Every finding on record at Divine Home Care Inc

On 9/22/25 to 9/23/25 a complaint survey was conducted. This resulted in a partial extended survey at Divine Home Care INC. 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 complaint was reviewed H80804905C (2615170) with a deficiency issued at G590.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to notify the physician of non- compliance regarding a medication order for a controlled substance for 1 of 3 patients (P1) reviewed during the survey. Findings include: P1's plan of care (POC) for certification period 2/17/25 to 4/17/25, indicated she received a skilled nursing visit (SNV) weekly for medication compliance and set up, home safety, and pain. Diagnosis included congestive heart failure (CHF), Diabetes Mellitus (DM), and chronic pain syndrome. Identified had orders for Oxycodone and Acetaminophen 5-325 mg (milligrams) one tablet every six hours as needed (prn) for pain. Review of a skilled nurses visit note dated 4/10/25, indicated P1 reported to the nurse that her pain flared up overnight so she took four tablets of Oxycodone between the hours of 10:00 p.m., and 5:00 a.m. P1 reported the oxycodone helped take some of the pain away but not all of it. P1's medial record lacked evidence the physician was notified of P1's non-compliance with the oxycodone order. During an interview on 9/23/25 at 10:35 a.m., registered nurse (RN)-A verified P1 had told her she had taken four tablets of Oxycodone between the hours of 10:00 p.m., and 5:00 a.m., on 4/10/25. RN-A stated she had not updated the physician of P1's non - compliance with the oxycodone orders but she should have updated the physician. During an interview on 9/23/25 at 12:57 p.m., director of nursing (DON) stated her expectation was the physician was updated with any changes with a client including non- compliance with medications. Review of an agency policy titled Medical Supervision undated, identified the physician would be contacted with any changes in client condition or agency services, including non-compliance of the client related to the plan of care.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 7/14/25 to 7/15/25 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 7/14/25 to 7/15/25 a recertification and complaint survey was conducted. This resulted in a standard survey at Divine Home Care Incorporated. 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: 286 Total home visits conducted: 3 Parent location visited: 322 Southwest 2nd Street, Willmar, Minnesota 56201 (Onsite, records reviewed, and home visit conducted.) List all other branch offices for this agency and identify which of these were visited during this survey and which you pulled records from Branch offices: Divine Home Care Inc. Little Falls (Onsite, records reviewed, and home visit conducted.) 50 1/2 E. Broadway, Little Falls, MN 56345 Divine Home Care Inc-Litchfield 2001 S. Sibley Ave. Litchfield, MN 55355 Divine Home Care Inc-Benson 112 13th St. S Benson, MN 56215 Divine Home Care Inc-Redwood Falls, (Onsite, records reviewed, and home visit conducted.) 321 E. Chest Nut Redwood Falls, MN 56283 List Hours of Operation: 9:00 a.m. to 5:00 p.m. List total number of records reviewed: 7 The following complaints were reviewed with no deficiencies: MN00101250/H80808772C MN00101960/H80808770C MN00102007/H80808773C MN00115241/H80808771C

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 documentation and interview, the facility failed to report all OASIS data collected in accordance with federal regulations. Total number of records submitted beyond the 30 days was 130, which equaled 4.50% of the submissions submitted. On the HHA Error Summary by Agency report period of 6/17/24 - 6/17/25, the agency had an error code 0f -3330: record submitted late. The description included the submission was more than 30 days after completion on the new record. During an interview on 2/12/257/15/25 at 10:15 a.m., administrator and director of nursing (DON) confirmed they had regular issues with their previous Oasis software vendor with some submitted assessment batches reports coming back with errors. The administrator and DON stated they had not followed up with their previous Oasis assessment vendor to resolve the issue at the time of the error reports being received. The administrator and the DON stated they had not had any further issues since switching to their new vendor. The agency policy Encoding and reporting OASIS Data undated, identified the facility will electronically report all OASIS data collected in accordance with federal regulations including encoding and transmitting each completed OASIS assessment within thirty days of completing the assessment.

An abbreviated survey was conducted at Divine Home Care Inc. on 2/8/21, through 2/9/21 to investigate a complaint. Divine Home Care is not in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. Complaint H8080008C/MN69682 was Substantiated. Deficiency was issued at G682.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure appropriate infection control prevention measures including hand hygiene and glove use, were followed for 1 of 1 patient (P1) observed to have peri-care and gastrostomy tube (G-tube) site care provided during a home visit. Findings include: The Centers for Disease Control and Prevention (CDC) Guidelines for Standard Precautions for All Patient Care, initial date 1/26/16, included: Standard Precautions are used for all patient care. They are based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. Use personal protective equipment (PPE) whenever there is an expectation of possible exposure to infectious material. The Centers for Disease Control and Prevention (CDC) Guidelines for Hand Hygiene in Healthcare Settings, review date 1/8/21, indicated healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal. P1's plan of care (POC) certification period 1/02/21 to 3/02/21, included diagnoses of disorder of psychological development, extreme immaturity of newborn, feeding difficulties and encounter for attention to gastrostomy, and indicated 13.25 hours of registered nurse or licensed practical nurse per day for various assessments and treatments. Hours to be shared with another home care agency. On review of a video taped registered nurse visit on 2/1/21, at 11:00 a.m., P1 was observed lying on a chair and ottoman. Registered nurse (RN)-A was observed to remove P1's soiled diaper with her ungloved hands. RN-A pulled several disposable wipes from an unseen container at her side and wiped P1's peri area for several minutes. RN-A pulled another disposable wipe and wiped the front peri area and lower stomach. Without performing hand hygiene, RN-A placed a clean diaper underneath P1 and applied ointment to her ungloved finger tips. RN-A applied the ointment to P1's peri area with her ungloved fingers. Without performing hand hygiene, RN-A obtained another disposable wipe and wiped P1's lower abdomen, folded the wipe and wiped P1's G-tube site. Without performing hand hygiene, RN-A assisted P1 to dress. RN-A picked up the soiled diaper and wipes from the floor and walked to another area of the room and placed them in the garbage. RN-A returned to P1 without washing her hands or gloving. Without performing hand hygiene or applying gloves, RN-A placed the G-tube extension tubing on P1's G-tube and placed a syringe in the tubing and was noted to be administering medication into the tube with the syringe. RN-A completed the task, removed the syringe and extension tubing, capped the bottles and pulled P1's shirt back into place. RN-A was not observed to wash her hands or to glove through out the entire videoed patient care episode of changing diaper, peri care and G-tube care. During a telephone interview on 2/9/21, at 8:45 a.m. RN-A stated she usually wore gloves if she knew she had to change a diaper with a bowel movement (BM). RN-A indicated she did not wear gloves for a urine soaked diaper. RN-A stated she does not wear gloves for G-tube cares. RN-A stated when she changes a diaper, she rolls it up and throws it in the garbage right away and then washes her hands. RN-A stated she thought she had washed her hands after the diaper change on 2/1/21. During a telephone interview on 2/9/21, at 2:55 p.m. LPN-A stated she wore gloves for diaper changes if there was BM, however, she did not wear gloves to change a urine soaked diaper. LPN-A indicated she did not glove for all diaper changes because it was in the patient's home and was in a home environment. LPN-A stated she has had training regarding the facilities infection control policies. When interviewed on 2/9/21, at 10:32 a.m. clinical care manager (CCM)-A stated he had reviewed the video of RN-A providing care to P1 and it really bothered him when he saw RN-A complete peri care and then immediately perform G-tube care without wearing gloves or performing hand hygiene. CCM-A stated he would expect all the nurses to know and follow basic infection control procedures and techniques. CCM-A indicated he had reprimanded nurses in the past for not wearing gloves with diaper changes. CCM-A stated he would send out memo's via text or bulletins via email to nursing staff related to lapses or for reminders and he would definitely be doing a bulletin to staff related to use of gloves with diaper changes. During a telephone interview on 2/9/21, at 3:35 p.m. the administrator stated the nurses go through infection control training and RN-A chose not to follow the facility's procedures. The administrator acknowledged another nurse had stated she did not always wear gloves with diaper changes and stated the boundaries get blurred when a nurse is working in a patient's home for many hours a day. Review of the agency's undated policy, Infection Prevention/Control, included, "Standard precautions apply to blood, all body fluids, secretions, excretions, non-intact skin and mucous membranes." "Gloves are to be worn when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated items." "Hands are washed immediately after gloves are removed, between client contacts and when indicated to prevent transfer of microorganisms between other clients or the environment."