Every finding on record at Interim Healthcare of the Twin Cities

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 1/22/24-1/24/24 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 1/22/24-1/24/24, a recertification survey was conducted. This resulted in a standard survey at Interim Healthcare. 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: 2753 Total home visits conducted: 7 List Hours of Operation: 8-4:30 List total number of records reviewed: 17

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 facility failed to ensure the initial start of care (SOC) visit was held within 48 hours of referral for 2 of 7 patients (P4, P7) currently receiving home care services. P7’s POC for certification period 1/10/24-3/9/24, indicated P7 had diagnoses which included a fractured radius, type II diabetes, chronic kidney disease, and a history of falling. P7’s POC further indicated, P7 received in home skilled nursing, physical therapy, occupational therapy, and home health aide services. P7’s home care referral (dated 1/4/24), lacked any indication a SOC date was scheduled. P7’s verbal physicians order received 1/9/24, indicated a SOC date of 1/10/24. The order lacked any indication of why the SOC visit was delayed. P7’s medical record lacked any indication P7 requested a delayed SOC date. During interview on 1/25/24 at 1:02 p.m., the director of therapy stated when a referral was received for a patient, it was best practice to complete the initial assessment within 48 hours. If the agency was unable to complete the initial assessment within the required time frame, he would expect the clinician to notify the physician stating the reason for the delay, which would ideally be driven by the patient. The clinician would also be responsible for communicating with the patient in order to see if they want to continue with the agency or go somewhere else and then documenting it in a communication note in the chart. The documentation should also include the reason for the delay of the SOC. During an interview on 1/25/24 at 1:10 p.m. the director of nursing (DON) stated when a referral was received, it was best practice to complete the initial assessment within 48 hours. If the agency was unable to complete the initial assessment, then the provider would need to be notified indicating the reason for the delay and documented in the patient's chart. During an interview on 1/24/24 at 2:46 p.m., the administrator stated the initial assessment of the patient should be completed within 48 hours of the referral. If the agency was unable to complete the assessment within the timeframe, the clinician was responsible for notifying the physician to get a new SOC order and the reason for the delay of care. The DON also stated the delay of services and the reason for the delay should be documented in the patients' medical record and verified P4 and P7 did not have a documented reason for why the SOC was delayed. The facility's policy titled initial comprehensive assessment dated 4/2/2021, indicated an initial comprehensive assessment of an individual was conducted within 48 hours of a referral for home care services, an individual's return home, or on the physician's ordered SOC date. P4’s plan of care (POC) for certification period dated 12/11/23-2/8/24, indicated P4 had diagnoses a leg laceration, peripheral vascular disease, and history of falling. P4’s POC further indicated P4 required in home skilled nursing, physical therapy, and occupational therapy services. P4’s home care referral dated 12/6/23, lacked indication a SOC date was scheduled. P4’s physician order dated 12/8/23, indicated P4’s SOC date was “ok” to be completed on 12/11/23. The order lacked indication of why the SOC visit was delayed. P4’s medical record lacked indication P4’s requested a delayed SOC date. When interviewed on 1/23/24 at 3:30 p.m., the Administrator stated it was best practice was to initiate SOC within 48 hours of the referral. If staff were unable to complete the SOC within the 48-hour time timeframe a provider order was obtained. An interview on 1/23/24 at 11:29 a.m., registered nurse (RN)-A stated SOC should be completed within 48 hours after a referral. If it cannot be done, the patient and provider were contacted, and an order obtained for an extension. If the delay was the patient’s wish, a provider order would still be obtained.

On 1/30/23 - 2/1/23 a complaint survey was conducted. This resulted in a standard survey at Interim Healthcare. 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. H71047675C/95361 was substantiated and a deficiency was issued at G430 as a result of the complaint investigation. H71048034C/71924 was unsubstantiated.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to protect 1 of 3 patients (P1) reviewed for allegations of misappropriation of property. P1’s as needed Acetaminophen-Hydrocodone Bitarate (a narcotic medication) was removed from the home by the agency nurse (RN)-A. RN-A told P1 that keeping the pain medication in her home was dangerous and RN-A would destroy the medication for her. P1 did not miss a dose of the as needed narcotic medication. P1’s Home Health Certification and Plan of Care dated 12/31/22, indicated P1’s diagnoses were infrarenal abdominal aortic aneurysm ruptured (enlargement of the artery around the kidney area), acute embolism and thrombus (obstruction of an artery), hypertension (elevated blood pressure), anxiety, depression, and osteoarthritis (the wearing down of protective tissue at the ends of bones causing pain and stiffness). P1’s mental status indicated she was not cognitively impaired. The disciplines assisting P1 were skilled nursing (SN), physical therapy (PT), speech therapy (ST) and occupational therapy (OT). SN orders included education for the patient/caregiver how to set-up medications; demonstrated medications set-up for the patient/caregiver, observe patient/caregiver setting up medications; observe compliance and independence with medication set-up. Teach and reinforce medication dosages, administration, actions/side effects, possible interactions, report any signs or symptoms to the provider. SN, PT, OT, SLP orders included to teach pain management and comfort measures. Assess P1 for risk and signs of neglect, financial exploitation, and/or abuse, including self-abuse or abuse or from others. Establish an individualized abuse prevention plan. P1’s medication sheet dated 12/31/22, indicated P1’s oral medications were Acetaminophen 325 milligrams (mg); take two tablets every six hours as needed for pain, a narcotic medication Acetaminophen-Hydrocodone Bitrate (Vicodin) 325 mg-5 mg; take one tablet every four hours as needed for severe pain, Fluoxetine (for depression) 20 mg; take one tablet once a day, Metoprolol Tartrate (for elevated blood pressure) 100 mg; take one tablet twice a day, Senna S 50 mg-8.6 mg; take two tablets daily as needed for constipation, Tizanidine 2 mg capsule; take one capsule every eight hours for severe pain, torsemide (diuretic) 40 mg tablet; take one tablet once a day, Warfarin Sodium (blood thinner) 2.5 mg; take one tablet once a day. Upon interview on 1/30/23, at 10:41 a.m. P1’s family member (FM)-A stated on 1/12/23, the home health agency nurse, registered nurse (RN)-A, called him informing him P1’s blood pressure was low, and she needed to be sent to the emergency department. FM-A stated he was already aware that her blood pressures have been low and a nurse from P1’s clinic instructed the family to monitor P1. RN-A spoke in a manner that made FM-A believe P1’s blood pressure was plummeting, and he was going to find her deceased. FM-A stated he arrived at P1’s assisted living apartment the same time as the paramedics but RN-A had already left P1’s apartment. The assisted living nursing staff and the paramedics took P1’s vital signs again and found her to be stable. P1 was not transferred to the hospital. FM-A stated shortly after he left P1’s apartment, P1 called him stating RN-A had taken her narcotic pain medication and was going to destroy them because they were dangerous. FM-A stated P1 said to him in a frightened tone over the telephone “well sure I told her to do what she is supposed to do, I didn’t want to question authority, but now what do I do without my medication?” FM-A stated after his conversation with P1 he informed the assisted living director of nursing RN-C and the home care case manager RN-D that RN-A had taken the medications away from P1. FM-A stated the agency made sure she received a refill of the narcotic medication the next day. FM-A stated that the family helps P1 manager her medications by reordering, picking them up from the pharmacy, and storing them at her apartment. Upon interview on 1/30/23, at 12:49 p.m. the agency case manager RN-B stated on 1/12/23, RN-A had called him and informed him about P1’s low blood pressure and the interaction with the son regarding wanting P1 sent to the emergency department. RN-A told RN-B that she had taken P1’s narcotic medication to be discarded and gave them to an assisted living staff member because P1 wasn’t using them anymore. RN-B stated he did not question RN-A during the conversation about removing the medication from P1’s home and why RN-A did not wait for the son to arrive to discuss with him. RN-B stated FM-A left him a voicemail RN-A had taken P1’s narcotic medication, stating it should be the family’s job or P1’s job to discard the medication and there was a “fair amount” of medication in the bottle. RN-B stated the agency policy is to provide the patient or patient representative with resources how to discard medications and never remove anything from the patient’s home. In addition, he stated the agency would not destroy an active medication that a provider prescribed. The agency should notify the provider with any medication concerns and educate the patient and/or the representative. RN-B stated the agency did not have a policy or education on controlled substances, keeping a log, counting narcotics or education on diversion in the homes. He stated the agency nurses reconcile medications, educate on medication and set-up, manage any medication changes, and watch for side effects. The home health agency does not order, administer, or store any medications for P1. Upon interview on 1/30/23, at 1:45 p.m. RN-A stated she was assigned to visit P1 and it was her first time to provide care and services. RN-A arrived seeing P1 seated in a recliner. P1 told RN-A her blood pressure was low as the agency OT staff had just taken it. RN-A stated the blood pressure was low, unable to recall the exact reading. She stated she was trying to figure out why P1’s blood pressure was low, so she began by reconciling her medications. RN-A reported P1 mentioned she had medications in her cupboard she takes as needed. RN-A found in the cupboard an anxiety medication, a narcotic pain medication, and a muscle relaxant. RN-A denied recalling the brand names of these medications upon interview. P1 told RN-A her she does not take the narcotic pain medication. RN-A told P1 narcotic medication could be dangerous, and she could suffer central nervous depression if she were to take the narcotic with low blood pressure readings. RN-A stated she took the medication and went to look for assisted living staff to inform them P1 needed an ambulance. RN-A stated she left the apartment with the medication and found an assisted living staff member by the elevator and asked the staff member, nursing assistant (NA)-A, could destroy the narcotic medication, then asked her to find the assisted living nursing staff because P1 needed an ambulance. RN-A stated she gave the narcotic medication bottle to NA-A then went back to the P1’s apartment where she reported P1’s blood pressure to licensed practical nurse (LPN)-A and assisted living facility registered nurse (RN)-C. RN-A stated she asked P1 three separate times if she could destroy the medication and P1 gave consent. RN-A stated she was aware that the agency policy was to not remove medications a patient’s home and patients, or family members should be taught how and where to destroy medications properly. She stated, “I wasn’t sure if the assisted living was managing her medications or not, so I did not know she wasn’t on their dispensing program.” RN-A stated she was given a write-up at the agency, completed “some education” on medication management and then resigned from her position. Upon observation on 1/31/23, at 9:19 a.m. P1 was seated in her recliner in her apartment. She was fully dressed and well groomed. She was able to stand-up without difficulty and sit at the kitchen table for an interview. On her kitchen table she had an am/pm medication box that her scheduled medications were set-up in. The scheduled medication bottles were on the kitchen table in a hard plastic bag. Her medication box was open to the day of the week (Tuesday), she had taken medications through Tuesday morning correctly. In her kitchen cupboard she had three bottles of medications; Tizanidine 2 mg capsule; take one capsule every eight hours for severe pain, last fille 10/22/22, a narcotic medication Acetaminophen-Hydrocodone Bitrate (Vicodin) 325 mg-5 mg; take one tablet every four hours as needed for severe pain, last filled 1/13/23, alprazolam 0.50 mg; take 1 tablet three times daily as needed for anxiety last filled 12/20/22. Apartment was tidy with clear pathways. Upon interview on 1/31/23, at 9:19 a.m. P1 asked if she did anything wrong, stating she didn’t know what to do when RN-A came that day insisting she go to the hospital for low blood pressure and “digging through my meds, telling me my pain medication was dangerous.” P1 stated RN-A took “the pain medication” out of the cupboard and asked multiple times if P1 was taking it and P1 replied sometimes for severe pain. RN-A told P1 that it was dangerous and said she would destroy it. RN-A placed the medication in a blue bag that she had sitting on the floor. RN-A told P1 to stay seated and she was going to find help from the assisted living staff and have her transported to the hospital. RN-A left the apartment, leaving her bag on the floor. She came back and waited for the assisted living staff to arrive, she spoke with the assisted living staff for a few minutes, grabbed her bag and left. P1 stated then the ambulance and my son came, and she wasn’t thinking about her medication until everybody left and she calmed down, then realized she should not have allowed RN-A to take her medications. P1 called FM-A and told him what RN-A said about her medication being dangerous and taking it. P1 stated RN-A scared my son and got her is a “such a flurry” she did not know what to do. Upon interview on 1/31/23, at 9:45 a.m. P1’s pharmacy stated the narcotic medication taken from P1’s apartment had been filled on 12/20/22 for 100 tablets. Prior to that the last refill was on 10/22/22 indicating she took the narcotic medication sparingly. He stated her narcotic, anxiety and muscle relaxant medication can cause central nervous depression. Upon interview on 1/31/23, at 10:05 a.m. the assisted living director of nursing, RN-C stated on 1/12/23, she was in a meeting when NA-A summoned her to leave because P1 was hypotensive (low blood pressure), and 911 needed to be called. LPN-A and RN-C arrived at the P1’s apartment where RN-A stated her blood pressure was low she needed to go to the emergency room. RN-A then left P1’s apartment. A few minutes later, P1’s FM-A and emergency medical services (EMS) arrived, her blood pressure was taken, and it read “somewhere around 100/60” so it was determined P1 would not be transported with EMS. She stated FM-A followed her to her office and stated he did not want the home health agency working with P1 anymore. RN-C instructed FM-A to call the agency directly because that was the employer of RN-A. A few hours later RN-C contacted the agency case manager, RN-B, to tell him RN-A had removed narcotics from P1’s apartment. RN-B stated she interviewed the staff member, NA-A, whom the agency claimed received the narcotics from RN-A and searched her coat and personal belongings. NA-A she denied having any conversation about medications or taking any medications from RN-A. RN-C stated she told the home health agency nurse manager RN-D she didn’t want RN-A on their property anymore, due to “weird behavior”, leaving before EMS arrived, upsetting the resident and family and the “narcotic diversion.” Upon interview on 1/31/23, at 10:30 a.m. LPN-A stated on 1/12/23, NA-A found LPN-A and told her that P1 needed an ambulance. LPN-A stated she would print off her paperwork and go to her apartment. She stated when she arrived at the apartment with the paperwork RN-A picked up a blue bag off the floor and left P1’s apartment without announcing her departure. ” LPN-A denied any conversation with RN-A. Upon interview on 1/31/23, at 1:26 p.m. RN-D stated the home health agency did not provide education on safety of controlled substances. “We educate that nothing is to be taken from the home.” The facility does not perform any specific controlled substance assessments or have a specific controlled substance policy. RN-D stated the agency did not find a root cause; however, the agency determined the findings were inconclusive, RN-A acted inappropriately by her reported statement of handing a controlled substance to a nursing assistant/unlicensed person and removal of patient property from the home. RN-A was pulled off the schedule immediately. She was given re-education in person and web based. RN-A did resign giving a month’s notice; however, the facility did not require her to fulfill the notice and let her go on the day of resignation dated 1/20/23. Upon interview on 1/31/23, at 2:22 p.m. physical therapist supervisor (PT)-A stated therapy services at times complete admissions on patients. When completing admission assessments, they perform a medication reconciliation where medication bottles in the home are compared with the medication list provided by the physician. This practice does give them access to patient’s medications. Therapy staff was not a part of the re-education given to the nursing staff. Upon interview on 1/31/23, at 2:34 p.m. the director of nursing (DON), stated she notified the police when the incident was reported to her, stating “none of this added up.” She stated that the agency provided training to nursing staff that consisted of re-educating to never take medications from patient’s home, educate on proper disposal per state, county, and pollution control guidelines and to remember medications are the patient’s property. The DON stated that therapy staff and the nursing assistances have access to the medications in the home and were not re-educated. She denied any education on preventing any diversion for controlled substances in the home. Upon interview on 1/31/23 at 3:09 p.m. the Chief Operating Office stated the agency did not find a root cause of the controlled substance theft and the agency does not have a specific controlled substance policy. Upon interview on 2/1/23, at 9:03 a.m. NA-A stated when she was escorting a resident to lunch, she was by the elevator and RN-A approached her saying she needed to send someone to the hospital and asked NA-A to find the assisted living nursing staff. NA-A stated she found LPN-A and RN-C who were in a meeting. She asked them to go to P1’s room as she needed an ambulance. When LPN-A and RN-C got to the room, NA-A left to finish her duties. She stated RN-A did not mention anything about medication to her nor did she give her any medication to destroy. She stated she found out later the medication was a narcotic. She stated NA’s don’t destroy any medications in the facility and all narcotics are locked up. If someone would have asked her to destroy a medication, she would have deferred them to the nursing staff. She stated LPN-A and RN-C checked her body, her bag, and her coat for any medications. She rides the bus to work, so she carries very minimal items to the facility. Upon interview on 2/1/23, at 12:15 p.m. the providers clinical nurse (RN)-E stated she was informed on 1/13/23 that P1’s narcotic medication had been “stolen” and a police report and Minnesota Adult Abuse Reporting Center (MAARC) report were filed. The provider granted the refill request for P1’s narcotic medication. A facility policy titled Education for Patients and Caregivers on Safe Disposal of Medications dated 1/17/2023 indicated medications are the property of the patient. Employees will not dispose of or remove medications from a patient’s home. Instead, the team can provider education and resources to assist with medication disposal. For patients who live in an assisted living or other licensed congregate settings, where the facility manages or administers the patient’s medications, the agency will collaborate with the facility nursing staff to establish a plan for safe medication disposal. A facility protocol titled Protocol for Medication Management undated, indicated under heading medication safety; patients and appropriate caregivers will be educated to store medications in a safe place where only they can access them to prevent theft, misuse, or improper disposal. A policy regarding controlled substances was requested, however none was provided. P1’s Home Health Certification and Plan of Care dated 12/31/22, indicated P1’s diagnoses were infrarenal abdominal aortic aneurysm ruptured (enlargement of the artery around the kidney area), acute embolism and thrombus (obstruction of an artery), hypertension (elevated blood pressure), anxiety, depression, and osteoarthritis (the wearing down of protective tissue at the ends of bones causing pain and stiffness). P1’s mental status indicated she was not cognitively impaired. The disciplines assisting P1 were skilled nursing (SN), physical therapy (PT), speech therapy (ST) and occupational therapy (OT). SN orders included education for the patient/caregiver how to set-up medications; demonstrated medications set-up for the patient/caregiver, observe patient/caregiver setting up medications; observe compliance and independence with medication set-up. Teach and reinforce medication dosages, administration, actions/side effects, possible interactions, report any signs or symptoms to the provider. SN, PT, OT, SLP orders included to teach pain management and comfort measures. Assess P1 for risk and signs of neglect, financial exploitation, and/or abuse, including self-abuse or abuse or from others. Establish an individualized abuse prevention plan. P1’s medication sheet dated 12/31/22, indicated P1’s oral medications were Acetaminophen 325 milligrams (mg); take two tablets every six hours as needed for pain, a narcotic medication Acetaminophen-Hydrocodone Bitrate (Vicodin) 325 mg-5 mg; take one tablet every four hours as needed for severe pain, Fluoxetine (for depression) 20 mg; take one tablet once a day, Metoprolol Tartrate (for elevated blood pressure) 100 mg; take one tablet twice a day, Senna S 50 mg-8.6 mg; take two tablets daily as needed for constipation, Tizanidine 2 mg capsule; take one capsule every eight hours for severe pain, torsemide (diuretic) 40 mg tablet; take one tablet once a day, Warfarin Sodium (blood thinner) 2.5 mg; take one tablet once a day. Upon interview on 1/30/23, at 10:41 a.m. P1’s family member (FM)-A stated on 1/12/23, the home health agency nurse, registered nurse (RN)-A, called him informing him P1’s blood pressure was low, and she needed to be sent to the emergency department. FM-A stated he was already aware that her blood pressures have been low and a nurse from P1’s clinic instructed the family to monitor P1. RN-A spoke in a manner that made FM-A believe P1’s blood pressure was plummeting, and he was going to find her deceased FM-A stated he arrived at P1’s assisted living apartment the same time as the paramedics and RN-A had already left P1’s apartment. The assisted living nursing staff and the paramedics took P1’s vital signs again and found her to be stable. P1 was not transferred to the hospital. FM-A stated shortly after he left P1’s apartment, P1 called him stating RN-A had taken her narcotic pain medication and was going to destroy them because they were dangerous. FM-A stated P1 said to him in a frightened tone over the telephone “well sure I told her to do what she is supposed to do, I didn’t want to question authority, but now what do I do without my medication?” FM-A stated after his conversation with P1 he informed the assisted living director of nursing RN-C and the home care case manager RN-D that RN-A had taken the medications away from P1. FM-A stated the agency made sure she received a refill of the narcotic medication the next day. FM-A stated that the family helps P1 manager her medications by reordering, picking them up from the pharmacy, and storing them at her apartment. Upon interview on 1/30/23, at 12:49 p.m. the agency case manager RN-B stated on 1/12/23, RN-A had called him and informed him about P1’s low blood pressure and the interaction with the son regarding wanting P1 sent to the emergency department. RN-A told RN-B that she had taken P1’s narcotic medication to be discarded and gave them to an assisted living staff member because P1 wasn’t using them anymore. RN-B stated he did not question RN-A during the conversation about removing the medication from P1’s home and why RN-A did not wait for the son to arrive to discuss with him. RN-B stated FM-A left him a voice mail RN-A had taken P1’s narcotic medication, stating it should be the family’s job or P1’s job to discard the medication and there was a “fair amount” of medication in the bottle. RN-B stated the agency policy is to provide the patient or patient representative with resources how to discard medications and never remove anything from the patient’s home. In addition, he stated the facility would not destroy an active medication that a provider prescribed. The agency should notify the provider with any medication concerns and educate the patient and/or the representative. RN-B stated the agency did not have a policy or education on controlled substances, keeping a log, counting narcotics or education on diversion in the homes. He stated the agency nurses reconcile medications, educate on medication and set-up, manage any medication changes, and watch for side effects. The home health agency does not order, administer, or store any medications for P1. Upon interview on 1/30/23, at 1:45 p.m. RN-A stated she was assigned to see P1 for ? and this was her first time to provide care and services. RN-A arrived seeing P1 seated in a recliner. P1 told RN-A her blood pressure was low as the agency OT staff had just taken it. RN-A stated the blood pressure was low, unable to recall the exact reading. She stated she was trying to figure out why P1’s blood pressure was low, so she began by reconciling her medications. RN-A reported P1 mentioned she had medications in her cupboard she takes as needed. RN-A found in the cupboard an anxiety medication, a narcotic pain medication, and a muscle relaxant. RN-A denied recalling the brand names of these medications upon interview. P1 told RN-A her she does not take the narcotic pain medication . RN-A told P1 narcotic medication could be dangerous, and she could suffer central nervous depression if she were to take the narcotic with low blood pressure readings. RN-A stated she took the medication and went to look for assisted living staff to inform them P1 needed an ambulance. RN-A stated she left the apartment with the medication and found an assisted living staff member by the elevator and asked the staff member, nursing assistant (NA)-A, could destroy the narcotic medication, then asked her to find the assisted living nursing staff because P1 needed an ambulance. RN-A stated she gave the narcotic medication bottle to NA-A then went back to the P1’s apartment where reported P1’s blood pressure to licensed practical nurse (LPN)-A and assisted living facility registered nurse (RN)-C. RN-A stated she asked P1 three different times if she could destroy the medication and P1 gave consent. RN-A stated she was aware that the agency policy was to not remove medications a patient’s home and patients, or family members should be taught how and where to destroy medications properly. She stated, “I wasn’t sure if the assisted living was managing her medications or not, so I did not know she wasn’t on their dispensing program.” RN-A stated she was given a write-up at the agency, completed “some education” on medication management and then resigned from her position. Upon observation on 1/31/23, at 9:19 a.m. P1 was seated in her recliner in her apartment. She was fully dressed and well groomed. She was able to stand-up without difficulty and sit at the kitchen table for an interview. . On her kitchen table she had an am/pm medication box that her scheduled medications were set-up in. The scheduled medication bottles were on the kitchen table in a hard plastic bag. Her medication box was open to the day of the week (Tuesday), she had taken medications through Tuesday morning correctly. In her kitchen cupboard she had three bottles of medications; Tizanidine 2 mg capsule; take one capsule every eight hours for severe pain, last fille 10/22/22, a narcotic medication Acetaminophen-Hydrocodone Bitrate (Vicodin) 325 mg-5 mg; take one tablet every four hours as needed for severe pain, last filled 1/13/23, alprazolam 0.50 mg; take 1 tablet three times daily as needed for anxiety last filled 12/20/22. Apartment was tidy with clear pathways. Upon interview on 1/31/23, at 9:19 a.m. P1 asked if she did anything wrong, stating she didn’t know what to do when RN-A came that day insisting she go to the hospital for low blood pressure and “digging through my meds, telling me my pain medication was dangerous.” P1 stated RN-A took “the pain medication” out of the cupboard and asked multiple times if P1 was taking it and P1 replied sometimes for severe pain. RN-A told P1 that it was dangerous and said she would destroy it. RN-A placed the medication in a blue bag that she had sitting on the floor. RN-A told P1 to stay seated and she was going to find help from the assisted living staff and have her transported to the hospital. RN-A left the apartment, leaving her bag on the floor. She came back and waited for the assisted living staff to arrive, she spoke with the assisted living staff for a few minutes, grabbed her bag and left. P1 stated then the ambulance and my son came, and she wasn’t thinking about her medication until everybody left, she calmed down, then e realized she should not have allowed RN-A to take her medications. P1 called FM-A and told him what RN-A said about her medication being dangerous and taking it. P1 stated RN-A scared my son and got her is a “such a flurry” she did not know what to do. Upon interview on 1/31/23, at 9:45 a.m. P1’s pharmacy stated the narcotic medication taken from P1’s apartment had been filled on 12/20/22 for 100 tablets. Prior to that the last refill was on 10/22/22 indicating she took the narcotic medication sparingly. He stated her narcotic, anxiety and muscle relaxant medication can cause central nervous depression. Upon interview on 1/31/23, at 10:05 a.m. the assisted living director of nursing, RN-C stated on 1/12/23, she was in a meeting when NA-A summoned her to leave because P1 was hypotensive (low blood pressure), and 911 needed to be called. LPN-A and RN-C arrived at the P1’s apartment where RN-A stated her blood pressure was low she needed to go to the emergency room. RN-A then left P1’s apartment. A few minutes later, P1’s FM-A and emergency medical services (EMS) arrived, her blood pressure was taken, and it read “somewhere around 100/60” so it was determined P1 would not be transported with EMS. She stated FM-A followed her to her office and stated he did not want the home health agency working with P1 anymore. RN-C instructed FM-A to call the agency directly because that was the employer of RN-A. A few hours later RN-C contacted the agency case manager, RN-B, to tell him RN-A had removed narcotics from P1’s apartment. RN-B stated she interviewed the staff member, NA-A, whom the agency claimed received the narcotics from RN-A and searched her coat and personal belongings. NA-A she denied having any conversation about medications or taking any medications from RN-A. NA-A was a new employee and facility NA’s do not destroy medications. RN-C stated she told the home health agency nurse manager RN-D she didn’t want RN-A on their property anymore, due to “weird behavior”, leaving before EMS arrived, upsetting the resident and family and the “narcotic diversion.” Upon interview on 1/31/23, at 10:30 a.m. LPN-A stated on 1/12/23, NA-A found LPN-A and told her that P1 needed an ambulance. LPN-A stated she would print off her paperwork and go to her apartment. She stated when she arrived at the apartment with the paperwork RN-A picked up a blue bag off the floor and left P1’s apartment without announcing her departure. ” LPN-A denied any conversation with RN-A. Upon interview on 1/31/23, at 1:26 p.m. RN-D stated the home health agency did not provide education on safety of controlled substances. “We educate that nothing is to be taken from the home.” The facility does not perform any specific controlled substance assessments or have a specific controlled substance policy. RN-D stated the agency did not find a root cause; however, the agency determined the findings were inconclusive, RN-A acted inappropriately by her reported statement of handing a controlled substance to an nursing assistant/unlicensed person and removal of patient property from the home. RN-A was pulled off the schedule immediately. She was given re-education in person and web based. RN-A did resign giving a month’s notice; however, the facility did not require her to fulfill the notice and let her go on the day of resignation dated 1/20/23. Upon interview on 1/31/23, at 2:22 p.m. physical therapist supervisor (PT)-A stated therapy services at times complete admissions on patients. When completing admission assessments, they perform a medication reconciliation where medication bottles in the home are compared with the medication list provided by the physician. This practice does give them access to patient’s medications. Therapy staff was not a part of the re-education given to the nursing staff. Upon interview on 1/31/23, at 2:34 p.m. the director of nursing (DON), stated she notified the police when the incident was reported to her, stating “none of this added up.” She stated that the agency provided training to nursing staff that consisted of re-educating to never take medications from patient’s home, educate on proper disposal per state, county, and pollution control guidelines and to remember medications are the patient’s property. The DON stated that therapy staff and the nursing assistances have access to the medications in the home and were not re-educated. She denied any education on preventing any diversion for controlled substances in the home. Upon interview on 1/31/23 at 3:09 p.m. the Chief Operating Office stated the agency did not find a root cause of the controlled substance theft and the agency does not have a specific controlled substance policy. Upon interview on 2/1/23, at 9:03 a.m. NA-A stated, when she was escorting a resident to lunch, she was by the elevator and RN-A approached her saying she needed to send someone to the hospital and asked NA-A to find the assisted living nursing staff. NA-A stated she found LPN-A and RN-C who were in a meeting. She asked them to go to P1’s room as she needed an ambulance. When LPN--A and RN-C got to the room, NA-A left to finish her duties. She stated RN-A did not mention anything about medication to her nor did she give her any medication to destroy. She stated she found out later the medication was a narcotic. She stated NAs don’t destroy any medications in the facility and all narcotics are locked up. If someone would have asked her to destroy a medication, she would have deferred them to the nursing staff. She stated LPN-A and RN-C checked her body, her bag, and her coat for any medications. She rides the bus to work, so she carries very minimal items to the facility. Upon interview on 2/1/23, at 12:15 p.m. the providers clinical nurse (RN)-E stated RN-D informed the provider on 1/13/23 that P1’s narcotic medication had been “stolen” and a police report and Minnesota Adult Abuse Reporting Center (MAARC) report were filed. The provider granted the refill request for P1. A facility policy titled Education for Patients and Caregivers on Safe Disposal of Medications dated 1/17/2023 indicated medications are the property of the patient. Employees will not dispose of or remove medications from a patient’s home. Instead, the team can provider education and resources to assist with medication disposal. For patients who live in an assisted living or other licensed congregate settings, where the facility manages or administers the patient’s medications, the agency will collaborate with the facility nursing staff to establish a plan for safe medication disposal. A facility protocol titled Protocol for Medication Management undated, indicated under heading medication safety; patients and appropriate caregivers will be educated to store medications in a safe place where only they can access them to prevent theft, misuse, or improper disposal. A policy regarding controlled substances was requested, however none was provided.