Every finding on record at Pennington & Red Lake County Public Health & Home Care

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 6/9/25 to 6/11/25during a recertification survey. The agency is in compliance with the Appendix Z Emergency Preparedness Requirements

On 6/9/25 to 6/11/25 a recertification survey was conducted. This resulted in a partial extended survey at Pennington & Red Lake County Public Health and Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 58 Total home visits conducted: 03 Pennington & Red Lake County Public Health & Home Care 101 Main Ave North Thief River Falls, MN 56701 No Branch Offices Hours of Operation: 8:00 a.m. to 4:30 p.m. Total Number of Records Reviewed: 07

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 interview and document review the agency failed to encode and electronically transmit completed OASIS assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment of the patient for 1 of 1 (P8) patient reviewed. The Center of Medicare and Medicaid (CMS) Outcome and Assessment Information Set (OASIS) Error Detail Report dated 1/1/24 through 12/31/24, identified one patient (P8) whose OASIS assessment records were submitted more than 30 days after the assessment had been completed. P8's plan of care (POC) identified a start of care date (SOC) of 3/31/17. P8's recertification OASIS assessment with completion date 10/16/24, was submitted to CMS 12/6/24, 51 days after completion of the assessment. During interview on 6/11/25, at 10:30 a.m. the director of nursing (DON) stated she was unable to find out the reason P8's oasis had been submitted so late. She felt it must have been missed on the list for submission that week. The Center for Medicare and Medicaid Services OASIS E Manual, updated 1/1/24, identified OASIS data was collected as part of the comprehensive assessment required by the Medicare Conditions of Participation. The CMS Home Health Conditions of Participation required a home health agency electronically transmit accurate, completed, and encoded OASIS data to a centralized data submission system within 30 days of the completion of the assessment (M0090 Date Assessment Completed). The agency's undated policy Oasis Implementation and Transmission Policy, identified the agency would electronically transmit accurate, completed, encoded and locked OASIS data for each patient to the state agency no later than 30 days from the date assessment was completed. Rejected data would be corrected and re-transmitted to the state within the 30-day time frame.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to send a completed transfer summary to the receiving health care facility within two business days of becoming aware of the unplanned transfer to 1 of 2 patients (P7) reviewed for discharge. P7's plan of care (POC) 4/3/25 to 6/1/25, identified a start of care (SOC) date 2/8/24. Services included skilled nurse visits (SNV) one time per week for nine weeks, plus one time per week as needed for medication changes. SNV to assess blood pressure, lung sounds, edema, skin, mobility, risk for falls and setup medications as ordered. A home health aide was ordered two times per week to assist with personal care such as bathing and skin care. Diagnoses included Parkinson's. weakness and gait abnormality. A skilled nurse visit note dated 5/20/25, identified nurse manager (NM)-A had received a telephone call from P7's son to notify her P7 had been seen by his primary provider that day and would be moving into the local nursing home that afternoon. NM-A documented P7 would be discharged from the agency. A discharge summary had been completed and sent to P7's primary provider, however, P7's medical record lacked evidence a transfer form had been completed and sent to the receiving facility as required. During interview on 6/11/25, at 10:30 a.m. the director of nursing (DON) stated the nurse manager had been notified by phone from P7's son that P7 would be going to the nursing home that day. It was not a planned transfer. NM-A should have still sent a transfer form with a current medication list to the facility but had not done so. The agency needed to do better with some kind of communication with patient transfers. The agency undated policy Termination of a Client's Home Care Services identified if a patient transferred to another health care provider or inpatient facility, the registered nurse would send a copy or summary of the patient's record to the new provider or facility. The agency would participate in a coordinated transfer to a new provider.

This facility is in compliance with Emergency Preparedness regulations at E1 through E39 and E42.

On 4/17/23-4/19/23, a recertification survey was conducted. This resulted in a standard survey at Pennington & Red Lake County Public Health & Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 86 Total home visits conducted: 4 List all other branch offices for this agency and identify which of these were visited during this survey and which you pulled records from: no branch offices List Hours of Operation: 8:00 a.m. - 4:30 p.m. Monday through Friday with 24/7 RN on-call coverage. List total number of records reviewed: 7

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 interview and record review, the agency failed to ensure a comprehensive medication review was completed for 1of 3 patient's (P2) in the sample whose drug regimens were not reviewed and updated. P2's plan of care (POC) for certification period of 3/1/23-4/29/23, indicated a start of care (SOC) date of 5/5/22. The POC identified P2's principal diagnosis of other sequelae of other cerebrovascular disease (stroke) with additional diagnoses of diplopia (double vision), essential hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (a chronic disease chronic disease characterized by high levels of sugar in the blood), and benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland). The POC identified P2 would be seen by the registered nurse (RN) for home health aide (HHA) supervision and catheter issues. P3 was to receive HHA visits one time the first week, followed by two visits per week for an additional eight weeks and was to receive assistance with personal cares, bathing, skin cares, light housekeeping and meal prep. During a home visit on 4/18/23 at 2:30 p.m., P2 was seen by HHA-A for assistance with personal cares. During the visit, family member (FM)-A stated she set up P2's medications and stated P2's medications were unchanged. Upon review of P2's medications in comparison to the medications in his home, it was noted P2 no longer used the following medications: loratadine (allergy medication), Brilinta (used along with low-dose aspirin to help prevent heart attack and stroke in people with a history of heart disease, stroke, or at increased risk for heart disease or stroke), Cipro (an antibiotic), Combivent (a product is used to treat and prevent symptoms (wheezing and shortness of breath) caused by ongoing lung disease (chronic obstructive pulmonary disease-COPD which includes bronchitis and emphysema), cranberry with vitamin C soft gels, Flomax (used by men to treat the symptoms of an enlarged prostate (benign prostatic hyperplasia-BPH)), Gabapentin (used with other medications to prevent and control seizures. It is also used to relieve nerve pain following shingles (a painful rash due to herpes zoster infection) in adults), and Novolog (used along with a proper diet and exercise program to control high blood sugar in people with diabetes.) P2 had orders for the following medications not listed on the POC: aspirin 81 milligram (mg) by mouth every day, Lipitor (used along with a proper diet to help lower "bad" cholesterol and fats (such as LDL, triglycerides) and raise "good" cholesterol (HDL) in the blood.) 40 mg by mouth at bedtime, Glipizide (used with a proper diet and exercise program to control high blood sugar in people with type 2 diabetes) 2.5 mg by mouth every day, and Nystatin powder (antifungal) apply to the skin four times a day as needed (PRN). FM-A stated P2's most recent After Visit Summary (AVS) provided by P2's physician was his most up-to-date medication list, and this is what she followed to set up P2's medications. During an interview on 4/19/23 at 10:00 a.m., RN-A stated she always asked a patient if there were any medications changes and check medication bottles for accuracy during every visit The patient's medication list would be updated but the POC would not be reprinted until the next recertification. During an interview on 4/19/23 at 11:30 a.m., the agency director stated patient medications were reviewed every 60 days. Upon review of P2's POC, the agency director stated his last recertification was the beginning of March 2023, however, P2's medication list had not been updated since 5/5/22. Additionally, P2's medical record last RN home visit documentation identified P2's medication review was "completed", but lacked to identify if medications were discontinued, changed or any new medications were started. The agency policy Patient Medication Review Policy dated 4/26/07, identified upon admission and continuing throughout service the nurse would review the patient medications and a current medication sheet would be left with the patient. The policy directed staff to document review for all clients and to notify the physician of problems. The review included: Adverse effects Drug interactions Ineffective drug therapy Side effects Significant drug interactions Duplicate drug therapy