Every finding on record at Guardian Angels Elim Home Care

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 2-11-25 to 2-13-25 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 2-11-25 to 2-13-25 a recertification survey was conducted. This resulted in a partial extended survey at Triniti Home Health and Hospice. 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: 1198 Total home visits conducted: 7 Parent Location: Triniti Home Health & Hospice 403 Main Street Elk River, MN 55330 All other branch offices for this agency. 1) Buffalo 1111 Highway 25 Buffalo, MN 55313 2) Cambridge - Visited 2-12-25 237 SW 2nd Avenue, Suite 224 Cambridge, MN 55008 3) Metro - Visited 2-12-25 7171 Ohms Lane Edina, MN 55349 List Hours of Operation: 8 a.m. - 4:30 p.m. List total number of records reviewed: 17

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 nine, which equaled 0.31% of the submissions submitted. On the HHA Error Summary by Agency report period of 1/1/24 - 12/31/2024, 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 2/12/25 at 1:07 p.m., clinical manager (CM)-A confirmed the agency staff had problems completing and submitting four of the nine assessments on time. CM-A stated the clinicians completing the assessment did not always complete them in a timely manner or there was miscommunication regarding the readiness for transmission of those four completed assessments. CM-A also confirmed the other five of the nine late Oasis submissions were related to coding errors requiring corrections and resubmissions. The agency policy Encoding and reporting OASIS Data dated February 2010, identified the facility will electronically report all OASIS data collected in accordance with federal regulations including encoding individual client assessment within thirty days of completing the assessment and transmitted within thirty days of the Oasis completion.

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 observation, interview and record review the agency failed to ensure provider orders were followed or revised for 1 of 2 patients (P7) reviewed for wound care. Findings include: P7's plan of care (POC) for certification period 1/23/25-3/23/25, indicated P7 was cognitively intact and had diagnoses of bladder dysfunction and post-polio syndrome. P7's required skilled nursing (SN) to perform pressure ulcer care to bilateral heels, cleanse with wound cleanser, apply skin prep to area, apply xeroform dressing to wound bed, cover with ABD and secure with roll gauze twice weekly. P7's SN visit note dated 1/28/25, indicated P7's wounds on bilateral heels were healed, and no wound care was provided. The note lacked indication P7's provider was notified, and wound care orders or interventions were updated. P7's SN visit note dated 1/31/25, indicated P7's wounds on bilateral heels were healed. P7's note further indicated the skin was still very fragile and required close monitoring and protective dressings. P7's heels were cleansed with wound cleanser, patted dry and skin prep was applied to full heel with ABD dressing and gauze. The note lacked indication P7's provider was notified, and wound care orders or interventions were updated. P7's SN visit note dated 2/7/25, indicated P7's skin was intact and bilateral heel wounds had healed and lacked indication wound care was provided. P7's note lacked indication P7's provider was notified, and wound care orders or interventions were updated. P7's electronic medical record lacked indication P7's provider had been updated or new orders requested. An observation on 2/11/25 at 12:30 p.m., home health aide (HHA)-A assisted P7 with bathing. P7 was in bed with their head of bed elevate. P7's had no socks on, heels were not wrapped and had no protective dressings in place. When HHA-A washed P7's feet, P7 stated nursing had only been cleaning the heels. When interviewed on 2/11/25 at 1:10 p.m., HHA-A stated P7's heels were much better, and it had been a "few weeks" since P7's heels had dressings or wraps in place. When interviewed on 2/13/25 at 10:20 a.m., the Director of Home Health (DHH) verified P7 had no provider notifications to obtain new orders for P7's heels. DHH expected staff to update the provider and obtain new orders when wounds have a change or had healed. A facility policy titled Physician Orders revised 8/2023, directed staff to ensure all treatments provided to patients must be ordered by a physician. The policy further directed the staff to review orders for appropriateness and obtain modification of orders when necessary.

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 record review the agency failed to ensure the provider was notified of a change in condition for 1 of 1 patients (P15) discharged patients reviewed who required hospitalization. Findings include: P15's plan of care (POC) for certification period 11/13/24-1/11/25, indicated P15 was cognitively intact and had diagnoses of gastrointestinal bleed, cancer, heart failure and lung disease. Furthermore, P15's POC indicated P15 required skilled nursing (SN) visits weekly to assess and evaluate P17's diagnoses to identify changes and to intervene to minimize complications. P15's SN visit note dated 12/16/24, indicated P15 had diminished lung sounds throughout the left and right lung and severe breathlessness. P15 had a cough with clear/yellow sputum and was short of breath while talking. P15 had reported weakness and fatigue and needed to lean forward to support breathing. P15 declined an ER visit. Furthermore, P15's note lacked indication P15's provider was notified. P15's electronic medical record lacked indication staff had notified P15's provider of the increased weakness, fatigue and severe breathlessness. When interviewed on 2/13/25 at 10:20 a.m., the Director of Home Health expected staff to notify providers when patient had a change in condition. The director further stated if a patient had a change from baseline, their provider should be notified, and a coordination of care note should be placed detailing the communication. The director verified P15's, medical record had not indicated P15's provider was notified of the increased SOB and weakness after the SN visit on 12/16/24. An agency policy titled Medical Supervision revised 8/2023, directed agency staff to promptly report to providers a change in client condition. An agency policy titled Coordination of Client Services revised 8/2023, directed staff to provide the attending provider with an ongoing assessment of the client and identify responses to the client's services and any care coordination will be documented in the client's medical record.

An abbreviated survey was conducted on 1/20/22-1/21/22, at Guardian Angels Elim Home Care to investigate a complaint. Guardian Angels Elim Home Care is NOT in compliance with requirements at 42 CFR Part 484, requirements 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 SUBSTANTIATED: H7263006C/ 21679. The Condition of Participation: Organization and Administration of Services 42 CFR 484.105 at G940 was found not met. As a result a partial extended survey was conducted.

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 record review and interview, the home health agency (HHA) failed to meet the Condition of Participation: Organization and Administration of services, when the agency failed to report branch locations to the State Agency (SA). This had the potential to affect all 145 current patients receiving services out of the Buffalo and Edina offices. Refer to G972- Based on record review and interview, the home health agency (HHA) failed to report branch locations to the State Agency (SA). This had the potential to affect all 145 current patients receiving services out of the Buffalo and Edina offices.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to report branch locations to the State Agency (SA). This had the potential to affect all 145 current patients receiving services out of the Buffalo and Edina offices. Review of the agency organizational chart, undated, indicated a Clinical Manager is assigned to parent office in Elk River, the branch office in Cambridge, the office in Buffalo and the Metro office. On 1/20/22, at 9:30 a.m. the CEO stated Elk River was the parent office. A branch office was located in Cambridge, MN and satellite offices (drop-sites) were located in Edina and Buffalo. The CEO stated the drop-sites in Buffalo and Edina each have a Clinical Manager (CM) assigned to those offices. Each of these offices also has a dedicated, private space for the CM to work. The CEO stated she had attempted to get approval for a branch office in Edina, but the last communication with the SA regarding that office was in June 2020. On 1/21/22, at 10:33 a.m. CM-A stated she understood the Edina office was a branch office not a drop-site, the Buffalo office is considered a drop-site. She confirmed, she has an assigned, private office in Edina. On 1/21/22, at 11:24 a.m. CM-B stated the Buffalo office is a drop-site. Staff for the home health agency (HHA) are assigned to the Buffalo territory, but not to the office. She confirmed having a private office in Buffalo and being assigned to the Buffalo territory. According to the State Operations Manual section 2182.4D Drop Sites (Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) Where permitted by state and local law, an HHA may utilize a drop site for field staff convenience. These drop sites are not considered branches and should not meet the Medicare definition of a branch or operate as such. HHAs that allow these locations to cross the line from drop site to branch are out of compliance with the Medicare requirements. The HHA should not assign staff to these locations, accept referrals at these locations, advertise them as a part of the HHA, or operate them in any other way as branches of the HHA.