Every finding on record at Mary T Home Health, Inc.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 1/28/25 to 1/30/25 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 1/28/25 to 1/30/25 a recertification and complaint survey was conducted. This resulted in a partial extended survey at Mary T Home Health. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 231 Total home visits conducted: 3 Parent Location visit. 11777 Xeon Boulevard NW, Coon Rapids, MN 55448 Branches Visited: 38873 14th Ave, Suite 6, North Branch, MN 55056 List Hours of Operation: 8:00 a.m. - 4:30 p.m. List total number of records reviewed: 7 The following complaints were reviewed: H72926121C (Complaint 109750)

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 document review and interview, the agency failed to timely encode and submit Outcome and Assessment Information Set (OASIS) in accordance with Center for Medicare (CMS) requirement. On the HHA Error Summary by Agency report period of 12/18/2023 - 12/18/2024, the agency had an error code 0f -3330: record submitted late. The description included the submission was more than 30 days after M0090 on the new record. The report included the number of assessments with this error code was 189, which equaled 16.41% of the submissions submitted. During an interview on 1/30/25 at 10:53 a.m., clinical manager (CM)-A confirmed the agency has had problems completing and submitting the assessments on time. CM-A stated the clinicians completing the assessment do not always complete them in a timely manner. After the assessment was closed by the clinician, it gets sent through a quality assurance process. The assessment was then submitted after the quality assurance process was completed. CM-A stated this process sometimes exceeds the required timeframe. Agency policy on OASIS submission data requested and not provided.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure 1 of 5 non-licensed staff completed required annual training. Agency provided document titled Associate List dated 1/28/25, included home health aide (HHA)-B had a start date of 4/4/22. Agency provided undated document titled Home Care Annual EduCare (an online healthcare education and training platform) Plan included the monthly assigned courses with continuing education hours. Total number of hours assigned was 12 hours per year. Agency document titled My Transcript with HHA-B’s name, undated, included transcript of EduCare courses completed. Courses completed for last 12 months included: HIPPA completed 3/7/24 worth 1 credit Home Care Bill of Rights completed 4/4/24 worth 0.75 credits Infection Control Techniques completed 2/7/24 worth 1 credit Waste-Wise Recycling Program Training completed 1/17/25 worth 1 credit Total of 3.75 credits (hours) During interview on 1/30/25 at 10:34 a.m., clinical manager (CM)-A confirmed HHA-B had not completed the required number of hours of annual training. CM-A stated the agency assigns a course each month to allow staff time to complete the required education. CM-A stated the agency regularly runs a report to monitor for incomplete education. She was aware HHA-B was behind on her education and believed it was discussed at her yearly review November 2024. Facility policy for annual training requested and not provided.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview, and document review the agency failed to identify, assess and educate 1 of 1 patients (P4) on use of a bedrail which was attached to his hospital bed. P4's Home Health Certification and Plan of Care identified diagnoses of cerebral infarction (stroke), and low back pain with a care goal of improved bed mobility with intervention of physical therapy to instruct patient/caregiver on techniques to improve bed mobility and safety. P4's durable medical equipment (DME) and supplies list included a hospital bed, shower chair, walker, wheelchair, elevated toilet seat and ramp. During observation and interview on 1/29/25 at 8:30 a.m., home health aide (HHA)-A was assisting P4 with a bed bath. P4 was noted to have a half rail on his hospital bed in the lowered position. When HHA-A was asked how P4 utilized the half rail she stated he sometimes would grab onto it in the lowered position to assist with sitting up or positioning in bed and had not seen it used in the raised position. When asked if any instruction or education had been provider to herself or P4 on appropriate and safe use of the half rail HHA-A stated not that she could remember. During interview on 1-30-25 at 9:50 a.m., clinical manager (CM)-A stated P4's half bed rail had not been assessed for appropriate and secure placement and should have been included in P4's DME list. CM-A confirmed P4 had not been educated on risks or safe use of the half rail. CM-A confirmed best practice would be to assess any bed rail for proper installation and safe use. CMA-A stated the agency had no policy or procedure regarding use of bed rails.

On 10/24/22 through 10/26/22, a survey for compliance with Appendix Z, Emergency Preparedness Requirements for Long Term Care facilities was conducted during a standard recertification survey. The facility was found to be in compliance.

On 10/24/22-10/26/22 a recertification survey was completed, along with a complaint investigation. This resulted in a standard survey at Mary T Home Health. The agency failed to meet 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: 223 Total home visits conducted: 3 List total number of records reviewed: 7 Parent Location visited, including the addresses as verified while on site: Mary T Home Health 299 Coon Rapids Boulevard, #105 Coon Rapids, MN 55433 Branch offices for this agency visited during this survey, with record review: Mary T Home Health North Branch/Branch office 6448 Main Street North Branch, MN 55056 List Hours of Operation: 8:00 a.m. to 4:30 p.m. The complaint investigation, H7292044C, was found to be unsubstantiated and no deficiencies were cited.

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 document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 1 of 1 patients (P4) who was observed for medication set up. P4's current plan of care (POC) for the recertification period of 9/13/22-11/11/22, identified a start of care date of 1/21/21. The POC identified P4 had knowledge deficit related to medication administration. The goal indicated P4 was to demonstrate compliance with medication regime as evidenced by correct administration. The physician orders directed staff to perform a skilled nurse visit (SNV) every 2 weeks. During observation on 10/25/22, at 2:30 p.m., licensed practical nurse (LPN)-A was observed after she had completed med set up for P4 in an MD2 automated pill dispenser as LPN-A had arrived early and completed med set up. LPN-A stated P4's medications were dispensed by pharmacy (Ph)-A in bubble packs which included all the medications for identified time period. LPN-A stated the medications were placed into the med cups and then placed into the MD2. LPN-A stated P4 had also requested additional vitamins be added into the medication cups in the MD2, so this was completed with med set up. LPN-A stated normally with med set up, individual prescription bottles were used, however, P4's were preset up by Ph-A and were placed into the med cups. A review of the medications dispensed by Ph-A as outlined on the label of the bubble pack in comparison to physician's orders on the POC. According to the POC dated effective 9/13/22 to 11/11/22, P4 was to receive the following medications: tiotropium (Spiriva) capsule 18 mcg 1 capsule inhaled daily into the lungs/inhalation fluticasone nasal (Flonase) spray 50 mcg/inhalation 1-2 sprays both nostrils daily/nasal epinephrine kit 0.3 1 device injected into muscle as needed for the allergic reaction/injectable montelukast table 10 mg 1 daily at bedtime/oral levothyroxine 25 mcg (0.25 mg) 1 tablet daily/oral lisinopril tablet 2.5 mg 1 tablet daily/oral solifenacin (VESIcare) tablet 10 mg 1 tablet daily/oral vortioxetine (Trintellix) tablet 20 mg 1 daily/oral trazodone tablet 100 mg tabs 2, 1-2 hours before bed cetirizaine tablet 10 mg 1 daily/oral diphenhydramine (Diphenhist) capsule 25 mg 1 tablet at bedtime/oral carbamazepine tablet 200 mg 1 tab in morning, 2 tablets at bedtime/oral buspirone tablet 7.5 mg 1 tablet three times daily/morning, noon, bedtime/oral hydroxyzine 25 mg 1 tablet three times daily fluticasone-salmeterol (Wixela inhaler) poweder 500 mcg 2 puffs two times daily albuterol sulfate/ipratopium bromide/0.5 mg and 3 mg Use 1 nebulizer inhalation every 6 hours as needed. Patient uses routinely every morning albuterol/Albuterol (Eqv-ProAir HFA) aerosol 90 mcg/inh 1 puff as needed daily (rescue inhaler)/inhalation prazosin capsule 3 mg 1 capsule 30 minutes before bed/oral rimegepant (Nurtec) tablet, disintegrating 75 mg. Take one tablet at onset of migraine. No more than 1 tablet a day or 15 days a month/oral duloxetine delayed release capsule 30 mg take one tablet by mouth daily/oral. The medication listing was compared with the label from Ph-A and this was noted to correlate with the orders, however, the following medications were identified as being dispensed and included in the med set up, however, they were not on the POC: methocarbamol 750 mg four times daily/oral gabapentin 300 mg three capsules (900 mg) three times daily/oral omeprazole 20 mg daily/oral Fiberlax 625 mg 2 tablets three times daily. P4 stated she had been using the above listed medications for years. Additionally, P4 stated she also had dosing for Naproxen 500 mg to be used as needed. A review of the vitamins and supplements was completed as had been set up with prescription meds in the MD2 and they included the following: Vitamin B Complex/oral Vitamin C 500 mg/oral Immune Health (Echinacea) 450 mg Biotin 5000 mcg/oral Upon review of inhalation medications in the living room, the following over the counter (OTC) medications were observed: Sinus Cough Medication/oral Calcium Carbonate 1000 mg/oral Acetaminophen 500 mg/oral Ibuprofen 200 mg/oral In addition to the OTC meds, the following prescription meds were also noted: Olopatadine 0.1% 1 drop twice daily/eye drops/ordered 2/23/21 Prochlorperazine 10 mg every 6 hours as need/oral/dispensed 9/22/21 A review of the POC dated 7/15/22 to 9/12/22 also lacked indication of use of the above listed meds identified as a discrepancy, including both the prescriptive medications and OTC meds. On 10/24/2022, at 3:00 p.m. this was reviewed with LPN-A, who identified there were no orders in place for the above listed medications. LPN-A stated it was important to review the medications in place in comparison to the physician's orders due to potential for drug interactions, as well as to identify what medications were currently being used by the patient. LPN-A stated when discrepancy was identified the physician was to be updated and consulted regarding the orders. On 10/24/22, at 3:30 p.m. registered nurse (RN)-C stated the medications set up for patients should be a direct match with the physician orders. This should include the medication, the correct dose and frequency. RN-C stated it was important to review all medications being used by the patient, including both OTC meds and prescriptions, as there was a risk for potential interactions with other meds, as well as a potential impact to patient health. A review of the facility policy, titled Content of Medication Prescriptions and Treatment or Therapy Orders, effective 2/1/15 identified a current, written or electronically recorder prescriber's prescription must be obtained for any medication, including over-the-counter medication or dietary supplement, which the agency is managing for the patient. The policy identified a current prescriber's order must be obtained for any treatment or therapy to be provided to a client. A facility policy, titled Medication Management Services, effective 2/1/15, identified when medications are set up, the RN/LPN will verify the dose and quantity of medications delivered is consistent with the prescription. The policy goes on to identify the RN/LPN was to review each client's medication record when the nurse is setting up medications and at other appropriate times. The policy identified this was done to verify the staff was administering medications as prescribed and was documented appropriately. Any issues or concerns require follow up and documentation by the nurse, including communications with the prescriber and pharmacy.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to ensure clinical notes were prepared to reflect specific medications set up during patient visits for 1 of 1 patients (P4) observed with medication set up. P4's current plan of care (POC) for the recertification period of 9/13/22-11/11/22, identified a start of care date of 1/21/21. The POC identified P4 had knowledge deficit related to medication administration. The goal indicated P4 was to demonstrate compliance with medication regime as evidenced by correct administration. The physician orders directed staff to perform a skilled nurse visit (SNV) every 2 weeks. During observation on 10/25/22, at 2:30 p.m., licensed practical nurse (LPN)-A was observed as she had completed med set up for P4 in an MD2 automated pill dispenser. LPN-A stated P4's medications were dispensed by pharmacy (Ph)-A in bubble packs which included all the medications for identified time period. LPN-A stated the medications were placed into the med cups and then placed into the MD2. LPN-A stated P4 also requested additional vitamins be added into the medication cups in the MD2. LPN-A stated once the medications were set up, documentation was entered into the service notes. LPN-A stated normally with med set up, individual prescription bottles were used. LPN-A stated, however, since P4's were preset up by Ph-A, this was not documented. The documentation for P4 included the fact the medications were set up as dispensed by Ph-A. LPN-A stated medications were set up in two-week increments. P4's Service Note of 8/11/22, signed by registered nurse (RN)-A indicated "filled md2 through 8/29". The note went on to identify "medication came in prepacked med sets and are filled in med cups and loaded in to MD2 by SN". Additionally, the note identified the nurse added vitamins as per client. The note lacked indication as to what vitamins were added. P4's Service Note of 9/23/22, signed by RN-B, indicated the nurse filled MD2 through 10/5/22. The note went on to identify ""medication came in prepacked med sets and are filled in med cups and loaded in to MD2 by SN". Additionally, the note identified the nurse added vitamins as per client. The note lacked indication as to what vitamins were added. P4's Service Note of 10/7/22, signed by RN-B, indicated "filled md2 through 8/29". [actual visit of 10/7/22]. The note went on to identify "medication came in prepacked med sets and are filled in med cups and loaded in to MD2 by SN". Additionally, the note identified the nurse added vitamins as per client. The note lacked indication as to what vitamins were added. During interview on 10/25/22, RN-C, at 3:30 p.m. registered nurse (RN)-C stated the documentation of medication set up was to match the physician orders, and should include the medication, dose, frequency, time set up for, and the duration the medication was set up for. A review of the agency policy, Medication Reminders, effective 2/1/15, identified when setting up medication for later administration the RN or LPN will verify the dose and quantity of medications delivered is consistent with the prescription. Additionally, staff are to review prescribed medications to identify contraindicates or other concerns. The policy indicates documentation of medication set up is to be complete as directed in policy 05-009. A copy of the policy was requested and not received.