 patients (P6) in the sample, who had been hospitalized. P6's plan of care (POC) for the certification period 12/31/20 through 2/28/21, indicated a start of care (SOC) date 9/2/20. The POC included diagnoses of diabetes, heart disease, and kidney disease. The POC indicated P6 received skilled nurse visits (SNV) every two weeks for nine weeks, for various assessments, medication monitoring, diabetes management, pain assessment and safety assessment. P6's POC for the certification period 3/1/21 through 4/29/21, included new diagnoses of cellulitis of left lower limb, streptococcus, and myocardial infarction. The POC indicated P6 received SNV weekly for 9 weeks, for various assessments, medication monitoring, diabetes management, pain assessment, safety assessment and wound care. Record review revealed P6 was admitted to the hospital on 2/5/21, and discharged on 2/26/21. P6's resumption of care (ROC) assessment visit was completed on 3/1/21. On 5/12/22, at 3:00 p.m. the clinical manager (CM)-A stated she was unable to find an order for the delayed ROC, following P6's discharge from the hospital. She was unsure why the ROC visit was delayed and felt it may have been due to staffing shortages. The agency's policy Home Care Certified Program Comprehensive Assessment dated 3/10/20, indicated a ROC following an inpatient facility stay must be completed within 48 hours of ROC or on date ordered by the physician. Although the policy indicated an OASIS would not be required for patients under programs that the payer does not require an OASIS assessment, the assessment was a functional assessment as part of the comprehensive assessment.

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 a description of the advanced directives for 2 of 7 patients (P1, P3), whose records were reviewed. P1's plan of care (POC) for certification 2/1/22 through 4/1/22, indicated a start of care (SOC) date 12/3/21. The POC included diagnoses of disorders of the arteries, nephritic syndrome, pressure ulcer of left buttock, kidney failure and hypertension. The POC indicated skilled nurse visits (SNV) one time per week for 8 weeks, as well as physical and occupational therapy visits. Code status was listed as "prior". P1's POC for certification period 4/2/22 through 5/31/22, indicated SNV one time per week for nine weeks. Code status was listed as "prior". Review of P1's medical record identified a referral dated 12/1/22, which included orders do not resuscitate (DNR). P1's POC failed to identify advanced directives. P3's POC for certification 5/2/22 through 6/30/22, indicated a SOC 5/2/22. The POC included diagnoses of myocardial infarction, chronic respiratory failure with hypoxia, atrial fibrillation, heart failure and diabetes. The POC indicated SNV for various assessments and evaluation. Code status was listed as "prior". Review of P3's medical record identified discharge orders dated 4/29/22, which included a full code (provide all resuscitation procedures) code status. P3's POC failed to identify advanced directives. During interview on 5/11/22, at 10:00 a.m. the clinical manager (CM)-A indicated patient's code status should be on their POC.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure all patient orders were recorded in the plan of care (POC) for 2 of 7 patients (P1 and P3) who were reviewed for home care services. P3's POC for certification 5/2/22 through 6/30/22, indicated a start of care (SOC) date of 5/2/22. The POC included diagnoses of myocardial infarction, chronic respiratory failure with hypoxia, atrial fibrillation, heart failure and diabetes. The POC indicated SNV for various assessments, teaching and evaluation. P3 was observed on 5/10/22, at 1:15 p.m. during a home visit. P3 had oxygen in his home and stated he was having difficulty in getting a small portable oxygen tank that he could take along when ambulating with his walker. Registered nurse (RN)-A entered P3's home and after greeting P3, was observed to obtain vital signs and a systems assessment. RN-A reviewed P3's oxygen use and discussed his concerns with obtaining a small portable tank he could manage when ambulating. Review of P3's medical record identified orders on his discharge summary dated 4/29/22, for oxygen at 3 liters per minute continuously per nasal cannula, however, oxygen was not listed on P3's POC or medication profile. During interview on 5/11/22, at 4:00 p.m. the clinical manager indicated the use of oxygen should be identified on the patient's POC and stated the lack of oxygen orders would have been caught and added during quality review of the POC.

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 3 of 7 patients (P1, P3, and P5), who had services ordered, but the service had not been provided, and the physician had not been notified the services were not provided. P1's plan of care (POC) for certification date 12/3/21 through 1/31/22, indicated start of care (SOC) date of 12/3/21. The POC included diagnoses disorder of arteries, unspecified nephritic syndrome, pressure ulcer of left buttock, acute kidney failure, hypertension and kidney disease. The POC indicated skilled nursing visits (SNV) one time per week for nine weeks to provide overall assessments, medication management, teaching and evaluation. Review of P1's medical record revealed a physician ordered referral for home care services to include skilled nurse and home health aide (HHA) visits, dated 12/2/22. Review of P1's clinical record revealed the agency did not provide the HHA visits as ordered and failed to notify the physician of the HHA visits not provided to P1. During interview on 5/11/22, at 4:00 p.m. the clinical manager (CM)-A verified HHA visits were ordered on P1's referral and had not been initiated and the record lacked physician notification the HHA visits had not been provided. P3's POC for certification 5/2/22 through 6/30/22, indicated a SOC 5/2/22. The POC included diagnoses of myocardial infarction, chronic respiratory failure with hypoxia, atrial fibrillation, heart failure and diabetes. The POC indicated SNV for various assessments, teaching and evaluation. No other services were listed on the POC. P3 was observed on 5/10/22, at 1:15 p.m. during a home visit. P3 told the surveyor he was receiving therapy and nurse services from the agency. Registered nurse (RN)-A was observed to enter the home and greet P3. She obtained vital signs and a systems assessment. P3 asked when therapy would be contacting him for a visit. RN-A stated P3 needed to setup a cardiac rehabilitation appointment at the clinic for therapy. Review of P3's medical record indicated physical and occupational therapy evaluations and treat if appropriate was ordered on P3's discharge orders from the hospital dated 4/29/22. During interview on 5/11/22, at 4:00 p.m. the clinical manager (CM)-A stated she had notified the hospital social worker when she took the referral that therapy could not be provided, however, an order had not been obtained to discontinue in home physical and occupational therapy. CM-A verified the record lacked documentation of physician notification of services not provided. P5's POC for certification date 12/17/21 through 2/14/22, indicated a SOC date 12/17/21. The POC included diagnoses of paraplegia, orthostatic hypotension, diabetes, kidney failure, weakness, unspecified convulsions, chronic obstructive pulmonary disease, and history of transient ischemic attack and cerebral infarction. The POC indicated SNV three times per week for eight weeks and as needed (prn) and HHA visits three times per week for nine weeks. P5's POC for certification date 2/15/22 through 4/15/22 indicated SNV two times per week for nine weeks and HHA visits three times per week for nine weeks. Review of P5's medical record revealed physician ordered referral for home care services to include SNV, HHA visits and occupational therapy (OT) visits, dated 12/17/21, Review of P5's clinical record revealed the agency did not provide the OT visits as ordered and failed to notify the physician of the OT visits not provided to P5. Review of P5's completed SNV and HHA visits revealed the agency did not provide SNV three times per week as ordered on the weeks of 1/9/22, 1/16/22, and 2/6/22. The agency failed to provide SNV two times per week as ordered on the weeks of 3/6/2, 3/13/22, and 3/20/22, or HHA visits three times per week as ordered on the weeks of 3/6/22, 3/13/22, 3/20/22, 3/27/22, 4/3/22, and 4/10/22. The agency failed to notify the physician of the SNV and HHA visits not provided. During interview on 5/11/22, at 4:00 p.m. the CM-A stated the physician should have been notified via the agency's computer system of the missed OT, SNV and HHA visits. An email sent by CM-A on 5/16/22, at 2:24 p.m. indicated when a missed visit occurred a Missed Visit Notification communication note was created and sent to the primary physician. It was expected this communication would be sent for all services the agency would provide if missed visits occurred. The agency's policy Coordination of Patient Services dated 2/26/18, indicated the primary nurse would be responsible for contacting the physician's office and reviewing medical orders. A policy for missed visits was requested, however, was not received.

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 interview and document review, the agency failed to ensure drugs, services and treatments were administered only as ordered by a physician for 1 of 7 patients (P5) who were reviewed for home care services. P5's POC for certification date 12/17/21 through 2/14/22, indicated a SOC date 12/17/21. The POC included diagnoses of paraplegia, orthostatic hypotension, diabetes, kidney failure, weakness, unspecified convulsions, chronic obstructive pulmonary disease, and history of transient ischemic attack and cerebral infarction. The POC indicated SNV three times per week for eight weeks and as needed (prn) and HHA visits three times per week for nine weeks. P5's POC for certification date 2/15/22 through 4/15/22 indicated SNV two times per week for nine weeks and HHA visits three times per week for nine weeks. Review of P5's medical record indicated physical therapy in home visits were initiated on 5/4/22. P5's medical record lacked orders for the start of physical therapy. During interview on 5/12/22 at 3:30 p.m. the clinical manager (CM)-A indicated orders were needed to initiate home care services and she would have to have therapy obtain orders for their services. The agency's policy Physical Therapy Services with revision date 8/31/18, indicated when it was determined a patient requires a physical therapy evaluation, the registered nurse would contact the physician and obtain an order to evaluate and treat.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure medication setup was provided as specified in the plan of care (POC) for 1 of 3 patients (P3) observed for skilled nurse visits (SNV) in the home. P3's POC for certification 5/2/22 through 6/30/22, indicated a SOC 5/2/22. The POC included diagnoses of myocardial infarction, chronic respiratory failure with hypoxia, atrial fibrillation, heart failure and diabetes. The POC indicated SNV for various assessments, teaching and evaluation including management of home medications including nurse to fill medication boxes every week. P3 was observed on 5/10/22, at 1:15 p.m. during a home visit. P3 stated he was receiving therapy and nurse services from the agency and the nurse was going to set up his medications today, as she ran out of time during her initial start of care visit. Registered nurse (RN)-A entered P3's home and after greeting P3, was observed to obtain vital signs and a systems assessment. Although RN-A reviewed P3's medication bottles, checked for changes and/or discrepancies, and brought out a new pill box for medication setup, she did not set up any medications for P3 to take daily as prescribed to him. RN-A stated P3 was capable of setting up his own medications, however, RN-A did not review or check P3's medication setup to determine if his medications were setup correctly or how many days the medications were setup for. During interview on 5/11/22, at 4:00 p.m. the clinical manager (CM)-A stated she would expect that the nurse would not have entered needs assistance with medication setup on P3's POC if he was able to set his medications independently. The agency's policy Medication Management Services dated 4/4/16, indicated the RN would develop an individualized medication management plan for each client receiving medication management services that must contain a statement describing the medication management services that will be provided. Upon admission the RN would assess the client for medication management services and develop an individualized medication plan for each client. The RN would document the medication management services the client would receive on the client's individualized medication plan. The RN would review the client's medication record when setting up all medications and would audit the medication record to ensure the agency was meeting the requirements of the medication service agreement.