Every finding on record at Northfield Home Care

On 10/25/23 - 10/26/23 an abbreviated complaint survey was conducted. This resulted in a standard survey at Northfield Home Care. 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. Deficiencies were issued for complaint. H71386604C (Intake 102023)

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on interviews and record review the facility failed to provide a thorough investigation by ensuring systems were in place to record, track and investigate all complaints. A complaint was made by the patient’s representative for physical abuse allegations for 1 of 1 patient (P1). P1’s Home Health Certification and Plan of Care dated 9/30/23 to 11/28/23 indicated P1 had a diagnosis of Alzheimer’s disease. P1 received one skilled nursing (SN) visit every week to assess for anxiety, assess need for skilled resources, behavior, Braden scale, confined to home, lab results, pain, risk for falls, safety measures, skin conditions, vital signs, and walking. P1 received one home health aide (HHA) visit weekly for assisting with bathing, mobility and personal cares requested by patient/family/caregiver. A facility Grievance Report dated 10/17/23 indicated during skilled nursing visit on 10/17/23 family member (FM)-A stated he felt the HHA’s were bruising P1’s wrists during the HHA visits. A phone call was placed to FM-A on 10/18/23 and FM-A stated, “I don’t know, I don’t know, they don’t do anything intentional.” FM-A could not identify any specific incidents or any HHA. The report indicated “all the HHA’s relayed the same information indicating the HHA’s don’t transfer P1." Home care visits were changed to be completed by two staff members at the same time for all visits. Education was provided to all staff through Learning Management Systems (LMS) training regarding Vulnerable Adult Reporting and Dementia Dealing with Difficult Behaviors. The report did not provide the names or documentation of the staff who were interviewed, any other clients interviewed, a police report, an onsite investigation of P1’s skin immediately following the allegations or the resolution of the complaint with FM-A. Upon interview on 10/25/23 at 11:08 a.m. HHA-A stated she noticed bruising over the past “few months” on P1. HHA-A stated she had always notified the agency nurse case manager, registered nurse (RN)-A for new bruising. She stated she did not document the bruising on her visit’s notes, she called the nurse case manager instead. HHA-A stated she was aware the agency provided additional (LMS) training recently. HHA-A stated she heard from “other staff” that FM-A complained that “a blonde staff member” kicked the family dog. She stated she was the only blonde and felt frightened to go back into P1’s home because she did not kick the dog. She stated the clinical manger (RN)-B called her and asked if she transfers P1 on the visits and she responded that she did not. HHA-A denied awareness of any other allegations. Upon interview on 10/25/23 at 12:05 p.m. HHA-B stated she was a newer employee to the agency and had only trained with P1. HHA-B stated she had noticed bruising on P1's chest, arms, and hands, but since she was new to P1 she could not tell what old bruising was and what was new bruising. She stated she did “not recall” the agency interviewing her about P1’s bruising. Upon interview on 10/25/23 at 12:18 p.m. HHA-C stated she has been seeing P1 for “many months.” She stated P1 always had bruising on her arms and legs and recently a chest bruise. HHA-C stated she had not been interviewed by the agency about P1’s bruising or any other allegations. She stated she received an email regarding addition abuse training and how to deal with difficult clients. Upon observation and interview on 10/25/23 at 1:30 p.m. during a home visit FM-A stated P1 has had bruising for months and he cannot understand how she got them. He stated the HHA’s appear friendly to her, and he tries to watch them during the visits. He stated he had never witnessed any physical or verbal mistreatment, but he also cannot explain the bruising. He was uncertain whether the bruising appeared during or shortly after the agency had visited. He stated P1 is feisty with the agency staff and will hit out at them and has bitten agency staff. FM-A stated the agency offered to increase P1’s HHA visits from once a week to twice and week. He declined the increased visits stating the reason was he wanted P1 to be left alone so all of bruising could heal. P1 was unable to participate in the interview, was unable to answer questions. P1 was attentive during visit, but her only response was “um hum.” P1 was dressed in a pants and a turtleneck sweater. The only part of her skin observed was her hands where multiple quarter sized blueish bruising covered the top of hands. She was able to move hands during the visit without difficulty as she shook the surveyor’s hand and moved her hands during the visit. Upon interview on 10/25/23 at 2:13 p.m. HHA-D stated she had not been interviewed by the agency. She stated she was aware P1's family had concerns that staff caused P1's bruising and a staff member kicked the dog. She stated she heard about the allegations from “other staff." She stated she received an email about additional online training. Upon interview on 10/25/23 at 3:10 p.m. RN-A stated during her skilled nursing on 10/17/23 FM-A told her the reason P1 had bruising all the time was because the agency HHA’s were rough with their cares. RN-A immediate notified the clinical manager and filed Minnesota Adult Abuse Reporting (MAARC) report. RN-A stated was not aware how the agency investigated the allegations. RN-A stated, “I think the agency asked the HHA’s about bruising, but no one came forward.” Upon interview on 10/26/23 at 9:02 a.m. a clinical nurse, RN-C stated the Primary Care Provider (PCP) was aware that P1 had bruising as P1 was seen in the clinic on 10/4/23 and the clinic filed a MAARC report after observing P1’s bruising. RN-C stated the clinic had no documentation that the agency had ever reported bruising or reported the recent allegations against the agency staff. Upon interview on 10/26/23 at 10:14 a.m. the director of home care (RN)-B stated the agency had no documentation of a formal investigation; she stated the only documentation was the grievance report from 10/17/23 which she provided. She stated she reached out to the HHA’s asking if there was a possibility that staff could have caused the bruising and none of the staff affirmed, they could have caused it. There was no documentation of the staff interviews. She stated the medical provider was aware of the allegations, however, could not provide documentation of notification. A facility policy titled Abuse Prevention and Detection Plan dated 8/2021 indicated a thorough investigation of the possible neglect or abuse cases will be conducted, an appropriate action will be taken to provide protective and/or counseling services as needed. The department director, house supervisor, social worker, or designee, will take statements from patient/resident, witnesses, and others involved in the care of the patient/resident. Patients/residents will be protected from abuse during an investigation of allegations when a staff member is under investigation,

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on observation, interviews and record review the facility failed to report allegations of physical, mental, and verbal abuse to the State Agency (SA) for 1 of 1 patient (P1). R1’s Home Care Registered Nurse (RN) Routine visit noted dated 9/7/23 indicated ecchymosis (bruising) to bilateral arms/hands. The cause is unknown. Some caregivers suspect P1’s family member (FM)-A maybe being rough when she is transferring or acting out, but P1 also hits and swings arms into items. Difficult to discern as this RN has not seen concrete evident of P1’s FM-A lashing out on her physically. Will keep a close and watchful eye on this and continue to keep track of new bruising. P1’s Home Health Certification and Plan of Care dated 9/30/23 to 11/28/23 indicated P1 had a diagnosis of Alzheimer’s disease. P1 received one skilled nursing visit every week to assess for anxiety, assess need for skilled resources, behavior, Braden scale, confined to home, lab results, pain, risk for falls, safety measures, skin conditions, vital signs, and walking. P1 received one home health aide (HHA) visit weekly for assisting with bathing, mobility and personal cares requested by patient/family/caregiver. Upon interview on 10/25/23 at 11:08 a.m. HHA-A stated she had not witnessed FM-A “actually verbally abusing” P1, but “he doesn’t speak kindly to her." She stated she had witnessed FM-A yell at P1 from across the room saying “shut-up, get-up, hurry-up, why are you so lazy?” She stated she had not reported the verbal behavior because the agency already knew about it. Upon interview on 10/25/23 at 11:39 p.m. Physical Therapist (PT)-A stated she has had “multiple” therapy rehabilitation episodes with P1 over the past few years. She stated she has witnessed FM-A become frustrated with P1, such as raising his voice to P1 and around her. PT-A stated a former private duty unidentified personal care attendant (PCA) told PT-A that he could not work with P1 anymore due to the way the “FM-A treats P1.” She stated she did not receive any more information from the PCA. She denied reporting P1’s behavior to the agency. Upon interview on 10/25/23 at 12:05 p.m. HHA-B stated she was a newer employee to the agency and had only trained with P1. HHA-B stated she had witnessed FM-A become “frustrated” with P1 and raise his voice when he tells her what to do. She stated the language was not vulgar but demeaning. HHA-B stated she had not reported how FM-A speaks to P1 to the agency. HHA-B stated during her training the other HHAs told HHA-B “he always acts like that.” Upon interview on 10/25/23 at 12:18 p.m. HHA-C stated she had provided care for P1 for “many months.” She stated she had witnessed on multiple occasions FM-A being “verbally short” with P1, meaning he raised his voice in a demeaning way when P1 would not follow his directions. In addition, P1 stated that “a few months back” P1’s private duty personal care attendant (PCA)-A stated to HHA-C that she had witnessed P1 hit FM-A and FM-A hit P1 back. HHA-C stated she had not documented the verbal behavior or the statement that PCA-A witnessed FM-A hitting P1. HHA-C stated she had reported the verbal abuse to the case manager, registered nurse (RN-A). Upon observation and interview on 10/25/23 at 1:30 p.m. during a home visit. The surveyor was introducing herself to P1. P1 was seated in a reclining chair in her living room. The surveyor sat next to P1 on a chair, faced P1, introduced herself to P1 and was making small talk. P1 was smiling, nodding her head, and saying “um hum” to every question asked. FM-A was in in the kitchen the room next to the living room where P1 was seated. FM-A shouted from the kitchen “why are you talking to her, why are engaging with her, she can’t answer you, she doesn’t understand you.” Upon interview FM-A stated recently he had been under stress because P1 had a urinary tract infection (UTI) and P1 was not sleeping, therefor he had not been sleeping and was “stressed out.” He stated he had never physically abused P1. He stated that him and P1 will argue and yell back and forth. Upon interview on 10/25/23 at 2:13 p.m. HHA-D stated she had worked with P1 for “a long time” and she had witnessed FM-A scream at P1. HHA-D stated the screaming behavior had been happening for months. She stated at times FM-A would scream using swear words at P1 and sometimes P1 would scream back, other times P1 would ignore FM-A screaming at her. HHA-D stated she had also witnessed FM-A scream to himself and not directed toward P1. HHA-D stated she had taken a break from completing visits for P1 because she feared FM-A even though the screaming had never been directed at her. Upon interview on 10/25/23 at 3:10 p.m. RN-A stated she had witnessed FM-A yell and swear at P1 when he got frustrated. She stated that she and the other agency staff try to diffuse the situation and are usually able to so. She stated she had never witnessed FM-A physically touch P1, but she stated the private duty (PCA)-A had mentioned to her in September of 2023 that PCA-A had witnessed FM-A be rough with P1. RN-A stated she did report the rough treatment because she believed it was just “hearsay.” RN-A stated she did not report the verbal statements to the agency because she was always able to diffuse the situation. She denied reporting the verbal behavior or rough treatment allegations to P1’s Primary Care Provider. Upon interview on 10/25/23 at 5:04 p.m. private duty attendant PCA-A stated she had never witnessed anything physical between P1 and FM-A. She stated everything she had witnessed was verbal, except one time FM-A had gotten angry and broken a vacuum cleaner by throwing it on the floor and witnessed FM-A kicking a hole in a bedroom wall. PCA-A stated she had reported the verbal abuse to RN-A and HHA-D a few “different times” over the past few months and both RN-A and HHA-D had witnessed the verbal abuse first-hand. In addition, she stated one of the few phrases P1 still can say is “I hate that man.” Upon interview on 10/26/23 at 10:14 a.m. the director of home care (RN)-B stated she was aware that P1 had other private duty staff in the home. She stated she had not heard of the allegations made by the private duty (PCA) and was not aware of the verbal abuse reported by the agency staff. She stated verbal abuse should be reported to the SA immediately. A facility policy titled Vulnerable Adults Abuse/Neglect reporting dated 5/2023 indicated that types of reportable abuse are: 1. Physical abuse – Physical conduct which deliberately produces pain or emotional stress. Includes hitting, slapping, pinching, scratching, splitting, holding roughly etc. 2. Verbal abuse – Repeated verbal conduct which produces mental or emotional stress. Includes oral, written, gestured language that includes disparaging, derogatory, humiliating, harassing, or threatening terms or statements to or within hearing distance from patients/residents or their families, regardless of age, ability to comprehend, or disability. 3. Mental abuse – May occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient/resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The incident must be reported immediately, but no later than two hours, if alleged violations involve abuse of results in bodily injury, or immediately but no later than 24 hours.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 4/10/23-4/12/23 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements

On 4/10/23-4/12/23 recertification and complaint surveys were conducted. This resulted in a partial extended survey at Northfield Home Care. 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: 208 Total home visits conducted: 3 List Parent Location visited: 1604 Riverview Drive, Northfield, MN 55057 List Hours of Operation: 7:30 a.m. to 4:00 p.m. List total number of records reviewed: 7 H7138002C/Intake #21799) was investigated. The agency was found to be in compliance.

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 medications and dosages for 1 of 2 patients (P4) whose medications were reviewed during home visits. P4’s admitting orders dated 2/6/23, included metoprolol succinate 25 mg extended release, one tablet taken by mouth daily, aspirin 81 mg EC (coated), one tablet by mouth daily, and identified clopidogrel bisulfate 75 mg (used to prevent heart attacks and chest pain), one tablet by mouth daily was “suspended”. P4’s plan of care (POC) with certification period 2/8/23 to 4/8/23 indicated P4 diagnoses included cancer of the lung, colon, gallbladder, and bone, and heart failure. P4 received weekly skilled nursing visits for medication set-up, including metoprolol succinate 25 mg extended release, one tablet taken by mouth daily for heart failure, and rosuvastatin 20 mg, one tablet by mouth at bedtime for high cholesterol. The POC lacked aspirin as prescribed at admission and did not include clopidogrel bisulfate. The POC for 4/9/23 to 6/7/23 was submitted to the provider but not yet signed. It included metoprolol succinate 25 mg extended release, one tablet taken by mouth daily, and rosuvastatin 20 mg, one tablet by mouth at bedtime. The POC lacked aspirin as prescribed at admission and did not include clopidogrel bisulfate. On 4/11/23, at 11:05 a.m. registered nurse (RN)-A was observed setting up P4’s medications and placed one of each of the following in the medication case for each day of week: ½ tablet of metoprolol succinate 25 mg extended release. The pharmacy label indicated take one tablet, with “one” crossed out and “half” handwritten on the label. ½ tablet of rosuvastatin 20 mg. The pharmacy label indicated take one tablet, with “one” crossed out and “half” handwritten on the label. one tablet of clopidogrel bisulfate (previously identified as suspended and not on POC) one tablet aspirin 81 mg EC (not on POC) P4’s record lacked current physician orders for aspirin and clopidogrel bisulfate, and indication of change in dosage of metoprolol succinate and rosuvastatin. RN-A stated she completed a medication reconciliation when R4 was admitted, but P4 had some medication changes since. RN-A reviewed P4’s Medication Profile dated 4/11/23, and confirmed it included one full tablet of metoprolol succinate 25 mg extended release daily, and one full tablet of rosuvastatin 20 mg at bedtime and verified clopidogrel bisulfate and aspirin were not listed. She stated she was at P4’s home the previous week for a recertification and usually updated the medications in the computer but might have missed some things. RN-A stated she always set up P4’s medication and knew P4 got four pills in the morning and four at night, and if another nurse needed to set them up, she would call and instruct to give them according to what was hand-written on the bottle and not the electronic record since the record was not correct. During interview on 4/12/23, at 12:28 p.m. director of home care and hospice (DH) stated she expected medications to be entered into the electronic record accurately by the admitting nurse and compared to the patient’s medication bottles, and if there were discrepancies the nurse should call the patient’s primary provider for reconciliation and to obtain any new orders as needed. She stated the nurses should use the Medication Profile when setting up patient medications as the source of truth, and a new updated copy should be printed after each change and recertification and kept in the home to ensure consistency, accuracy, and patient safety. The Medication Management and Administration for Home Care policy dated 3/23, indicated physician orders are required for all medications currently being taken by patient in the home, medication management records must be current and updated with changes, and medication reconciliation must be completed.

An abbreviated survey was conducted at Northfield Home Care on 2/2/21, through 2/3/21 to investigate a complaint. Northfield Home Care is not in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. Complaint H7138001C / MN69428 was not substantiated. However, deficiency was issued at G488.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview, and document review, the agency failed to report allegations of physical abuse for 1 of 1 patients (P1) reported by family members. Findings include: P1's plan of care (POC) for the certification period 10/17/20 to 12/15/20, identified diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder recurrent severe without psych features, anxiety disorder, abnormalities of gait and mobility and dysphagia (difficulty swallowing). The POC also identified functional limitations including bowel/bladder incontinence, paralysis, endurance and ambulation, use of wheelchair and walker. The POC identified behaviors including agitated, anxious, depressed, easily distracted and poor concentration. Primary care giver identified as family member (FM-A). P1 received skilled nurse (SN) visits weekly and home health aide (HHA) visits 3 times per week. During interview on 2/2/21, at 11:26 a.m. the administrator stated HHA-A was at P1's residence on 1/20/21, to assist with P1's bath. The administrator stated she received an email from P1's case manager regarding HHA-A's visit the previous day. Per HHA-A patient was mad about time the aide was there and indicated the aide explained that she can call and change her time if P1 wants to. The administrator stated HHA-A indicated P1 was in a bad mood from the start of visit, that P1 was in the bathroom and HHA-A thought she was done so she went in and asked if she was finished. P1 screamed No! get out of here and also was swearing at HHA-A. HHA-A stated she then went into the bedroom and made the bed. When P1 was ready HHA-A returned to bathroom to assist with bath. HHA-A reported she was trying to wash under P1 stomach and P1 was screaming at her. HHA-A stated she quit and asked P1 if she would like her to just rinse it. P1 screamed, no and called her derogatory names and P1 stated she was not going back to be treated like that again. The administrator stated she interviewed HHA-A the day after the event and that HHA-A reported P1 was yelling, cussing and swearing at HHA-A the whole time she was there. HHA-A further stated got patient into the tub and she continued to scream, swear and call aide names. HHA-A stated this is what P1 does when aides give her a bath. HHA-A also stated that when P1 told HHA-A to get away from her and swore and called her names, HHA-A dropped the shower head into the tub and left the bathroom. HHA-A also stated FM-A came to the bathroom door as she was walking out and stated he would finish the bath. The administrator stated that on 1/21/21, she called family to inform them that she would be issuing a 30 day discharge notice due to continued verbal abuse and harassment of the HHA's by P1. The administrator stated on 1/21/21, FM-B told her the aide threw the shower head at P1, and FM-C stated P1 was hit over the head. The administrator also stated stated FM-B said she had documents that the aides had abused her mom and they had made complaints prior and nothing was done. Neither FM-B nor FM-C were present when the incident allegedly occurred. Per the administrator no complaints were made to the nurses or aides regarding abuse and stated the only complaints she had were related to P1 verbally abusing and harassing the staff. She asked the family to bring in the documents but she has not heard from them. During interview on 2/3/21, at 10 48 a.m. the administrator stated she had not even thought about filing a report with the state agency (SA). She stated that she understood and agreed that a report should have been filed. Review of the policy Vulnerable Adults Abuse/Neglect Reporting revised 2/2018, identified any Northfield Hospital & Clinic (NH&C) workforce member who knows or has reason to believe a vulnerable adult is being neglected or physically, emotionally sexually or financially abused has a responsibility to report the information to the appropriate authorities, as outline below. A workforce member who observes or suspects abuse or neglect of a patient who meets the definition of a vulnerable adult will immediately report concerns to a NH&C social worker, department director or supervisor. The following steps will be taken: 1. Notify administrator. The department director or supervisor will immediately report the incident or concern by phone to the appropriate administrator or the administrator on call during off hours. 2. Report incident. a. Mandated reporters will immediately or within 24 hours report concerns via the statewide reporting system by completing and online report.