Every finding on record at Ecumen Home Care - Pathstone

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 8/8/23- 8/10/23 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 8/8/23- 8/10/23 a recertification survey was conducted. This resulted in a partial extended survey at Ecumen Home Care- Pathstone. 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: 356 Total home visits conducted: 4 List Parent Location visited, including the addresses as verified while on site: 718 Mound Avenue Mankato, MN 56001 List Hours of Operation: 8:00 a.m.- 4:30 p.m. List total number of records reviewed: 10

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 the required information for 2 of 7 patients (P1 and P7) who’s POCs were reviewed. P7's plan of care (POC) for certification period 7/22/23 to 9/19/23, indicated P7's start of care date was 7/22/23. the POC lacked a medication list, primary diagnoses and secondary diagnoses, Code status, DME, safety measures, allergies activity level and mental status. On 08/10/2023 at 11:04 AM, the clinical director (CD) reviewed the POC and acknowledged there were several areas missing that should have been entered. All data needed to be entered at the time of admission or recertification so staff would have complete data to provide the best care possible. Also all information needed to be entered according to agency policy and procedure. Policy Plan of Care-CMS #485 and Physician/Practitioners Orders undated, indicated the POC needed to include pertinent diagnoses, client's mental, psychosocial and cognitive status, safety measures, nutritional requirements and all medications. P1's POC for certification period 7/25/23-9/22/23, indicated P1's diagnoses included Alzheimer's disease and dementia with anxiety. P1's POC failed to include current medications, risk for rehospitalization and prognosis. On 8/10/23, at 9:30 a.m. clinical manager (CM) confirmed these items were missing from the POC. CM expected all required information was filled in on the POC to ensure all home care staff and medical providers were aware of the patient's needs and for continuity of care between providers and clinicians.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to update the plan of care (POC) for 1 of 7 (P6) patients reviewed for recertification and changes to medications. P5's POC certification period 7/7/23 to 9/4/2023, indicated a primary diagnosis of congenital malformations of the lower limbs, included the pelvic girdle. Medication orders indicated Carbidopa-levodopa 25mg-100mg tablet (for multiple sclerosis), one tablet by mouth three times daily. P5's POC certification period 5/8/23 to 7/6/23, indicated an order received on 9/22/22, for Carbidopa-levodopa 25mg-100mg to titrate up dose starting with one tablet three times a day to a max dose of 3 tablets three times a day, which was reached on 5/25/23. During observation on 8/9/23 at 8:36 a.m. licensed practical nurse (LPN)-A placed three tablets of Carbidopa-levodopa into the am, noon and pm containers for medication administration. on 08/09/2023 at 9:40 a.m., LPN-A stated P6 was to get three tablets of Carbidopa-levodopa three times a day. She was aware the POC indicated one tablet three times a day but did review the order to confirm it should be three tablets three times a day. She did not know why the POC was not updated at the recent recertification visit. LPN-A indicated if somebody different had set up the medications they would not know to give three tables instead of one tablet as per the POC. On 8/10/2023 at 11:04 a.m. the clinical director (CD) stated all medications listed on the POC should be updated when the order is placed or when the recertification is performed for accuracy of medications and client safety. Facility Policy Medication Reconciliation undated, indicated the medication list would be compared to the medication bottles to make sure they matched.