Every finding on record at Professional Resource Network HHC

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 5/15/23 to 5/18/23 during a recertification survey. The facility is not in compliance with the Appendix Z Emergency Preparedness Requirements.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to ensure their communication plan included; a method for sharing protected health information and medical documentation with other providers; and release patient information as permitted under 45 CFR 164.510(b)(1)(ii). This had the potential to affect all patients receiving services from the HHA. A review of the HHA's undated Emergency Preparedness plan revealed the communication plan did not address how the HHA was going to share protected health and medical information with other providers. On 5/17/23 at 2:30 p.m., the Administrator verified the emergency preparedness plan's communication plan did not address how the HHA was going to share health and medical information with other entities.

On 5/15/23 to 5/18/23 a recertification survey was conducted. This resulted in a partial extended, survey at Professional Resource Network. 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: information requested but not given. Total home visits conducted: 2 List Hours of Operation: 9:00 a.m. to 3:00 p.m. List total number of records reviewed: 7 In addition to the recertification, the following complaints were reviewed. As a result: No deficiency was issued for complaint H8054028C (MN00053284) No deficiency was issued for complaint H8054029C(MN00060403) No deficiency was issued for complaint H8054030C(MN00059377) No deficiency was issued for complaint H8054031C(MN00057220)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure a plan of care (POC) was completed every 60 days for 1 of 5 patients (P4) who currently receive home care services. P2’s POCs for recertification periods 7/7/2022 thru 5/3/2023 reviewed and noted to lack signature of P2’s primary physician. P4’s medical record reviewed 5/2022 thru 5/2023. The medical record lacked completed and signed POCs after 8/16/2022. On 5/18/23, at 10:00 a.m. the Administrator stated she did not realize the POCs were unsigned. The process included faxing the POC to the primary physician every 60 days. The agency changed to a new charting system approximately six months ago. During that transition, faxes were received in paper form instead of electronic. The Administrator stated some of the signed POCs are likely in a box still waiting to be scanned into the medical records for P2 and P4. Sending the POC to the primary physician is important for continuity of care. Agency policy, Client Clinical Record 485 Contents, noted the 485 [plan of care] is completed every 60 days and signed by the physician.

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: Based on interview and record review the agency failed to ensure the plan of care included all required components for treatment orders for 2 of 5 patients (P2, P7) who currently receive home care services. Additionally, the POC lacked identification of potential risks to require emergency department risk and potential interventions to avoid the need for emergency room (ER) visits for 2 of 5 patients (P3 and P4) who currently receive home care services. P2’s POC certification period 5/3/23 through 7/1/23, indicated P2’s diagnoses included diabetes mellitus and metabolic encephalopathy (a brain dysfunction which causes an altered mental state). P2 was authorized for skilled nursing visits (SNV) 7/1/22 to 6/30/23 for medication set up, assessment and education. P2’s POC lacked the frequency the SNV should occur. P3’s POC certification period 3/29/23 through 5/27/23, indicated P3’ diagnoses included legal blindness and hypertension. P3 had home health aid (HHA) visits ordered twice weekly to assist with bathing. P3’s POC lacked P3’s risk for hospitalization and emergency room visits as well as interventions to prevent these. On 5/18/23 at 10:00 a.m., the Administrator stated P2’s was completed and contained the required information. She did not know the POC was required to contain the frequency of visits. She confirmed P3’s POC did not include the risk for hospitalization or emergency room visits as well as possible interventions to prevent these. She expected all POCs included this information to ensure staff providing care could monitor and intervene as necessary. Agency policy, Client Clinical Record 485 Contents, indicated the 485 [POC] should include orders for disciplines and treatments including amount, frequency and duration as well as risk for hospitalization. P7’s POC certification period 1/30/20 through 3/29/20, indicated P7’s diagnoses included localization-related symptomatic epilepsy and epileptic syndrome with simple partial seizures. P7 was authorized for skilled nursing visits (SNV) 1/30/20 to 3/29/20 for medication set-up, assessment and education. P7’s POC indicated SNV one time a week but lacked the duration the SNV should occur. On 5/18/23 at 10:00 a.m., the Administrator stated P7’s was completed and contained the required information. She did not know the POC was required to contain the frequency of visits. Agency policy, Client Clinical Record 485 Contents, indicated the 485 [POC] should include orders for disciplines and treatments including amount, frequency and duration as well as risk for hospitalization.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure a plan of care (POC) was sent to the primary physician for revision and signature every 60 days for 2 of 5 patients (P2 and P4) who currently receive home care services. P2’s unsigned POC certification period 5/3/23 to 7/1/23, indicated P2’s diagnoses included diabetes mellitus and metabolic encephalopathy (a brain dysfunction which causes an altered mental state). P2 was authorized for skilled nursing visits (SNV) 7/1/22 to 6/30/23 for medication set up, assessment and education. P2’s POC lacked the frequency the SNV should occur. P2’s POC 5/2022 to 5/2023 were reviewed. These POCs were not signed by P2’s primary physician or other licensed provider. P4’s signed POC certification period 6/18/22 to 8/16/22, indicated P4’s diagnoses included epilepsy and hyperglycemia (high blood sugar). Requests for more recent POC were requested but were not provided by the agency. P4’s medical record included orders for physical therapy and occupational therapy but lacked completed and signed POCs, even though P4 continued to receive home services through the agency. On 5/18/23 at 10:00 a.m., the Administrator stated she did not know why P2 and P4 did not have signed POCs. She thought they were likely in a box, in storage, waiting to be scanned into the electronic record. She expected each patient had a POC completed and signed by the primary provider at least every 60 days while the client was receiving home care services. Agency policy for physician orders was requested but was not received.

On 3/1/22 through 3/2/22, and 3/10/22, an abbreviated on-site survey was conducted. The agency was NOT in compliance with requirements at 42 CFR Part 484 requirements 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. The following complaints were found to be unsubstantiated: H8054026C (62003) H8054027C (62200) The Condition of Participation: 484.70 Infection prevention and control was not met at G680. An immediate jeopardy was identified at G684: The immediate jeopardy was identified on 3/2/22, when the agency failed to maintain and document an infection control program. The owner was notified of the immediate jeopardy at 12:20 p.m. on 3/2/22. The immediate jeopardy was removed at 1:15 p.m. on 3/10/22, when the agency developed and implemented policies and procedures to track staff and patient illnesses, report applicable illness to the appropriate officials, develop quarantine and return to work policies as recommended by the CDC and monitor and enforce the agency’s personal protective equipment (PPE) policies with all staff. An immediate jeopardy was identified at G687: The immediate jeopardy began on 3/1/22, when the agency failed to follow policies and procedures to ensure all staff were vaccinated for COVID-19, had proof of vaccination on file, or had an exemption on file, 60 days after vaccine requirement. The agency failed to follow a contingency plan for staff who were not fully vaccinated. The owner was notified of the immediate jeopardy at 12:20 p.m. on 3/2/22. The immediate jeopardy was removed at 1:15 p.m. on 3/10/22, when the agency developed and implemented updated policies and procedures to address tracking and documentation of the agency's staff vaccination status, developed a contingency plan following CDC recommendations, and implemented additional precautions to mitigate the spread of COVID-19 by unvaccinated staff. As a result, a partial extended survey was conducted.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to meet the Condition of Participation at 484.70, Infection Prevention and Control. The agency had a staff vaccination rate of 84%. The HHA failed to enforce processes in place for staff to request and exemption, and failed to have unvaccinated staff follow additional precautions to mitigate the risk for transmission of COVID-19. In addition, the agency failed to consistently implement infection control practices related to COVID-19 requirements including employee and resident symptom screening, and provision of appropriate PPE. Further the agency failed to maintain and document an infection control program. The agency failed to have a system for infection surveillance, identifying infections or risk of infection in their patients or staff and failed to provide updated infection control training to their employees. These combined failures resulted in Condition level noncompliance as well as immediate jeopardy at G684, and G687. See citation at G684: Based on interview and record review, the agency failed to establish and implement an infection control program that incorporated tracking staff and patient’s illness, failed to screen patients prior to conducting home visits, failed to monitor and enforce appropriate Personal Protective Equipment (PPE), and failed to follow current COVID-19 guidance related to COVID positive patients and staff, resulting in a risk of potential serious harm or death to all 286 patients. This resulted in an immediate jeopardy (IJ) situation as this system failure had the potential to cause serious harm or death to agency patients, patient families, caregivers and staff. See citation at G687: Based on interview and record review, the agency failed to follow polices and procedures for unvaccinated staff and had failed to meet the 100% vaccination rate as required by QSO 22-07-ALL, resulting in a risk of potential serious harm or death to all 286 patients. This resulted in an immediate jeopardy (IJ) situation as this system failure had the potential to cause serious harm or death to agency patients, patient families, caregivers and staff.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to establish and implement an infection control program that incorporated tracking staff and patient’s illness, failed to screen patients prior to conducting home visits, failed to monitor and enforce appropriate Personal Protective Equipment (PPE), and failed to follow current COVID-19 guidance related to COVID positive patients and staff, resulting in a risk of potential serious harm or death to all 286 patients. This resulted in an immediate jeopardy (IJ) situation as this system failure had the potential to cause serious harm or death to agency patients, patient families, caregivers and staff. The immediate jeopardy was identified on 3/2/22, when the agency failed to maintain and document an infection control program. The owner was notified of the immediate jeopardy at 12:20 p.m. on 3/2/22. The immediate jeopardy was removed at 1:15 p.m. on 3/10/22, when the agency developed and implemented policies and procedures to track staff and patient illnesses, report applicable illness to the appropriate officials, develop quarantine and return to work policies as recommended by the CDC and monitor and enforce the agency’s personal protective equipment (PPE) policies with all staff. During interviews on 3/2/22, with nine staff (PCA-A, PCA-B, PCA-C, PCA-D, PCA-E, PCA-F, PCA-G, LPN-A and LPN-B), they stated they do not wear eye protection while providing direct care to the patients. Based on agency vaccination status, PCA-A, PCA-B and PCA-C were not vaccinated. During interview on 3/2/22, at 10:40 a.m. LPN-A stated there was no process to contact clients before each visit, she was not concerned because they never leave the home. During interview on 3/2/22, at 10:50 a.m. when asked about conducting a symptom screen, LPN-B stated she really doesn’t screen her client, he never leaves the house and she would know if he is sick when she got there. During interview with PCA-F on 3/2/22, at 12:46 p.m. he stated he donned a mask prior to entering the apartment building his client resides in, but once in the apartment, he removes it. He stated he was educated on COVID from his parents and the news and was not aware of having to screen his client or wear eye protection. He stated he wasn't sure of the current policy. During interview with unvaccinated PCA-A on 3/2/22, at 12:59 p.m. she stated she is not testing for COVID-19 weekly. During interview with agency owner on 3/2/22, 1:35 p.m. she stated if a staff person tests positive for COVID-19, they stay home for 14 days and is not sure if it is in a policy or not. At 3:11 p.m. she stated she was not aware that staff is not wearing eye protection. Further, at 4:10 p.m. she stated is not able to show the surveyor any illness/COVID tracking because it is all on the director of nursing’s (DON) computer and she does not have access to it. The DON is on vacation. Upon review of agency’s undated COVID 19 policies, it was revealed that there was no guidance for eye protection while providing direct client care. Upon review of agency’s policy, Universal Precaution policy and Employee Infection Control and Reporting policy, undated, it was revealed there was no process established for screening patients prior to home visits. Agency policy, COVID-19 Precautions for Staff not Fully Vaccinated, undated, indicated the unvaccinated staff was required to complete a rapid antigen test for COVID-19 weekly and provide results to the agency. Further, it indicated all staff regardless of vaccination status will wear a face mask, and masks will not be removed for any reason. The agency lacked documentation for any of the 32 of 33 exempted and unknown vaccination status staff had been testing weekly as per their policy.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to follow polices and procedures for unvaccinated staff and had failed to meet the 100% vaccination rate as required by QSO 22-07-ALL, resulting in a risk of potential serious harm or death to all 286 patients. This resulted in an immediate jeopardy (IJ) situation as this system failure had the potential to cause serious harm or death to agency patients, patient families, caregivers and staff. The immediate jeopardy began on 3/1/22, when the agency failed to follow policies and procedures to ensure all staff were vaccinated for COVID-19, had proof of vaccination on file, or had an exemption on file, 60 days after vaccine requirement. The agency failed to follow a contingency plan for staff who were not fully vaccinated. The owner was notified of the immediate jeopardy at 12:20 p.m. on 3/2/22. The immediate jeopardy was removed at 1:15 p.m. on 3/10/22, when the agency developed and implemented updated policies and procedures to address tracking and documentation of the agency's staff vaccination status, developed a contingency plan following CDC recommendations, and implemented additional precautions to mitigate the spread of COVID-19 by unvaccinated staff. Based on review of agency vaccination tracking, the agency had a vaccination rate of 84%. The agency had 164 total staff, 126 had been vaccinated, 7 had an exemption that had been approved and 26 had not provided proof of vaccination, nor had been granted an exemption. Hennepin county community level for transmission of COVID-19 was recorded as high. During interview with PCA-F on 3/2/22, at 12:46 p.m. he stated he donned a mask prior to entering the apartment building his client resides in, but once in the apartment, he removes it. During interview with unvaccinated PCA-A on 3/2/22, at 12:59 p.m. she stated she is not testing for COVID-19 weekly, nor did she receive a letter that her employment was on hold. PCA-A stated she continued to care for her client daily. During interview with unvaccinated PCA-B on 3/2/22, at 1:20 p.m. she stated she had not turned an exemption to the agency. She did not get a letter that her employment was on hold, and she continued to care for her client. During interview with PCA-C on 3/2/22, at 2:15 p.m. confirmed she unvaccinated and can’t remember if she turned in an exemption form. She stated she does not wear eye protection and she was still working. During interview with PCA-D on 3/2/22, at 2:19 p.m. she stated she was vaccinated, but had not reported this to the agency yet. She stated she continued to work and did not wear eye protection. During interview with PCA-E on 3/2/22, at 1:05 p.m. he stated he was vaccinated but didn't think he had turned in the proof to the agency. He stated he continued to provide care for his clients. During interview with agency owner on 3/2/22, at 1:35 p.m. she stated if a staff person tests positive for COVID-19, they stay home for 14 days and is not sure if it is in a policy or not. At 3:11 p.m. she stated she was not aware that staff is not wearing eye protection. Further, at 4:10 p.m. she stated is not able to show the surveyor any illness/COVID tracking because it is all on the director of nursing’s computer and she does not have access to it. Agency owner stated if staff was not vaccinated, they would have an exemption on file or their employment would be put on hold. She further stated that unvaccinated staff were required to test for COVID weekly, which she identified as the mitigation plan for staff not fully vaccinated. Upon review of agency policy, COVID-19 Vaccination Requirement Contingency Plan for Staff Who are not Fully Vaccinated, undated, indicated employment would be suspended at 60 days after vaccination requirement QSO 22-07-ALL. However, five PCA’s (PCA-A, PCA-B, PCA-C, PCA-D, PCA-E) who were identified as unvaccinated or did not have an exemption stated they provided cares their clients after 2/28/22. Upon review of agency policy, COVID-19 Precautions for Staff not Fully Vaccinated, undated, indicated the unvaccinated staff was required to complete a rapid antigen test for COVID-19 weekly and provide results to the agency. Further, it indicated all staff regardless of vaccination status will wear a face mask, and masks will not be removed for any reason.

On August 10th, 2021, through August 18th, 2021, an abbreviated survey was conducted at your agency to conduct a complaint investigation. Professional Resources Network was found NOT to be in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. During the survey, the following complaint was investigated and substantiated at H8054016C (MN75290) The Condition of Participation: Patient Rights 42 CFR 484.50 at G406 was found not met. An Immediate Jeopardy (IJ) was identified at G430 The Immediate Jeopardy began on 7/19/21, at 5:08 p.m. when P1 went to the emergency department (ED) at United Hospital with Chief Complaint of pressure wounds. The ED report further indicated she was bed bound and lived alone and had limited help from family and when family repositioned P1 concern was noted when P1’s skin on left buttock came off. P1 was receiving 10.5 hours a day of personal care assistance (PCA) services from Professional Resources Network. The agency administrator and assistant director of nursing (ADON) were notified of the IJ on 8/12/21, at 2:10 p.m. The IJ was removed on 8/18/21, at 10:10 a.m. when it was verified an acceptable removal plan had been implemented. As a result, an extended survey was conducted Hours of Operation: Monday through Friday 8:00 a.m. to 4:30 p.m.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to meet the Condition of Participation at 484.50, Patient Rights. The HHA failed to ensure 1 of 1 patient (P1) was free from abuse and neglect while receiving care from personal care attendants (PCA)-A, (PCA-B) and registered nurse (RN)-A who provided care for P1 who developed unstageable pressure ulcers which required hospitalization and admission to a long-term care facility. Findings include: Refer to G430: Based on interview and document review the facility failed to assure patient neglect did not occur for 1 of 1 patient (P1) who depends on staff for cares, had a history of pressure ulcers, and developed unstageable pressure ulcer which required hospitalization for sepsis and infection of ulcers. Personal care attendants (PCA) were not reporting the seriousness of the condition P1’s skin, in addition P1’s registered nurse case manager (RN)-A was not aware of the pressure ulcers. This resulted in a immediate jeopardy (IJ) situation.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on interview and document review, the facility failed to assure patient neglect did not occur for 1 of 1 patient (P1) who depends on staff for cares, had a history of pressure ulcers, and developed unstageable pressure ulcers which required hospitalization for sepsis and infection of ulcers. Personal care attendants (PCA) were not reporting the seriousness of the condition P1’s skin, in addition P1’s registered nurse case manager (RN)-A was not aware of the pressure ulcers. This resulted in a immediate jeopardy (IJ) situation. The Immediate Jeopardy began on 7/19/21, at 5:08 p.m. when P1 went to the emergency department (ED) at United Hospital with Chief Complaint of pressure wounds. The ED report further indicated she was bed bound and lived alone and had limited help from family and when family repositioned P1 concern was noted when P1’s skin on left buttock came off. P1 was receiving 10.5 hours a day of personal care assistance (PCA) services from Professional Resources Network. The agency administrator and assistant director of nursing (ADON) were notified of the IJ on 8/12/21, at 2:10 p.m. The IJ was removed on 8/18/21, at 10:10 a.m. when it was verified an acceptable removal plan had been implemented. Findings include: P1’s Plan of Care (POC) certification period 7/15/21 thorough 9/12/21, indicated P1 had cervical spina bifida (incomplete closing of the spine and spinal cord) urinary incontinence and pressure ulcer. The POC further indicated P1 was to receive 8-12 hours a day with RN supervision. The POC also indicated the PCA was to report any red or open areas to the RN and the RN was to notify the medical doctor of any changes or concerns. The POC further indicated the PCA was to assist with dressing, bathing, grooming, mobility, positioning every two hours, toileting and eating due to decreased limited range of motion of upper and lower extremities. P1’s Care Plan For PCA dated 7/14/21, indicated the PCA to assist with dressing upper and lower body as needed, assist with comping hair, hands on assistance with showering and drying off as needed, assist with eating, assist with transfers, assist with walking as needed required hands on assistance, assist with positioning as needed, assist with the toilet and toileting hygiene as needed. The Care Plan further indicated to call with any injuries, falls, or changes in condition and call if hospitalized. During interview 8/11/21, at 9:00 a.m. with the agency assistant director of nursing (ADON) stated since COVID P1’s 60-day nursing supervisory visits and comprehensive assessments are done over the telephone and not in the home. The ADON further stated they were instructed by the director of (DON) there is a waiver where they had the ability to complete their visits and assessments that are required by telehealth. However, the 60-day comprehensive assessment requirement is not waived by CMS. During interview 8/11/21, at 9:20 a.m. registered nurse (RN)-A stated she had been the nurse case manager for P1 since July of 2019. RN-A further stated she had a stage 3 pressure ulcer in the past but was unaware of her having any since she was her nurse. RN-A stated her last 60-day supervisory visit and assessment was completed over the phone on 5/14/21, with P1 and her personal care attendant (PCA). RN-A stated she goes through a series of questions regarding her cares and the PCA’s never informed her of any skin issues. In addition, the RN-A stated P1 never refused any visits. During interview 8/11/21, at 2:22 p.m. ADON, indicated P1’s care plan could have been clearer to identify specifically for the PCA to turn and reposition P1 every 2 hours instead of “assist with positioning as needed” and reporting to the nurse, so the PCA would know exactly what to do. During interview 8/11/21, at 3:45 p.m. with P1’s clinical coordinator (CC) from Medica who indicated P1 went to the United Hospital emergency department (ED) on 7/19/21 and her hospital medical records indicated she was admitted with bed sores on her bilateral hips, had foul urine smell. The medical records further stated the family had her come to the ED as when they were wiping her bottom her skin “just feel off her bottom.” P1 lives alone, and her sister was her primary care giver and had limited help at home. In addition, the CC stated looking further into the notes she saw communication from the family to Handi Medical Supplies in May of 2021 requesting gauze, bandages and ointment and the CC was concerned she had a pressure ulcer back then and the home care agency was unaware of that. Review of P1’s emergency department record at United Hospital dated 7/19/21, at 5:08 p.m. indicated her chief complaint was pressure ulcers, one to right buttock full thickness, unstageable which measured 4 centimeters (cm) x 6 cm, and one to left buttock. The ED record also indicated P1 had visit diagnoses of, urinary tract infection, septic shock, decubitus ulcer due to spina bifida that paralyzed legs and partially in her arms, osteomyelitis (bone infection) of sacroiliac region (bony structure above tailbone), feeding difficulties, acute respiratory failure. The ED record further indicated P1 was bed bound and lived alone, limited help from family and recently developed a pressure ulcer on her left buttock. While family repositioned her the skin on her left buttock fell off P1 was admitted to the intensive care unit (ICU). The hospital notes indicated on 7/21/21, she had incision and drainage done to her wounds and a wound vac was placed on 7/22/21, to her right ischial tuberosity (curved bone back of pelvis) and left buttock. In addition, the hospital notes indicated on 8/5/21, a GJ tube (provides feeding) was placed for nutritional support and a tracheostomy (airway made for breathing). P1 was discharged on 8/9/21, to a long-term care facility due to needing complex care family could no longer provide. During interview 8/12/21, at 8:30 a.m. PCA-A stated P1 has always had pressure ulcers on and off for years and they always treated them with ointments and nursed them back to health. PCA-A stated they were allowed to provide 10.5 hours a day to care for her and the other hours she would be left alone. PCA-A added P1 can’t reposition herself. PCA-A stated P1 had a pressure ulcer in February 2021 to March 2021 and had requested supplies from Handi Medical Supply company. In addition, she had redness on her bottom back in May 2021 to July 2021, which she documented in her notes. PCA-A indicated PCA-B on 7/19/21 went to clean P1’s bottom and her skin just “fell off” and PCA-B called her, and they decided to call 911 and have her sent to the ED department. P1 now has a tracheostomy, infected wounds and will not be able to go back home since they can no longer care for her. On 8/12/21 at 12:00 pm interview with ADON who stated the case manager had access to the PCA progress notes in the computer and they are located on the back of the PCA’s timesheets. During interview 8/12/21, at 2:00 p.m. PCA-B stated she has been the primary care giver for P1. PCA-B stated she is her sister and is an employee of Professional Resources Network (PRN). PCA-B further stated her sister PCA-A also helps when she can but lives out of state. PCA-B stated once her sister moved out of state a few months ago she was the only caregiver for P1 and was working 10.5 hours a day 7 days a week. PCA-B stated she would have to leave P1 alone during the night and she was incontinent of urine and was unable to reposition herself. PCA-B stated she requested more help from PRN HHA and was told they had no staff available, so she had her friend PCA-C hired to help out on the weekends. PCA-B stated she does not recall ever receiving a call from a nurse from PRN completing a assessment and was in fact not aware the agency even had nurses on staff. PCA-B stated P1 had pressure ulcers on and off for months and she would do her best to try and heal them with ointments and bandages. PCA-B stated Handi Medical came out and removed her special bed pump to prevent the pressure ulcers and was very upset, and if a nurse called her from PRN she would had told her. During interview 8/13/21, at 12:00 p.m. RN-A stated she was unaware the PCA’s were documenting on the back of their timesheets, and she had access to them in the computer. RN-A stated she had just been informed of this and if she was aware she would have seen the documentation of the pressure wounds on P1 and would have addressed them. The Immediate Jeopardy began on 7/19/21, was removed 8/18/21, at 11:00 a.m. when it was verified that staff were trained on assessing and reporting changes in skin condition. A facility policy was requested but was not provided.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on interview and document review, the agency was found not to be in compliance with the Condition of Participation at 484.55, Comprehensive Assessment of Patient. The agency failed to conduct an in person comprehensive assessment every 60 days. Findings include: P1's plan of care (POC) with the start of care (SOC) date 3/28/19, and certification periods 5/16/21 to 7/14/21, and 7/15/21 to 9/12/21, indicated P1 received PCA services 8-12 hours a day along with registered nurse to supervise PCA. The POC further indicated for the registered nurse (RN) to complete initial and re-certification visits via telehealth during public health emergency. Review of P1's clinical record identified the recertification comprehensive assessment for the recertification period 5/15/21 to 7/14/21, was completed timely on 5/14/21, but was not done in person rather over the phone. The recertification assessment for the period of 7/15/21 to 9/12/21 was not completed due to P1’s hospitalization on 7/19/21. P2's POC with the SOC dated 5/07/19 and certification period 4/26/21 to 6/24/21, and 6/25/21 to 8/23/21, the POC indicated P2 received home health aide services 4 hours per day, 24-32 hours a week to assist with transfers, mobility, activities of daily living. In addition, the POC indicated the recertification assessment and PCA supervision was done via telehealth due to public health emergency. This was completed on 6/23/21 via telehealth. Due to COVID-19. P3's POC with the SOC date of 0710/14, and certification period 8/02/21 to 9/30/21, indicated P3 received PCA services, 5.25 hours per day, to provide and assist with personal care assistance with ADL's and hygiene needs. The POC indicated the Recertification was done over the phone on 7/30/21 to COVID-19. During interview 8/11/21, at 9:00 a.m. the agencies assistant director of nursing (ADON) stated due to COVID the nurses are doing the recertification's and supervisory visits via telehealth. The ADON further stated she was informed by they director of nursing (DON) who was on vacation they could provide those supervisory visits by telehealth either by phone or video if the patients would prefer this. During interview 8/11/21, at 9:20 a.m. RN-A stated she completed her assessment and supervisory visits with P1 over the telephone and did the best she could with her assessments by asking the patient and the PCA the assessment questions. RN-A stated P1 was hospitalized on 7/19/21, due to pressure ulcers and was never aware she had them and was unable to complete a visual skin assessment on her and when she asked the patient and PCA they denied she had any skin issues. Even though the patient did have skin issues present on and off for months a direct assessment was not completed by RN-A to P1 during COVID-19. A policy was requested but was not received.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on interview and document review the agencies care plan for personal care assistants (PCA) failed to give specific direct details on how to care for 1 of 1 patient (P1) who had a history of pressure ulcers. Findings include: P1’s Plan of Care (POC) certification period 7/15/21 thorough 9/12/21, indicated P1 had cervical spina bifida (incomplete closing of the spine and spinal cord) urinary incontinence and pressure ulcers. The POC further indicated P1 was to receive 8-12 hours a day with registered nurse (RN) supervision. The POC also indicated the PCA 's were to report any red or open areas to the RN and the RN was to notify the medical doctor of any changes or concerns. In addition the POC directed the PCAs to assist with dressing, bathing, grooming, mobility, positioning every two hours, toileting and eating due to decreased limited range of motion of upper and lower extremities. P1’s Care Plan For PCA dated 7/14/21, indicated the PCA to assist with dressing upper and lower body as needed, assist with comping hair, hands on assistance with showering and drying off as needed, assist with eating, assist with transfers, assist with walking as needed required hands on assistance, assist with positioning as needed, assist with the toilet and toileting hygiene as needed. The Care Plan further indicated to call with any injuries, falls, or changes in condition and call if hospitalized. The PCA care plan did not direct the PCA's to turn and reposition the patient every two hours and to report any red or open areas to the RN. During interview 8/11/21, at 2:22 p.m. the assistant director of nursing (ADON) stated the PCA care plan could have skin integrity on it and explained to report skin issues to the RN 's and be more specific to repositioning every 2 hours instead of just positioning as needed. During interview 8/12/21, at 2:00 p.m. PCA-B stated she has been the primary care giver for P1. PCA-B stated she is her sister and is an employee of Professional Resources Network. PCA-B stated she does not recall receiving a Care Plan for P1 and was not even aware the agency had nurses and was supposed to be reporting if P1 had skin issues. PCA-B stated she does not remember having training and might have, but it would have been awhile ago. A care plan policy was requested but was not provided.