Every finding on record at Hendricks Community Hospital Assn & Retirement Home

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 3/30/26 to 4/1/26 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 3/30/26 to 4/1/26 a recertification survey was conducted. This resulted in a partial extended survey at Hendricks Community Hospital Assn & Retirement Home. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 40 Total home visits conducted: 3 List Parent Location visit: 503 E Lincoln St., Hendricks, MN 56136 List Hours of Operation: 8 A.M. - 4:30 P.M. List total number of records reviewed: 7

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 interview and document review the agency failed to timely encode and submit Outcome and Assessment Information Set (OASIS) in accordance with Center for Medicare (CMS) requirement. Findings include: The Home Health Agency (HHA) Error Summary by Agency report dated 3/19/26, indicated the agency had an error code of -3330 (record submitted late). The description included the submissions was more than 30 days after assessment completion. The report included the number of assessments with this error code was 189, which equaled 4.52% of the submissions submitted. During interview on 3/31/26 at 3:00 p.m., office manager (OM) confirmed she submits the OASIS submissions. OM stated that once visiting staff complete the OASIS form, she gets a notification that it is ready to submit. OM stated after submission, she will note any error codes and pass them on for follow up. OM stated she was unsure why there were late submissions but feel it may have been because the staff exceeded the time before closing the assessment. During interview on 4/1/26 at 9:00 a.m., clinical manager (CM) stated that it appeared the assessments were closed and there was a period of time that passed prior to the assessments being submitted. No additional information provided.

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 proper hand hygiene was completed for 1 of 1 patients (P3) observed for wound care. Findings include: During observation on 3/30/26 at 2:00 p.m., licensed practical nurse (LPN)-A was observed assisting P3 with a shower. LPN-A was wearing a gown and gloves during shower and dressing after. LPN-A then wiped down a table prior to setting up wound care supplies without changing gloves or completing hand hygiene. LPN-A removed soiled dressing and cleaned wound with wound cleanser. LPN-A changed gloves but did not complete hand hygiene. LPN completed wound care on left foot, did not change gloves or complete hand hygiene, and completed wound care on right foot. LPN-A applied lotion to both legs with same gloves used for wound care. During interview on 3/30/26 at 3:10 p.m., LPN-A confirmed she did not complete wound care when changing gloves and did not complete hand hygiene immediately prior to completing wound care. During interview on 4/1/26at 9:00 a.m., clinical manager (CM)-A stated she expected staff to complete hand hygiene every time gloves were changed. CM-A confirmed gloves should be changed between clean and dirty tasks. CM-A stated this was important for infection control. Licensee policy for hand hygiene dated February 2026, included gloves should have been changed when moving from dirty to clean party for the body and hand hygiene should be completed any time glove are removed.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on August 7, 2023 through August 9, 2023 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 8/7/23 to 8/9/23 a recertification survey was conducted. This resulted in a partial extended survey at Hendricks Community Hospital Association. 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: 32 Total home visits conducted: 3 Number of records reviewed: 7 Hours of Operation: 8:00 a.m. to 4:30 p.m. No branch offices.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; 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 patient centered strengths/goals in order to be consistent with the principles of patient-centered care for 3 of 7 patients whose records were reviewed. P1's POC indicated start of care (SOC) date of 4/28/22. P1's certification period of 6/22/23 to 8/20/23, included diagnoses of essential hypertension, history of peptic ulcer disease, hyperlipidemia and anemia. The POC indicated P1 received one nurse visit every week for medication set up and one registered nurse visit within five days of the end of certification for assessment, teaching and medication management and set up. P1's POC lacked documentation of patient centered strength/goal as required. P5's POC indicated start of care (SOC) date of 11/01/22. P5's certification period of 6/29/23 to 8/27/23, included diagnoses of unilateral primary osteoarthritis, pain in right shoulder and essential hypertension. The POC indicated P5 received one registered nurse visit within five days of the end of the certification for assessment, teaching and medication review/assessment. P5's POC lacked documentation of patient centered strength/goal as required. P7's POC indicated start of care (SOC) date of 11/07/22. P1's certification period of 11/07/22 to 01/05/23, included diagnoses of atherosclerotic heart disease of native coronary artery with angina pectoris, heart failure and paroxysmal atrial fibrillation. The POC indicated P7 received one registered nurse visit within five days of the end of the certification for assessment, teaching and medication review/assessment. P7's POC lacked documentation of patient centered strength/goal as required. When interviewed on 8/29/23, at 3:30 pm, RN manager indicated P1, P5 and P7 were assisted living residents that the agency had under their comprehensive home care license. She confirmed some of the elements of the plan of care may be missing due to software issues. RN nurse manager planned to discuss, with administration, the need to have the assisted living patients under the assisted living licensure, which is under a different set of regulations. A policy addressing components of the plan of care was requested, but not received.

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 risk for emergency department visits and hospital re-admission for 3 of 7 patients (P1, P5, P7), whose records were reviewed. P1's POC indicated start of care (SOC) date of 4/28/22. P1's certification period of 6/22/23 to 8/20/23, included diagnoses of essential hypertension, history of peptic ulcer disease, hyperlipidemia and anemia. The POC indicated P1 received one nurse visit every week for medication set up and one registered nurse visit within five days at end of certification for assessment, teaching and medication management and set up. P1's POC did not indicate P1's risk for risk for emergency department visits and hospital readmission, including all necessary interventions to address the underlying risk factors as required. P5's POC indicated start of care (SOC) date of 11/01/22. P5's certification period of 6/29/23 to 8/27/23, included diagnoses of unilateral primary osteoarthritis, pain in right shoulder and essential hypertension. The POC indicated P5 received one registered nurse visit within five days of the end of the certification for assessment, teaching and medication review/assessment. P5's POC did not indicate P5's risk for risk for emergency department visits and hospital readmission, including all necessary interventions to address the underlying risk factors as required. P7's POC indicated start of care (SOC) date of 11/07/22. P7's certification period of 11/07/22 to 01/05/23, included diagnoses of atherosclerotic heart disease of native coronary artery with angina pectoris, heart failure and paroxysmal atrial fibrillation. The POC indicated P7 received one registered nurse visit within five days of the end of the certification for assessment, teaching and medication review/assessment. P7's POC did not indicate P7's risk for risk for emergency department visits and hospital readmission, including all necessary interventions to address the underlying risk factors as required. When interviewed on 8/29/23, at 3:30 pm RN manager indicated P1, P5 and P7 were assisted living residents that the agency had under their comprehensive home care license. She confirmed some of the elements of the plan of care may be missing due to software issues. RN nurse manager planned to discuss, with administration, the need to have the assisted living patients under the assisted living licensure, which is under a different set of regulations. A policy addressing components of the plan of care was requested, but not received.