Every finding on record at Mille Lacs Home Care

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 10/26/22 through 10/29/22, during a recertification survey. The facility was found to be in compliance with the Appendix Z Emergency Preparedness Requirements.

On 10/26/22 through 10/29/22 , a partially extended survey was conducted at your agency. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census: 280 Total home visits conducted: 03 No Branch offices. Hours of Operation: 8:00 a.m. to 4:30 p.m. Total number of records reviewed: 07 A complaint investigation was also completed. As a result, the following deficiencies are issued: H7194002C was substantiated with a deficiency cited at G462.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to discharge 1 of 2 patients (P6) for appropriate cause, when the patients were discharged from the agency without notice or assistance in identifying other entities in the area that may be able to meet the patient's needs. Further, the agency failed to document efforts to resolve behavioral issues exhibited during visits in the patient's clinical record. P6's plan of care for certification period 3/15/21 to 5/13/21, identified a start of care date (SOC) 10/7/16. P6's diagnoses included congestive heart failure, diabetes, social phobia, and hepatitis. Skilled nurse visits (SNV) were ordered two times per week for nine weeks for various assessments, observation and medication management. P6's nurse visit documentation was reviewed February 18, 2021 through March 30, 2021. SNV were completed on 2/18/21, 2/22/21, 3/2/21, 3/8/21, 3/11/21, 3/15/21, 3/18/21, and 3/25/21. The visit notes documented P6 was uncooperative with assessments and exhibited verbally abusive behavior toward staff. The visit notes lacked documentation of physician notification of behaviors, attempts to resolve disruptive behaviors, attempts to schedule appointments to evaluate new behavioral concerns, nor had any discharge planning been documented during any of the nursing visits. A nurse visit was completed on 3/30/21, and documentation indicated P6 continued to be uncooperative and verbally abusive during the visit. After completion of the visit, it was determined to discharge P6 from the agency. The medical record lacked documentation of 10 day notice, list of resources or notification to P6 of the agency's discharge. No further SNV were documented after the visit on 3/30/21. P6's discharge summary dated 4/5/21, identified verbally abusive, sexually inappropriate comments and uncooperative behaviors had occurred during SNV on 3/18/22, 3/22/21, 3/25/21, and 3/30/21. Concerns were identified related to P6's self care without services as he was dependent on the agency for medication setup During interview on 9/28/22, at 3:45 p.m. the director of nursing (DON) stated she was unable to find documentation P6's physician had been updated with his verbally abusive and uncooperative SNV. The DON stated she felt P6's behaviors were ongoing and not new for him. The agency had not provided 10 day notice, referrals to other agency's or additional resources P6 could contact for services. The DON indicated the paper work could have been handled better. P6 did have a mental health worker and county social services involvement, however, they would not be able to provide disease or medication management services to P6. There was a concern identified for the need for P6 to have medication management. The agency's undated policy Discharge or Transfer indicated when a patient is discharged, relevant information would include reason for discharge, and instruction of referrals provided to the patient. A policy to discharge a client with cause was requested, however none were received.

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 ensure each patient had an initial assessment visit within 48 hours of the referral date for 1 of 7 patients (P2) reviewed in the sample. P2's plan of care for certification date 9/11/22 to 11/9/11, indicated a start of care (SOC) date 3/15/22. Diagnoses included diabetes, peripheral vascular disease, chronic pain, heart disease, and kidney disease. P2's medical record identified a Discharge Request form dated 3/7/22, which indicated P2 would be discharged from a long term care facility on 3/9/22, and needed skilled nurse visit, in home physical therapy and in home occupational therapy. P2's Outcome and Assessment Information Set, SOC assessment was not completed until 3/15/22. The medical record failed to identify any reason why P2 had not been assessed within 48 hours of the discharge date of 3/9/22 and lacked evidence P2's physician was notified of the delay in the SOC date. During interview on 9/28/22, at 12:30 p.m. the director of nursing (DON) indicated it was the agency's practice to see patients within 48 hours of discharge or to have documentation in the medical record of why they were not seen in the 48 hour window. The DON indicated she was unable to find any documentation why P2 was not seen within 48 hours of discharge from the long term care facility and there should have been a physician order to indicate a later SOC date was discussed and approved. A facility policy for client admission process was requested, however, none were received.

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 for 3 of 3 patients (P3, P4, and P5) whose medications were reviewed during home visits and record review. P3's plan of care (POC) for the certification period 9/17/22 to 11/15/22, indicated a start of care (SOC) date 5/20/22. P3's diagnoses included heart failure, thrombocythemia (body produces to many platelets that help with clotting) and atrial fibrillation (irregular heartbeat). Skilled nursing visits were ordered one visit per week for nine weeks for various assessments, observation and medication management. P3's POC included the following medications: acetaminophen 500 milligrams (mg) orally (p.o.) three times per day as needed (PRN), carvedilol (heart medication) 6.25 mg p.o. two times per day (BID), clopidogrel (blood thinner) 75 mg p.o. every day, fluoxetine (an antidepressant) 10 mg p.o. daily, furosemide (diuretic) 20 mg p.o. every other day, hydroxyurea 500 mg 15 mg/kg p.o. BID, tamsulosin (prostate medication) 0.4 mg daily, terazosin (prostate medication) 5 mg p.o. daily, vitamin D3 25 micrograms (mcg) daily, warfarin (blood thinner) 5 mg every other day, warfarin 3 mg every other day. During a home visit conducted on 9/27/22, at 9:00 a.m. registered nurse (RN)-A was observed setting up P3's medication in weekly pill boxes labeled with each day of the week. Furosemide was added to the med tender on Monday, Wednesday and Friday and not every other day as ordered. P3's medical record identified medication setup documentation on 9/13/22, 9/20/22, and 9/27/22, furosemide was documented as setup three days for the week and not every other day as ordered. P4's POC for the certification period 9/18/22 to 11/16/22, indicated a SOC date 11/27/20. P4's diagnoses included myasthenia gravis, intestinal malabsorption, immunodeficiency, and cardiomyopathy. Skilled nursing visits were ordered one time per week for nine weeks for various assessments, observation and assessment of medications. Home health aide visits were ordered two times per week for eight weeks to assist with bathing and grooming. P4's POC included the following medications: Isosource (a nutrition formula) infuse 500 milliliters (ml) per gastrostomy tube two times per day, Isosource infuse 80 ml by gastrostomy tube one time per day, and Prednisone (a steroid medication to treat inflammation) 10 milligrams mg oral every other day. During a home visit conducted on 9/27/22, at 11:10 a.m. P4 stated he was able to administer his medications, tube feeding and flushes independently. P4 indicated he was taking Prednisone 25 mg every other day. He could not recall when the dosage had changed as he felt he had been on the current dosage of Prednisone for awhile. He had nurse visits weekly and they assisted him with his catheter changes, checks his vital signs and assists him with scheduling appointments. He was not sure when they last had reviewed his medications with him. P4's medical record identified medications were reviewed during skilled nurse visit on 9/23/22, however no new or changed medications were identified. P5's POC for the certification period 9/24/22 to 11/22/22, identified SOC date 3/28/22. P5's diagnoses included spinal stenosis, post traumatic stress disorder, depression and chronic obstructive pulmonary disease. Skilled nurse visits were ordered one time per week for nine weeks for various assessments, observation and medication management. A home health aide was ordered two times per week for eight weeks then one time per week for one week to assist with shower, and light housekeeping. P5's POC included the following medications: acetaminophen 500 mg two tablets p.o. three times per day as needed (PRN), ascorbic acid 500 mg p.o. daily, aspirin 81 mg p.o. daily, cholecaliferol 25 mcg two tablets p.o. daily, colestipol 1 gram two tablets p.o. daily, cyanocobalamin 1000 mcg/ml one ml injectable one time per month, furosemide 40 mg daily, gabapentin 300mg three times per day, gabapentin 600 mg daily, ibuprofen 600 mg BID PRN, loperamide 2 mg three times per day PRN, Norco 325-5 mg one tablet every six hours PRN, omeprazole 40 mg p.o. PRN daily, oxybutynin 5 mg p.o. BID, Senna 8.6 mg p.o. BID PRN, terazosin 10 mg p.o. daily. During a home visit on 9/27/22, at 1:30 p.m. P5's medication bottles were observed out on his kitchen counter. P5 stated he took his medications every day from the bottles. P5 stated he took his medications independently and he had them memorized so he knew how to take them. A bottle of finasteride (used to treat prostate) was observed on the counter with the other bottles of medication prescribed to P5. P5 verified he did take this medication exactly as prescribed on the bottle. The prescription bottle of finasteride was labeled to take 5 mg p.o. daily. P5's medical record medications were reviewed during skilled nurse visit on 9/23/22, however no new or changed medications were identified. When interviewed on 9/28/22, at 12:30 p.m. the director of nursing (DON) stated medications were always reviewed on patients recertification visits and it was the agency's practice to review patient medications at every visit. It would be important to review medications to ensure patients were taking medications as ordered and the physician was aware of what the patient was taking in the home. The agency undated policy Medication Management indicated a review of all medications would be performed at the initial assessment visit and with ongoing nurse visits.