Every finding on record at Lakeview Memorial Hospital Association, Inc.

On 6/12/23, to 6/14/23, a survey for compliance with Appendix Z, Emergency Preparedness Requirements, §483.73(b)(6) was conducted during a standard recertification survey. The facility was IN compliance.

On 6/12/23, to 6/14/23, a recertification survey was conducted. This resulted in a partial extended, survey at Lakeview Homecare. 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: 887 Total home visits conducted: 7 List Parent Location visited, including the addresses as verified while on site: 5803 Neal Ave. N. Oak Park Heights MN 55082 List all other branch offices for this agency and identify which of these were visited during this survey and which you pulled records from: N/A List Hours of Operation: 8a.m.-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 document review, the agency failed to complete an initial assessment visit within 48 hours of patient referral for 1 of 5 patients (P18) reviewed for closed records. Findings include: P18’s physician’s order dated 1/31/23, identified a referral for homecare start of care (SOC) within one to two days. Physical therapy to (PT) and occupational therapy (OT) were ordered to evaluate and treat due to fracture of the lower leg, decreased activity tolerance and decreased strength and mobility. P18’s nursing home discharge summary dated 1/31/23, identified P18 discharged home on 2/3/23. P18’s Home Health Certification and Plan of Care was dated 2/6/23, which identified the initial assessment had not been completed within 48 hours as required. P18’s medical record lacked documentation for rationale for delayed initial assessment. During an interview on 6/13/23 at 1:43 p.m., the rehabilitation supervisor (RS) stated R18's SOC was outside of the 48-hour range and upon further record review was not sure why. During an interview on 6/14/23 at 9:35 a.m. the administrator agreed R18's initial assessment was done on 2/6/23, instead of 2/5/23, and there was no rationale in the medical record for the delayed SOC. Agency policy titled Initial and Comprehensive Assessments, undated, identified the initial assessment visit must be completed within 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date identified by the physician or at the patient/family request with the approval of the physician (or another authorized licensed independent practitioner).

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: During observation, interview, and record review the facility failed to ensure the plan of care included the correct medication dosage as prescribed by the physician for 1 of 3 patients (P9) reviewed for medication management. P9's plan of care with a certification period of 6/6/23-8/4/23, indicated a diagnosis of spinal stenosis, lumbar region with neurogenic claudication and she received skilled nursing services two visits every week for two weeks, for medication management and education, symptom management, observe and assess for change in condition, and to assess for signs and symptoms of infection. During observation and interview on 6/12/23 at approximately 2:45 p.m., registered nurse (RN)-D was setting up P9's medications by comparing the medication bottles to the medication list in the computer (EPIC remote). RN-D also had a handwritten medication list she was referring to. P9's plan of care for the recertification period of 6/6/23-8/4/23 included a physician's order for Hydrochlorothiazide 25 mg tablet [started 2/13/23] take 1 tablet by mouth daily. RN-D stated she was setting up Hydrochlorothiazide 12.5 mg tablet, take 3 by mouth daily. The surveyor questioned the dosage and referred to the orders on the plan of care. RN-D stated the handwritten medication list indicated the dosage to be 12.5 mg tablet and to take 3 tablets by mouth daily but the medication list in the computer indicated the dose was 25 mg tablet and to take one tablet by mouth daily. RN-D looked in P9's medical record and was able to find a new physician's order which indicated the dose to be 12.5 mg's stating the medication list in the computer should have been updated. She further stated she will call the physician and get clarification on the order. During an interview on 6/14/23 at 8:24 a.m., the nursing supervisor RN-C verified the medication list had not been updated in the computer system (EPIC remote) and stated the nurses were responsible for updating the medication list when they receive a new physician's order. RN-C further stated the nurses should use the medication list in EPIC remote (computer) when setting up medications and if there was a discrepancy, they should call the physician the same day. During an interview on 6/14/23 at 8:35 a.m., the clinical manager (CM)-A stated the nurses were expected to follow the medication list in EPIC remote (computer) when setting up medications and if there was a discrepancy, they should call the physician for clarification. The facility's policy regarding medication profiles (undated), indicated patient's receiving medications will have a current, accurate medication profile in the clinical record.

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 follow accepted standards of practice related to cleaning and disinfecting of point-of-care devices used for more than one patient, in order to prevent transmission of potential bloodborne pathogens for 1 of 1 patient (P10) who had an international normalized ratio (INR) blood test during a home visit. This had the potential to affect 10 patients identified by the agency who had INR tests ordered to be completed during home visits. Findings include: P10’s Home Health Certification and Plan of Care dated 6/4/23 through 8/2/23, identified diagnoses of blood clot of the lower extremity and long-term use of anticoagulants with therapeutic drug level monitoring. P10’s orders dated 6/11/23 through 6/24/23, identified skilled nurse visits once weekly for INR tests. On 6/12/23 at 3:00 p.m. through 4:15 p.m., P10’s skilled nurse home visit was completed with registered nurse (RN)-A and rehabilitation supervisor (RS) in attendance. RN-A removed an INR machine stored in a black case from her backpack of home visit equipment. RN-A assembled her supplies. RN-A used an alcohol-based hand rub on her hands, applied gloves, cleaned P10's finger with an alcohol prep pad, used a lancet to obtain sample of blood from the finger, picked up the meter and applied the blood to the INR test strip in the meter. After the result was obtained, the test strip was removed and disposed. RN-A removed her gloves, used an alcohol-based hand rub on her hands and applied new gloves. RN-A then removed another alcohol prep pad from an orange and white packet, cleaned the INR meter, let it dry for several minutes and put the meter back in the pouch and then her backpack. During an interview on 6/12/23 at 4:15 p.m., RN-A stated the INR meters were used for more than one patient. RN-A stated training from the agency directed her to clean the meter with 70% alcohol prep pads. RN-A stated she was not sure if anything else should be used on the meters. During an interview on 6/13/23 at 12:15 p.m., RN-B also stated the INR meters were used for more than one patient. RN-B stated she would disinfect the meters and all other shared patient care equipment with Sani-Cloth wipes because those were effective against blood-borne pathogens. During an interview on 6/13/23 at 2:18 p.m., Roche Diagnostics Coag-Check XS System technical support (TS) stated there was a potential risk of infection of bloodborne pathogens with shared meters. The TS also stated the only cleaning agents approved for the meters were 70% alcohol or 10% bleach, in accordance with the meter's user manual. The TS stated if those cleaning agents were not available, agencies should consult the manufacturers for guidance. During an interview together on 6/14/23 at 9:00 a.m., with the agency's nurse educator (NE), infection preventionist, quality control supervisor and administrator, the NE stated the agency used Sani-Cloth wipes to disinfect all shared patient care equipment as Sani-Cloths were effective against bloodborne pathogens. The NE also stated shared patient care equipment including point-of-care devices such as INR meters should be cleaned and disinfected prior to being packed up for the next home visit. The administrator stated the facility practice to clean the INR meters with alcohol wipes was based off the INR meter user manual, and the facility policy directed staff to clean the meters with alcohol as well. The facility provided Coag-Check XS System User Manual dated 2022, by Roche Diagnostics, under the Infection Control section, identified there was a potential risk of infection. Medical staff and other persons using the meter to perform tests on more than one patient must be aware that any object coming into contact with human blood was a potential source of infection. Under the Cleaning/Disinfection section the following items were approved for cleaning/disinfecting the meter: 70% isopropyl alcohol and 10% sodium hypochlorite solution (one part bleach to nine parts deionized water made fresh every 24 hours). The Center for Disease Control (CDC) Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration dated 3/2/11, identified the following information regarding cleaning and disinfection: Appropriate products and procedures for cleaning and disinfection of blood glucose meters (a point-of-care blood testing meter used in the same manner as an INR meter) should be effective against HIV (human immunodeficiency virus), Hepatitis C, and Hepatitis B virus. 70% ethanol solutions are not effective against viral bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of the device. The EPA list of registered antimicrobial products effective against bloodborne pathogens dated 2/22/23, identified Sani-Cloth Germicidal disposable wipes and certain bleach wipes were effective. 70% isopropyl alcohol prep pads were not listed. The facility policy INR Testing dated 2/23, identified the meters would be cleaned with alcohol wipes between uses. The policy lacked a disinfection technique effective against bloodborne pathogens.