Every finding on record at Home Based Services Initiative LLC D/B/A St John's United Home Health

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.102 Emergency Preparedness (EP) Final Rule Requirement for Home Health Agencies effective 04/16/21, an EP survey was performed on 1/15/26. The facility completed a review of their EP plan on 10/13/25. No deficiencies were cited.

An unannounced recertification survey was completed by the State of Montana, Office of Inspector General, Certification Bureau on 1/15/26. Standard Level deficiencies were cited. The facility census at the time of entrance was 61. Glossary: PT Physical Therapy RN Registered Nurse SLP Speech Language Pathology SOC Start of Care

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 record review, the agency failed to ensure there was an initial assessment completed within 48 hours of referral or hospital discharge date for 2 (#s 2 and 3) of 10 sampled patients. Findings include: 1. Patient #2's SOC (Start of Care) date was 8/1/25. Review of the form titled, Referral, showed the patient's referral date was 7/18/25. The admission exceeded the required 48 hours to complete the initial assessment. Review of patient #2's Communication note, dated 7/28/25, showed the patient was scheduled for home health admission on 7/26/25. The agency received notice from the skilled nursing facility the patient was due to be discharged on 7/28/25. The note showed the first available date for admission was 8/1/25. This was four days following the discharge from the skilled nursing facility. This admission date exceeded the required 48 hours to complete the initial assessment. During an interview on 1/12/26 at 1:00 p.m., staff member A stated the agency tried to get into the home of patient #2 within 48 hours following the date of the referral. 2. Patient #3's SOC date was 7/23/25. The date of referral was 7/17/25. The admission exceeded the required 48 hours to complete the initial assessment. Review of patient #3's form titled, Referral, did not show a SOC date within the required 48 hours. During an interview on 1/14/26 at 4:00 p.m., staff member G stated the agency attempted to contact the patient one time on 7/18/25 at 8:13 a.m. Staff member G stated the agency left a message detailing the times available for admission. Staff member G stated there were not any other attempts made to schedule a visit. Review of the agency policy, Initial Assessments/Comprehensive Assessment, showed: #5 Initial Assessment and Time Frame showed, "The initial assessment bridges the gap between when the first patient encounter occurs and when a plan of care can be implemented. Immediate care and support needs are those items and services that will maintain the patient's health and safety through this interim period..." "...An agency that is unable to complete the initial assessment within 48 hours of referral or the patient's return home will not request a different start of care date." "A RN, PT or SLP must conduct the initial assessment visit withing 48 hours of referral within 48 hours of the patient's return home or on the physician/practitioner-ordered start of care date."

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the agency failed to ensure staff member D verified, compared, and clarified medications the patient was currently taking upon admission against the listed allergies for 1 (# 7) 10 sampled patients. This deficient practice had the potential to cause adverse medication side effects to the patient. Findings include: During an observation and interview on 1/13/26 at 1:20 p.m., patient #7 was seated in a chair in her home and showed no outward signs of distress or discomfort. Patient #7 stated she was more tired since her discharge from the hospital, especially in the morning. Patient #7 had asked staff member D if tiredness was a side effect of the medications she was taking. Staff member D stated the tiredness was more than likely a result of her medical condition and recent hospitalization. Review of patient #7's nursing communication notes, dated 1/6/26, by staff member D, showed patient #7 presented to the emergency department on 12/26/25 with facial droop, slurred speech, and weakness in her left lower extremity. Imaging was performed which showed bilateral carotid artery stenosis and patient #7 underwent right carotid endarterectomy on 12/29/25. Patient #7 was discharged home from the hospital on 1/1/26. Patient #7 had self-discontinued multiple medications prior to her admission to the hospital due to her reported unfavorable medication side effects. "She (patient #7) has 18 listed allergies/intolerances." Patient #7 had visited her primary care physician this day, 1/6/26, with medication changes including increased carvedilol dosage due to continued high blood pressure readings. Review of patient #7's document titled, Patient Face Sheet, as of 1/13/26, with a start of care on 1/6/26, showed seventeen allergies listed, which included but were not limited to: - aspirin, - atorvastatin, and - carvedilol. During an interview on 1/13/26 at 1:32 p.m., NF1 stated patient #7 had three nosebleeds in the last week (1/6/26 - 1/13/26). NF1 stated patient #7 would refuse to take her prescribed aspirin for a day following a nosebleed, then would resume taking the aspirin. NF1 stated aspirin was listed as an allergy for patient #7, which caused the nosebleeds. NF1 stated the nosebleeds had been self-limited. During an observation and interview on 1/13/26 at 1:35 p.m., staff member D went into patient #7's kitchen to look at her current medications. Staff member D stated aspirin, atorvastatin, and carvedilol were currently part of patient #7's medication regimen. Staff member D stated, "I don't have a good answer," when asked about patient #7 taking medications which were listed as allergies for aspirin, atorvastatin, and carvedilol. Staff member D stated she should reach out to patient #7's primary care provider for clarity on the allergies versus intolerances but had not done it yet. During an interview on 1/13/26 at 2:20 p.m., staff member B stated medication regimen review was completed on patient #7 at the start of care on 1/6/26. Staff member B stated staff member D should have clarified patient #7's listed allergies versus intolerances with the primary care provider when the medication regimen review was performed upon admission to the home health agency. Review of patient #7's allergies listing from (hospital name), provided by staff member B, dated 1/13/26 at 2:42 p.m., showed but was not limited to: - aspirin, noted as of 11/5/12, causes bleeding, mainly nose bleeds that do not stop unless cauterized, - atorvastatin, noted as of 9/16/22, patient loses her balance and keeps falling, and - carvedilol, noted as of 9/22/22, leg cramps. Review of patient #7's nursing communication notes, dated 1/13/26 at 2:28 p.m., showed staff member D had contacted patient #7's primary care provider regarding listed allergies and current prescribed medications, specifically aspirin, atorvastatin, and carvedilol. The primary care provider's nurse stated these medications listed as allergies should remain on patient #7's allergies list and monitored for adverse events. The primary care provider's nurse stated patient #7 had sensitivities and intolerances to aspirin, atorvastatin, and carvedilol in the past, but seemed to be tolerating them well at this time. The primary care provider was aware of past sensitivities and intolerances and advised patient #7 to continue currently listed medications. Review of the agency's policy titled, Medication Reconciliation, last revised 2/24, showed: - "Policy - The Agency will reconcile patient's medications at time of admission and on an ongoing basis in order to identify any potential adverse effect and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy. - ... Procedure - 1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. - Any concerns or discrepancies will be reconciled by a RN with the patient's physician/practitioner. ..." [sic]