Every finding on record at Provident Home Healthcare

On 3/13/25 through 3/14/25 a complaint survey was conducted. This resulted in a partial extended survey at Provident Home Healthcare. 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. The following complaints were reviewed: H81369885C (MN113865 and MN113914).

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to inform the patient’s representative of changes in care for 1 of 3 patients (P1) when the patient was sent to the hospital. P1’s plan of care (485) dated 3/7/25, for certification period 3/10/25 to 5/8/25 indicated P1 had diagnoses of acute and chronic respiratory failure, chronic kidney disease, tracheostomy, gastronomy tube, and epilepsy. P1’s 485 indicated P1 was non-ambulatory, non-verbal, and dependent on caregiver for all activities of daily living (ADLs). P1’s clinical note, dated 3/11/25 at 12:54 a.m. indicated P1’s physician wanted P1 to go to the hospital due to abnormal lab values. P1 left home at 4:41 p.m. (on 3/10/25) to go to the hospital. P1’s signed Combined Federal and State Home Care Bill of Rights, signed 10/25/24 by P1’s guardian, indicated the right to be told in advance, before receiving services, of the right to participate in, be informed about and consent to or refuse care in advance of and during treatment, with respect to (i) any changes in the care to be furnished. On 3/13/25, at 1:28 p.m., licensed practical nurse (LPN)-A stated he was working with P1 on 3/10/25 when he was sent to the hospital. LPN-A accompanied P1 to the hospital and stayed with him in the emergency room until he was admitted. LPN-A stated he did not notify P1’s guardian of P1’s transfer to the hospital. LPN-A stated the case manager (CM) is responsible to notify the responsible party. On 3/13/25, at 2:24 p.m., registered nurse (RN)-A, the CM, stated he did not notify P1’s guardian when he was transferred to the hospital. RN-A stated he expected LPN-A to notify the responsible party. On 3/13/25, at 3:37 p.m., P1’s guardian stated she was not notified by the home health agency (HHA) when P1 was transferred to the hospital. She stated the hospital notified her of the transfer. On 3/14/25, at 10:10 a.m., the director of nursing (DON) stated the responsible party should be notified when the patient is transferred to the hospital. She stated either the bedside nurse or the CM can notify the resident representative. On 3/14/25, at 10:21 a.m., the assistant director of nursing (ADON) stated either the bedside nurse or the CM were expected to notify the patient’s responsible party when they are transferred to the hospital. A facility document, Emergency Procedure Plan, undated, directed staff to call emergency contact after calling 911. A facility document, Protocol for Client Hospitalization, undated, directed staff notify the family and/or emergency contacts. This communication should come from (the agency), not the hospital. A facility document, Coordination of Client Services, dated 4/21/21, directed (3) the client, representative, and caregivers will participate by identifying what they want to achieve and what they feel comfortable doing. This will be built into the plan. Information provided to clients must be verbally and in writing and the agency documentation will also clarify what the plan is and who was informed. (6) Clients, their representatives, and other caregivers will be included in the coordination activities and will receive direct communication related to planning and change in the plan. (8) When there are significant changes made to the client’s plan of care, the agency must inform the client and their representative and the physician directing the care.

On 2/6/25 through 2/7/25 a complaint survey was conducted. This resulted in a partial extended survey at Provident Home Healthcare. 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. The following complaints were reviewed: H81366943C (MN113018 and MN112996).

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 injuries of unknown origin to the State Agency (SA) immediately for 2 of 3 (P1 and P2) were reviewed for abuse. Findings include: P1’s plan of care (485), dated 1/14/25, for certification period 1/15/25 to 3/15/25, indicated P1 had diagnoses of acute and chronic respiratory failure and transient cerebral attack (TIA). P1’s 485 indicated she had residual weakness, was completely dependent on assistance from staff for all cares and was ventilator dependent and in a persistent vegetative state. P1’s 485 indicated she had a history of a brain aneurysm in 2002 resulting in her immobility and comatose status. P1’s clinical note, dated 2/3/25 at 2:27 p.m., indicated P1 had bruising under her left arm, and it was reported to the registered nurse case manager (RN-B). P1’s clinical note, dated 2/3/25 at 3:46 p.m., indicated left arm edema (swelling) and bruising noted under the arm. RN-B notified. P1’s clinical note, dated 2/4/25 at 12:46 a.m., indicated left upper extremity was grossly swollen with area of darkness measuring two inches and P1 was sent to the hospital. P2’s 485, dated 1/3/25, for certification period 1/9/25 to 3/9/25, indicated P2 had diagnoses of acute on chronic respiratory failure and tracheostomy (a surgical procedure that provides an opening in the trachea to provide an airway when the natural airway is blocked or compromised) status. P2’s 485 indicated P2 was unable to speak, had paralysis and contractures and required total assistance with all activities of daily living (ADLs). P2’s 485 indicated he had swelling in right hand around middle finger on 12/13/24, with heavy bruising noted on 12/16/24. An x-ray was ordered and found to have a broken finger. Case manager assessed the injury as coming from the client getting hand caught in the side rails and tensing up per usual when getting touched. P2’s clinical note, dated 12/13/24 at 5:52 a.m., indicated right middle finger was swollen. RN-C notified. P2’s clinical note, dated 12/14/24 at 11:28 p.m., indicated his right middle finger was bruised and swollen. P2’s clinical note, dated 12/16/24 at 3:37 p.m., indicated his right middle finger had significant bruising throughout the finger. An x-ray report, dated 12/18/24, indicated an x-ray of P2’s right hand was completed on 12/16/24. Results of the x-ray showed a possible fracture of the base of the proximal phalanx (first bone) of the fourth finger. On 2/7/25 at 10:03 a.m., RN-A stated P1 had new bruising this past week. RN-A stated she thought it might be health related because of edema that was present. RN-A stated she thought a blood clot could cause bruising. RN-A stated she reported the bruise to RN-B as soon as she noticed it. On 2/7/25 at 10:33 a.m., the hospital medical doctor (MD) stated P1 was still at the hospital. He stated P1 had left arm edema. He stated the swelling was not likely to be related to bruise. On 2/7/25 at 11:24 a.m., the assistant director of nursing (ADON) stated P2 recently had a broken finger. She stated P2 has spastic movements when he is repositioned, and his finger likely got caught or jammed in the bed rail. The ADON stated she was not involved with the situation as there was no indication of foul play. The ADON stated she was not sure if a full investigation took place. The ADON stated P1 had bruising to her left arm, and she was unsure how it got there. The ADON stated the on-call nurse took care of the scenario. On 2/7/25 at 11:30 a.m., the interim director of nursing (DON) stated when injuries are noted, they try to find the likely cause. She stated the investigations was not sufficient for P1’s left arm bruise or P2’s fractured finger. The interim DON stated bruises of unknown origin should be reported to the SA immediately, but P1 and P2’s were not. On 2/7/25 at 3:07 p.m., RN-B stated she informed the ADON of the bruise on P1’s left arm. RN-B stated she thought the bruise may be due to a blood-pressure cuff, but stated she was not sure how that happened as she did not conduct an investigation. On 2/7/25 at 3:32 p.m., RN-C stated he was called regarding P2’s swollen finger on 12/13/24. He stated the swelling changed from swelling to significant bruising on 12/16/24 and an x-ray was performed. RN-C stated the x-ray indicated P2 had a fracture, and it was thought to have come from P2’s clenching his hand very stiff and getting his hand caught on the side rail of the bed. RN-C stated there was not a specific time and date this occurred, it “seemed to be the mechanism of injury.” RN-C stated he talked to the staff about the injury, but did not document the conversations. RN-C stated he did not assess the other patients the staff cared for. RN-C stated he informed the ADON and DON of the bruise. A facility document, Identifying and Reporting Abuse Neglect and Exploitation of Clients policy, dated 3/1/22, directed: The employee shall immediately make an oral report by phone or otherwise to the Director of Clinical Services or Administrator. The employee shall be instructed to complete a written report of the suspected abuse and/or neglect. (See state-specific requirements for reporting time frames and types of report required.) The Director of Clinical Services/designee will review the information presented and investigate to determine if this is a reportable incident. If so, the information will then be reported to the appropriate county social service Agency or Adult/Child Protection Agency by the Administrator or an appropriate designee.

On 11/20/20/24 -11/25/24 a complaint survey was conducted. This resulted in a partial extended survey at Provident Home Health Care. The agency was found to have met the requirements at 42 CFR. Part 484 for Home Health Agencies. The following complaints were reviewed: H81361376C/111176

On 10/30/24 through 11/1/24 and 11/5/24 through 11/6/24, a complaint survey was conducted. This resulted in a partial extended survey at Provident Home Healthcare. The agency was found to have met the requirements at 42 CFR. Part 484 for Home Health Agencies. The following complaints were reviewed: H81369985C (103988) H81369984C (108386)

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (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: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to investigate an allegation of staff to patient verbal abuse and a patient grievance of care for 2 of 4 patients (P3 and P4)) reviewed for patient rights. Findings include: P3's Home Health Certification and Plan of Care for certification period 9/7/24 through 11/5/24, identified diagnosis that included acute and chronic respiratory failure, muscular dystrophy, and dependence on a respirator. The Plan of Care indicated registered nurse (RN)/Licensed practical nurse (LPN) up to 24 hours per day, seven days per week. A Client Grievance form dated 10/2/24, indicated on 10/1/24 through 10/2/24, P3 sent a text message to the recruitment manager (RM), "Long story short, after yelling into the phone for 15 minutes she [RN-B] is now my nurse. I do not feel safe with her, she has scared me twice now with my tubes. I don't feel safe sleeping under her care." The resolution section of the complaint form was blank. During interview on 10/31/24 at 12:50 p.m. the RM stated P3 had sent her a text message around 2:00 a.m. and said he did not feel safe with RN-B because of something she had done with his tubes. The RM stated it sounded like it had happened before and said he reported not feeling safe sleeping under her care. The RM stated RN-B had been assigned to care for another patient but had not felt comfortable and did not want to work with him. During interview on 10/31/24 at 12:54 p.m. RN-B stated the day of the care concern, she had gone to the house and did not feel she had been properly trained to work with the client she had been assigned to. RN-B stated she called the on-call staffer (RM) and asked to switch for another client. RN-B stated she went to P3's room and said P3's ventilator had a drainage system, and she notice the humidifier cup was full, so she emptied it. RN-B stated immediately after she left the room P3 called and said he could not breathe and asked what she had done to his ventilator. RN-B stated P3's vital were assessed and stable but said she got a call that P3 was not comfortable working with her. RN-B stated the facility had not reached out to her however, she had reached out to them and told them she had worked with P3 many times and told them she did not touch his ventilator. RN-B said she did not know why P3 had acted that way because she felt there had not been an issue. During interview on 10/31/24 at 1:21 p.m., the staffing coordinator (SC) stated RN-B had sent her a text message but said she had not understood the context. the SC stated she had received a report from the RM that P3 did not feel safe with RN-B. The SC stated she talked to the staffing manager (SM) who said, "let's get her in here." The SC stated RN-B acted like she could not come into the agency and then "I am not sure how long after, but at a staff meeting we called her, and the SM said she needed to come in." The SC said the concern was that P3 felt unsafe and said we needed to bring her in and get her side of the story and investigate it more. The SC stated the SM did the follow up with RN-B. Regarding follow up with P3, the SC stated, "probably the case manager." During interview on 101/31/24 at 1:27 p.m. the director of nursing (DON) stated the facility had been trying to get hold of RN-B to talked about P3's concerns. The DON stated she had not spoken to P3 about his concerns. During interview on 10/31/24 at 1:32 p.m. RN-A stated she knew the RM and SM had called RN-B. RN-A stated she had not followed up with P3 about his concerns and said she thought they were trying to get RN-B to come in. RN-A stated, I know it is on the to do list to give her and ultimatum that if she did not come in that she could not work. RN-A stated, "We need to hear from her about the whole incident." During interview on 10/31/24 at 2:11 p.m. the SM stated the agencies leverage for getting staff to come to the office for discipline was to take them off the schedule. The SM stated, "We can't devote time to talk to her if she is not on the schedule for say 12 days." The SM stated he believed the nurse manager had gone out and spoken with P3. The SM then got up and left the room. He returned a few minutes later and said RN-A reported she did not think anyone in the clinical department had talked to P3 to find out what his concerns were. During interview on 10/31/24 at 2:32 p.m. the administrator stated she did not know if anyone had spoken to P3 about his concerns. Agency Client/Family Grievance Policy dated 5/18/23, indicated grievances would be addressed by the department director or designee and response made to the complainant within seven days of receipt. If the grievance will take longer than seven days to complete the director will contact the complainant within the initial seven days to let them know the grievance has been received and is being investigated. Grievances are considered completed when an approved response has been mailed to the client complainant. P4's Home Health Certification and Plan of Care for certification period 10/1/24 through 11/29/24, identified diagnosis that included respiratory failure, muscular dystrophy, and a tracheostomy. The Plan of Care indicated he was unable to report abuse/neglect independently and identified him as high risk for abuse. The plan indicated on call was available 24 hours per day to report actual or suspected abuse. Facility Client Grievance form dated 5/28/24, indicated on 5/25/24, LPN-A reported LPN-B had gotten into a yelling/swearing match with P4. The form indicated the staffing manager called and spoke to LPN-B about the incident. The form identified a grievance resolution date of 6/26/24, however, lacked evidence of an investigation or follow up with the staff member, client, or complainant. An e-mail to LPN-B, written by RN-A dated 5/25/24, indicated RN-A followed up on how things were going at the home P4 resided in and indicated "I have also been following up with P4" and his behavior about how he sometimes treated his nurses. RN-A wrote she knew it was a challenge. RN-A wrote P4 had told her he wanted his nurses to be attentive to his needs and offer care and indicated P4 made comments about LPN-B being focused too much on his phones/computers. RN-A wrote, "I just want to make sure we all mindful of putting the client's needs first." RN-A further wrote P4 was very young and not mature yet and could be crabby and wrote, remaining calm when he acted up tended to help P4 act with better behavior. The e-mail ended with RN-A thanking LPN-B for working weekends at the home. An untitled document dated 5/28/24, identified the following summary written by LPN-A. P4 had an ongoing problem with LPN-B, had brought up the subject to the staffing coordinator (SC) more than once and indicated P4 stated he felt "very intimidated" by LPN-B. The document indicated P4's family members had been visiting when LPN-B arrived for his shift. The form indicated when the family members left, LPN-B went into P4's room and LPN-B and P4 were heard swearing at each other. During interview on 10/31/24 at 1:35 p.m. RN-A stated she was aware there had been a yelling match between P4 and LPN-B and said LPN-B had called for help from other staff because P4's behaviors had been escalating. RN-A stated P4 was verbally derogatory and stated he was challenging. RN-A stated she had spoken to P4 but was not sure if she had written it down. RN-A stated she had a general conversation with P4 about "his ability to shape people verses put them into fear." Regarding LPN-B, RN-A stated the staffing manager (SM) had an extensive conversation with him. During interview on 10/31/24 at 2:03 p.m., the SM stated P4 had a history of provoking people and said he felt LPN-B reacted poorly after being provoked. The SM stated he thought LPN-B had lost his composure and said P4 felt it was inappropriate, "which I believe it was." The SM stated the clinical department had reached out to LPN-B and stated nothing had been done other than what had been documented in the e-mail. The SM stated he had spoken to LPN-B but had not documented anything. The SM stated the agency did not discipline staff over the phone and said they tried to coax them to come into the agency and were "gentle" with them. The SM stated, "they know what they did wrong." The SM further stated the agency did not tolerate staff to resident verbal abuse. During interview on 10/31/24 at 2:32 p.m. the administrator stated when a complaint came in the complaint went to the SM, the administrator, and the director of nursing. The administrator stated they should have talked to the client, staff involved and if needed, a staff retraining was completed. The administrator stated the facility complaint process had been a little fragmented over the past year due to staff turnover. During a subsequent interview on 11/1/24 at 8:34 a.m., the administrator stated there was no documented interview with wither P4 or LPN-B and stated it was a disservice to both to have not done proper diligence. During interview on 11/1/24 at 10:37 a.m., LPN-B stated on the day of the incident he had approached P4 about using the urinal and said P4 "just went off, I don't know why." LPN-B stated P4 had been yelling at him, swearing, and told him to get out of his room while making derogatory comments. LPN-B stated he asked another staff member to come into the room and said he had been repeating to the other staff member what P4 had been saying to him. Agency Policy Client Care, Vulnerable Adults Protection identified abuse as the intentional and non-therapeutic infliction of pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. This included verbal abuse intended to upset or disturb a person. Agency policy related to investigation of allegations of abuse was requested. The Agency was unable to locate a policy.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to have systems in place to ensure patient protections for 2 of 4 patients (P3 and P4) reviewed following an allegation of verbal abuse. Findings include: P3's Home Health Certification and Plan of Care for certification period 9/7/24 through 11/5/24, identified diagnosis that included acute and chronic respiratory failure, muscular dystrophy, and dependence on a respirator. The Plan of Care indicated registered nurse (RN)/Licensed practical nurse (LPN) up to 24 hours per day, seven days per week. A Client Grievance form dated 10/2/24, indicated on 10/1/24 through 10/2/24, P3 sent a text message to the recruitment manager (RM), "Long story short, after yelling into the phone for 15 minutes she [RN-B] is now my nurse. I do not feel safe with her, she has scared me twice now with my tubes. I don't feel safe sleeping under her care." The resolution section of the complaint form was blank. During interview on 10/31/24 at 12:50 p.m. the RM stated P3 had sent her a text message around 2:00 a.m. and said he did not feel safe with RN-B because of something she had done with his tubes. The RM stated it sounded like it had happened before and said he reported not feeling safe sleeping under her care. The RM stated RN-B had been assigned to care for another patient but had not felt comfortable and did not want to work with him. During interview on 101/31/24 at 1:27 p.m. the director of nursing (DON) stated the facility had been trying to get hold of RN-B to talked about P3's concerns. The DON stated she had not spoken to P3 about his concerns. During interview on 10/31/24 at 1:32 p.m. RN-A stated she knew the RM and SM had called RN-B. RN-A stated she had not followed up with P3 about his concerns and said she thought they were trying to get RN-B to come in. RN-A stated, I know it is on the to do list to give her and ultimatum that if she did not come in that she could not work. RN-A stated, "We need to hear from her about the whole incident." During interview on 10/31/24 at 2:11 p.m. the SM stated he spoke with RN-A who reported she did not think anyone in the clinical department had talked to P3 to find out what his concerns were. During interview on 10/31/24 at 2:32 p.m. the administrator stated she did not know if anyone had spoken to P3 about his concerns. P4's Home Health Certification and Plan of Care for certification period 10/1/24 through 11/29/24, identified diagnosis that included respiratory failure, muscular dystrophy, and a tracheostomy. The Plan of Care indicated he was unable to report abuse/neglect independently and identified him as high risk for abuse. The plan indicated on call was available 24 hours per day to report actual or suspected abuse. Facility Client Grievance form dated 5/28/24, indicated on 5/25/24, LPN-A reported LPN-B had gotten into a yelling/swearing match with P4. The form indicated the staffing manager called and spoke to LPN-B about the incident. The form identified a grievance resolution date of 6/26/24, however, lacked evidence of an investigation or follow up with the staff member, client, or complainant. An untitled document dated 5/28/24, identified the following summary written by LPN-A: P4 had an ongoing problem with LPN-B, had brought up the subject to the staffing coordinator (SC) more than once and indicated P4 stated he felt "very intimidated" by LPN-B. The document indicated P4's family members had been visiting when LPN-B arrived for his shift. The form indicated when the family members left, LPN-B went into P4's room and LPN-B and P4 were heard swearing at each other. During interview on 10/31/24 at 1:35 p.m. RN-A stated she was aware there had been a yelling match between P4 and LPN-B and said LPN-B had called for help from other staff because P4's behaviors had been escalating. RN-A stated P4 was verbally derogatory and stated he was challenging. RN-A stated she had spoken to P4 but was not sure if she had written it down. RN-A stated she had a general conversation with P4 about "his ability to shape people verses put them into fear." Regarding LPN-B, RN-A stated the staffing manager (SM) had an extensive conversation with him. During interview on 10/31/24 at 2:03 p.m., the SM stated P4 had a history of provoking people and said he felt LPN-B reacted poorly after being provoked. The SM stated he thought LPN-B had lost his composure and said P4 felt it was inappropriate, "which I believe it was." The SM stated the clinical department had reached out to LPN-B and stated nothing had been done other than what had been documented in the e-mail. During interview on 10/31/24 at 2:32 p.m. the administrator stated when a complaint came in the complaint went to the SM, the administrator, and the director of nursing. The administrator stated they should have talked to the client, staff involved and if needed, a staff retraining was completed. The administrator stated the facility complaint process had been a little fragmented over the past year due to staff turnover. Agency Client/Family Grievance Policy dated 5/18/23, indicated grievances would be addressed by the department director or designee and response made to the complainant within seven days of receipt. If the grievance will take longer than seven days to complete the director will contact the complainant within the initial seven days to let them know the grievance has been received and is being investigated. Grievances are considered completed when an approved response has been mailed to the client complainant. Agency Policy Client Care, Vulnerable Adults Protection identified abuse as the intentional and non-therapeutic infliction of pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. This included verbal abuse intended to upset or disturb a person.

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 an allegation of staff to client verbal abuse to the state agency (SA) for 1 of 4 patients reviewed for patient rights. Findings include: P4's Home Health Certification and Plan of Care for certification period 10/1/24 through 11/29/24, identified diagnosis that included respiratory failure, muscular dystrophy, and a tracheostomy. The Plan of Care indicated he was unable to report abuse/neglect independently and identified him as high risk for abuse. The plan indicated on call staff was available 24 hours per day to report actual or suspected abuse. Facility Client Grievance form dated 5/28/24, indicated on 5/25/24, Licensed Practical Nurse (LPN)-A reported LPN-B had gotten into a yelling/swearing match with P4. The form indicated the staffing manager called and spoke to LPN-B about the incident. An untitled document dated 5/28/24, identified the following summary written by LPN-A. P4 had an ongoing problem with LPN-B and had brought up the subject to the staffing coordinator (SC) more than once and indicated P4 stated he felt "very intimidated" by LPN-B. The document indicated P4's family members had been visiting when LPN-B arrived for his shift. The form indicated when the family members left, LPN-B went into P4's room and LPN-B and P4 were heard swearing at each other. During interview on 11/5/24 at 3:25 p.m., the administrator stated the complaint should have been reported to herself, the director of nursing (DON) and the assistant DON's and a report should have been made to the SA. The administrator stated none of them had been made aware of the complaint. Agency policy Identifying, and Reporting Abuse/Neglect/Exploitation of Clients date 3/1/22 indicated clients had the right to be free from mental, physical, and verbal abuse. Purpose: To protect persons who are either by physical or mental disability or dependence on institutional services, particularly vulnerable to abuse or neglect. The policy indicated when abuse was suspected, the employee shall immediately make an oral report by phone or otherwise to the DON or administrator. The DON or designee will review the information presented and investigate to determine it the incident was reportable and if so, report to the appropriate agency.

On 6/1/22 - 6/2/22, a complaint and FIC survey were conducted. This resulted in a partial extended survey at Provident Home Healthcare. 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. H814361791C/70669 was substantiated. Deficiencies were issued at G572 as a result of the complaint investigation. The Condition of Participation: 484.60, Care Plan, Coordination of Services, and Quality of Care at G570 was found not met.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. 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 484.60, Care Plan, Coordination of Services, and Quality of Care. The HHA failed to ensure 1 of 1 patients (P1) received services as directed in the plan of care resulting in a lack of supervision. Refer to G572: Based on interview and document review the agency failed to ensure the plan of care was followed for 1 of 2 patients (P1) resulting in P1 being left unattended in the home when P1 required up to 24-hour complex nursing care. According to P1's plan of care, P1 was non-verbal and did not have the capacity to seek emergency services.

On 2/7/22 through 2/8/22, 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 following complaints were found to be substantiated; however, no deficiencies were issued due to actions taken by the agency prior to survey. H8136027C (61814) H8136028C (61815) H8136029C (61816) The following complaints were found to be unsubstantiated: however an unrelated deficiency was cited at G687. H8136030C (61891) H8136031C (61895) The Condition of Participation: 484.70 Infection prevention and control was not met at G680. A partial extended survey was conducted and resulted in substandard quality of care. Hours of Operation: Monday through Friday 8:00 a.m. to 4:30 p.m.

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 document review, the home health agency (HHA) failed to meet the Condition of Participation at 484.70 Infection Prevention and Control. The agency failed to ensure they developed and implemented policies and procedures for COVID-19 Vaccination of Home Health Agency Staff. Refer to G687: The agency failed to ensure a 100% vaccination rate for COVID-19 as required, 60 of 302 staff did not have proof of vaccination or proof of an exemption from vaccination. In addition, the agency failed to develop a process for ensuring unvaccinated staff had addition requirements to mitigate transmission and spread of Covid-19.

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 document review, the agency failed to ensure 100% of staff had been vaccinated for COVID-19, 60 of 302 staff had not been vaccinated for a vaccination rate of 80.1%. In addition, the agency failed to develop a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not vaccinated. The agency's policy titled COVID-19 Vaccination, revised 2/7/22, included, "1. All staff are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations." The policy also included, "Additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 are as follows: a. Unvaccinated staff to wear masks and exercise universal precautions during their shift. b. Unvaccinated staff to maintain social distancing from colleagues and/or others present in the clients home." The contingency plan for staff who are not fully vaccinated included, "Staff who are not fully vaccinated or do not have an approved exemption are removed from the schedule." The DHS (Department of Human Services) Version of COVID-19 Vaccine Tracking form completed by the agency on 2/8/22, included 302 staff members, 60 of which had not received any vaccine, nor were they pending or granted a medical or religious exemption to receiving the vaccine, nor did they have a temporary delay for vaccination per CDC guidelines. When interviewed on 2/8/22, at 12:00 p.m. the administrator stated, "We currently have 60 staff members that are unaccounted for," and verbalized understanding 60 staff members that are unaccounted for did not meet the requirement of having 100% of staff being vaccinated or having an exemption in place. When interviewed on 2/8/22, at 12:47 p.m. licensed practical nurse (LPN)-I, who was not vaccinated for COVID-19 and did not have an exception stated she wore a mask and eye protection while in patient homes. LPN-I provided close personal contact with patients while in their homes and was not expected to take any additional precautions because she was not vaccinated. When interviewed on 2/8/22, at 12:51 p.m. registered nurse (RN)-A stated she had an exemption to the vaccine and continued to make home visits where she would be within 6 feet of the patients to perform assessments and provide care. RN-A stated she did not use any extra precautions to prevent the spread of COVID-19 because she was not vaccinated. She wore a surgical mask and eye protection like all staff were expected to wear during the COVID-19 pandemic. When interviewed on 2/8/22, at 1:00 p.m. the administrator stated, they expected all staff to wear eye protection and a surgical mask while in patient homes and did not have any additional requirements to mitigate the spread of COVID-19 for staff were not vaccinated. They continued to have unvaccinated staff working in patient homes and having close personal contact during cares.

An abbreviated survey was conducted at your agency on 5/5/21, through 5/6/21. Provident Home Healthcare was found NOT to be in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. The following complaints was found to be SUBSTANTIATED: H8136021C/MN00072349 with deficiencies issued at G572 H8136022C/MN00072345--with deficiencies issued at G590 The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance.

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 document review the agency failed to inform the physician of services that were not provided for 1 of 3 patients (P1) reviewed for care planning, coordination and quality of care. Findings include: P1's Plan of Care (POC) certification period 5/3/21, through 7/1/21 included diagnoses of chronic respiratory failure with hypoxia, Parkinson's disease, ventilator dependence and tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and indicated P1 required complex nursing RN/LPN (registered nurse/licensed practical nurse), up to 24 hours per day for 60 days. The POC failed to identify the use of family was supplement caregiver when the agency was not able to provide nursing care as directed by the POC. Review of P1's clinical record, revealed P1 did not not receive complex nursing RN/LPN up to 24 hours per day for 60 days during the following dates and shifts in the last three months as directed by the POC. In addition, the medical record lacked documentation that P1's physician was notified of the missed visits. -3/2/21 2:00 a.m. to 6:00 a.m. -3/8/21 2:00 a.m. to 7:00 a.m. -3/9/21 12:00 a.m. to 8:00 a.m. -3/15/21 5:00 a.m. to 8:00 a.m. -3/16/21 2:00 a.m. to 6:00 a.m. and 10:00 p.m. to 12:00 a.m. -3/19/21 8:00 p.m. to 12:00 a.m. -3/23/21 12:00 a.m. to 8:00 a.m. -3/27/21 8:00 p.m. to 12:00 a.m. -3/30/21 4:00 p.m. to 12:00 a.m. -4/4/21 8:00 a.m. to 4:00 p.m. -4/5/21 12:00 a.m. to 8:00 a.m. -4/6/21 2:00 a.m. to 8:00 a.m. -4/8/218:00 p.m. to 12:00 a.m. -4/11/21 8:00 a.m. to 4:00 p.m. -4/13/21 12:00 a.m. to 8:00 a.m. -4/16/21 12:00 a.m. to 8:00 a.m. and 8:00 p.m. to 12:00 a.m. -4/18/21 8:00 a.m. to 4:00 p.m. -4/19/21 2:00 a.m. to 8:00 a.m. and 8:00 a.m. to 4:00 p.m. -4/20/21 12:00 a.m. to 8:00 a.m. and 8:00 a.m. to 4:00 p.m. -4/21/21 10:00 a.m. to 4:00 p.m. -4/22/21 8:00 p.m. to 12:00 a.m. -4/23/21 8:00 a.m. to 4:00 p.m. and 4:00 p.m. to 12:00 a.m. -4/24/21 8:00 p.m. to 12:00 a.m. -4/25/21 8:00 a.m. to 4:00 p.m. -4/26/21 12:00 a.m. to 8:00 a.m. -4/27/21 12:00 a.m. to 8:00 a.m. and 4:00 p.m. to 12:00 a.m. -4/28/21 6:00 p.m. to 12:00 a.m. -4/29/21 8:00 p.m. to 12:00 a.m. -4/30/21 12:00 a.m. to 8:00 a.m. and 8:00 p.m. to 12:00 a.m. -5/1/21 12:00 a.m. to 8:00 a.m. -5/2/21 8:00 a.m. to 4:00 p.m. -5/3/21 2:00 a.m. to 8:00 a.m. -5/4/21 12:00 a.m. to 8:00 a.m. -5/5/21 8:00 a.m. to 4:00 p.m. During interview on 5/5/21, at 3:03 p.m. P1's insurance care coordinator (ICC), stated she was not made aware by the agency about concerns with staffing until 3/30/21. The ICC stated P1 had discharged home with recommended 24 care as it was not culturally appropriate for P1 to be admitted to any nursing facility. The ICC stated after she received a call from the agency director of staffing indicating they were not able to provide adequate staffing, she had called P1's family member (FM)-A who told her for four to five months once in a while the agency was not able to send a nurses but it had now become a daily problem. The ICC stated when she reached out to the agency director of staffing, asking why she had not been informed staffing had been an issue, she was told the agency had been communicating with P1's family who resided in the same home. The ICC stated "they should have called me and we would have worked together to figure out what we would have done for this situation. Maybe we would have made other calls and coordinated as I was the one who coordinated her going home and would have made sure to coordinator to address the issue sooner." The ICC stated she was currently working with on getting P1 to another agency and she was aware the agency had offered to put P1 in one of the group sites however this was something that was not culturally practicable. During interview on 5/5/21, at 2:03 p.m. the director of nursing (DON) stated agency staff, P1's responsible family members and other care team members had a care conference and staffing had been brought up and discussed. The DON stated there were concerns with the family not having a backup plan in place when the agency was not able to able to provide adequate staffing in the home. The DON stated from her understanding there were arrangements being made for another agency to assist with nursing coverage and family had also been trained to provide cares, however, there had not been follow up of where this plan was at the time. The DON stated staffing the patient home had been a challenge for the agency as there were other concerns brought up from the nurses assigned at P1's home with how family handled issues when nurses were providing care. The DON stated because of these issues, the nurses were communicating with each other and were declining to work at P1's home. The DON stated although the agency had the intention to have full coverage as this was what was in the service agreement and authorized by the State, "We are having issues with staffing. I don't have an answer we have gone through 30 to 40 nurses in the home and majority will not return." The DON stated the family had been offered to transfer P1 to one of the agency "group sites" as a possible solution but they had declined citing cultural concerns. The DON stated she was also waiting for the insurance care coordinator to return from vacation to coordinate on a solution to the staffing issue in the home. The DON stated she had not been directly working on this issue and directed the surveyor to speak with the director of staffing. During interview on 5/5/21, at 4:21 p.m. the director of staffing (DOS) stated the agency had full intention to cover all the shifts however they started to notice the nurses did not want to work in the home. The DOS stated the agency had found out from the nurses other concerns and the family behavior in the home which caused the staff not to want to work in the home. The DOS stated because of the nurses communicating to each other this had made it difficult for the agency to staff nurses in the home but the agency was working through other ways to staff the home despite the challenges. The DOS stated due to the staffing issues in the home, he had offered the family to have P1 move to a group site owned by the company to live for free to assist the staff to bond with the patient but family had cited cultural concerns. During interview on 5/5/21, at 5:00 p.m. the DON stated in the current physician ordered POC for the certification period 5/3/21, through 7/1/21, registered nurse (RN)-A had included in the POC that family had been trained as care givers to allow the patient to remain in the community due to staff shortage. The DON verified in the POC for 3/4/21, through 5/2/21, there was no indication the physician had been notified that agency was not able to provide nurses as directed for 24 hours per day. The DON stated the physician was supposed to be notified if services were not furnished as ordered and she verified the medical record lacked documentation of the physician being notified of the missed 42 visits from 3/1/21, through 5/5/21. During interview on 5/6/21, at 10:12 a.m. FM-A stated at the beginning the agency was able to provide the nurses but this had changed in the recent months. FM-A stated since the staffing issue started it had become more regular for family to care for P1 because there was no nurses being sent to the shared home with P1 and family. FM-A stated because the agency was not able to provide the nurses 24 hours a day as approved by the "government" family was the caregiver for 13 to 14 hours on some days for P1. FM-A stated they were trained by the agency on P1's care and because they did not have a choice they were obligated to care for P1 because they were family. FM-A stated the agency had not provided them a reason why there were issues with staffing but had told them they would do the best to cover the shifts. FM-A stated the agency had provided them with a schedule and they basically worked with what coverage the agency provided with them. FM-A stated there was both cultural and language barrier issues between the agency and the family and the family was in the process of getting another agency which would be a better fit to provide services. The agency Plan Of Care policy revised 6/25/20, directed professional staff to promptly alert the physician to any changes that suggest a need to alter the plan of care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to notify the physician timely for 1 of 2 patients (P2) who sustained a burn to the right shin reviewed for patient rights. Findings include: P2's plan of care (POC) for certification period of 3/31/21, through 5/29/21, included diagnoses of dependence on respirator [ventilator], encounter for attention to tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and amyotrophic lateral sclerosis (ALS). The POC indicated P1 required complex nursing RN/LPN (registered nurse/licensed practical nurse), up to 24 hours per day and personal care assistant (PCA) up to 300 hours per certification period. An incident report dated 4/27/21, at 3:37 p.m. indicated on 4/24/21, personal care attendant (PCA)-A had used the microwave to heat a warm pack for the feet which normally PCA-A knew should be heated up for only 2 minutes. P2 told registered nurse (RN)-B the warm pack was burning him right away after being applied and the pack was removed. RN-B indicated the skin in the right shin was noted to be pink and a small blister 1.0 centimeter (cm) by 3.0 cm developed later. RN-B applied a cold rag on the top of the right shin for 30 minutes and P2 requested RN-B to apply toothpaste afterwards. P2 had reported mild pain rated at 3 out of 10 and mild burning sensation as a result. Review of P2's medical record revealed from 4/24/21 through 4/26/21, the medical record indicated several nurses had cared for P2, however, the medical record lacked notification was made to the physician of the burn. During interview on 5/5/21, at 11:20 a.m. the director of nursing (DON) stated RN-B had failed to notify both the agency RN on-call about the incident and the physician. The DON stated RN-B had acknowledged she had reviewed the change of condition policy the previous week on 4/23/21, however she had not followed through with the policy to notify P2's physician after the burn incident. The DON also stated the warm rice pack which caused the burn was not in the POC and when they interviewed, RN-B she stated she had not reported it because she was not the one who caused the burn. The DON stated she informed RN-B she was the nurse assigned to P2 at the time of the incident and she was responsible for reporting the incident. During interview at 11:32 a.m. RN-C stated the physician was notified of the burn on 4/27/21, which was 3 days later and the physician gave orders to do a dressing to the burn and apply antibiotic ointment daily and also an order had been obtained for the use of heating packs. On 5/6/21, at 12:00 p.m. the DON stated the agency did not have a specific policy and procedure for first aid, however, would expect the nursing to follow the individual patient plan of care integumentary system plan of care with concerns about patient skin. The agency Plan Of Care policy revised 6/25/20, directed professional staff to promptly alert the physician to any changes that suggest a need to alter the plan of care.

On 4/20/21, 4/21/21, and 4/23/21, an abbreviated survey was conducted to investigate a complaint. The agency was found NOT to be in compliance with the requirements of 42 CFR Part 484, requirements for Home Health Agencies. The Condition of Participation: Patient Rights 42 CFR 484.50 at G406 and the Condition of Participation: Care Planning, Coordination of Services, and Quality of Care 42 CFR 484.60 at G570 were found not met. As a result a partially extended survey was conducted. H8136020C/MN00071859 was substantiated with additional standard deficiencies issued at G430, G574 and G590 An Immediate Jeopardy (IJ) began on 3/30/21, when staff turned on the space heater and placed it close to P1's hand which resulted in a burn which required hospitalization. The agency Administrator and Case Manager registered nurse (RN)-A were notified of the IJ on 4/21/20, at 2:20 p.m. The immediate jeopardy was removed on 4/23/21 at 1:00 p.m. after it could be verified the agency had implemented an acceptable removal plan. In addition, An Immediate Jeopardy began on 3/30/21, when staff did not notify the physician timely resulting in delayed treatment for P1 who required hospitalization in the burn unit for 9 days and was discharged home with wound care treatment. The agency Administrator and Case manager registered nurse (RN)-A were notified of the IJ on 4/21/20, at 2:20 p.m. The immediate jeopardy was removed on 4/23/21 at 1:00 p.m. after it could be verified the agency had implemented an acceptable removal plan.

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 observation, 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 patients (P1) was free from neglect and received prompt treatment related to a burn sustained due to the use of a space heater. Findings include: Refer to G-430: Based on observation, interview and document review, the home health agency (HHA) failed to ensure 1 of 4 patients (P1) was free from neglect of care when a staff placed a space heater close to P1's hand resulting in a burn and subsequent hospitalization. An Immediate Jeopardy was called for P1 due to lack of procedure, staff instruction or care planning on use of a space heater to prevent subsequent injury for P1. This had the potential to affect the additional 3 of 3 patients (P2, P3, P4) who were identified to use space heaters in the home and received services from the agency.

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 observation, interview and document review, the home health agency (HHA) failed to ensure 1 of 4 patients (P1) was free from neglect of care when staff placed a space heater close to P1's hand resulting in a burn and subsequent hospitalization to a burn unit. An Immediate Jeopardy was called for P1 due to lack of procedure, staff instruction or care planning on use of a space heater to prevent subsequent injury. This had the potential to affect an additional 3 of 3 patients (P2, P3, P4) who were identified to use space heaters in the home and received services from the agency. The immediate jeopardy (IJ) began on 3/30/21, when staff turned on the space heater and placed it close to P1's hand resulting in a burn which required hospitalization. The agency administrator and case manager registered nurse (RN)-A were notified of the IJ on 4/21/20, at 2:20 p.m. The immediate jeopardy was removed on 4/23/21, at 1:00 p.m. after it could be verified the agency had implemented an acceptable removal plan. Findings include: P1's plan of care (POC) for certification period of 4/13/21, through 6/11/21, included diagnoses of dependence on respirator [ventilator], acute respiratory failure, encounter for attention to tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and C-spine quadriplegia (paralysis of all 4 limbs). The POC indicated P1 required complex nursing RN/LPN (registered nurse/licensed practical nurse), up to 24 hours per day. P1's vulnerability assessment/prevention plan included on current POC, indicated patient was at high risk for abuse/neglect. The assessment indicated safety measures in place included up to 24-hour supervision by nurse/personal care assistant (PCA) staff with Provident HHC (home health care) and case management/on call RN with Provident HHC available to report actual or suspected abuse or neglect with agency 24 hours per day. POC also indicated all staff were trained as mandated reporters to report directly to Minnesota Adult Abuse Reporting Center (MAARC) or indirectly through the agency. An incident report dated 3/30/21, at 5:30 p.m. indicated patient was noted with multiple blisters on the client's left hand which were caused by a space heater. The index finger and the middle finger were all blistered with 3 medium size blisters on top of the left hand. The index finger was 5 centimeters (cm) by 2.1 cm and the middle finger was 6.2 cm by 2.2 cm. No notification was made to the physician. The incident report indicated RN-B was the case manager on-call and the incident had been reported to her on 3/30/21, at 7:15 p.m. by RN-A. In addition, the incident report indicated the actions taken following the incident was to monitor for signs and symptoms of infections, keep dry and clean. During interview on 4/20/21, at 9:52 a.m. family member (FM)-A stated the agency staff nurse had notified her of the incident. FM-A stated she was informed the blisters were caused by a space heater, but she was not told which staff had left it close to P1. FM-A stated due to P1's diagnosis of quadriplegia, P1 was not able to move her extremities, and she thought the hand may have slipped out of bed due to spasms and fell close to the space heater thus causing the burn. During interview on 4/20/21, at 10:14 a.m. RN-D stated she was informed P1 had sustained a burn on the left hand related to the use of the space heater. RN-D stated she had worked on 4/5/21 when the physician came to the home and had P1 sent the hospital for burn treatment. During interview and observation on 4/20/21, at 11:29 a.m. P1 stated she had been admitted to the hospital for 9 days for treatment due to the burn she had on her left hand. P1's left hand was observed lying by the edge of the bed on a red blanket and was wrapped in Kerlix and secured with paper tape. During the interview and observation, an approximately 12-inch-high black space heater was observed on the floor by the window about two feet from P1's bed. Also, right next to P1's bed was a black wooden stool which was approximately 15 inches tall. P1 stated at the time of the incident she had asked the staff to set the space heater on the stool after the staff turned it on. P1 stated she did not feel anything during and after when staff identified the burn on her left hand. P1 further stated she always used the space heater with the assistance of the staff as it was cold in her room. During interview on 4/20/21, at 11:50 a.m. RN-A stated she identified the blisters and notified RN-B who was the case manager and the on-call nurse that evening. RN-A stated prior to discovering the blisters she had been in P1's room with licensed practical nurse (LPN)-A who worked the day shift, to get report and do a spot check. At that time RN-A stated P1's room felt warm, and she unplugged the space heater off the wall. RN-A stated she returned to the room between 5:30 to 6:00 p.m. and when she uncovered P1 from the blankets, she discovered the blisters. RN-A stated all the patients in the home currently had space heaters and used then regularly because they were hot and cold due to having trach's. RN-A stated the space heaters were not supposed to be close and staff who had put the space heater on for P1 on 3/30/21, should have not brought it close because P1 had told her she did not feel anything. RN-A stated there was no training that had been offered to her following the incident, however, she was aware the space heater was not supposed to be placed next to the patients. During interview on 4/20/21, at 12:21 p.m. RN-C stated she had sent a text message to RN-B case manager on 4/2/21, asking if she was aware of P1's burn because the left hand did not look good. RN-C stated the left hand "was big, swollen and the blisters were fluid filled and [P1] said she did not feel any pain." RN-C stated RN-B had sent a message back thanking her for letting her know. RN-C stated she had reported the burn to RN-B because the agency policy was to report any concerns and she assumed by RN-B's response, the incident had been addressed. RN-C stated all the patients at the home had and used space heaters regularly. RN-C stated following the incident no training had been provided to them. RN-C stated she did not do or get any specific training for the use of space heaters and was just common sense not to set it close and to unplug it when not being used. RN-C stated P1 used the space heater all the time and staff turn it on for P1. RN-C stated P1 stated to her she did not feel burning and P1 would not have been capable of moving her hand from the heat due to her diagnosis of quadriplegia. During interview on 4/20/21, at 1:07 p.m. the physician care coordinator (PCC) stated P1's physician had concerns that the agency nurse had not notified the provider when the incident happened and subsequently there was a delay in treatment for 6 days. The PCC stated according to the report, the physician had received, the agency staff had placed the space heater in the room too close to P1's hand and since P1 was quadriplegic, and was not able to feel the heat, she was not able to remove her hand that resulted in the burn. The PCC stated there was a concern about the use of the space heaters and how long the staff left it on P1. The PCC stated following the incident the physician's office had contacted RN-B who told the physicians office that several staff had notified her and sent her pictures over the weekend as the nurses were concerned about the left hand, however, no one from the agency had contacted the physician. The PCC stated the physician had made a routine visit to the home on 4/5/21, and found out P1 had a burn on the left hand and had sent P1 to the hospital and P1 was admitted to the burn unit for 9 days. During interview on 4/20/21, at 1:58 p.m. RN-B stated according the P1's medical record, on 3/30/21, LPN-A had assisted P1 with a bath and afterwards staff had turned the space heater on for P1. RN-B stated after the burn to P1's left hand was identified, RN-A had called the on-call agency line and she (RN-B) was the on-call staff and she received a report about the burn. RN-B stated, "I told her to send a picture to ensure it was intact because if it was not open it was not a wound, and to notify the family and to fill an incident report." During interview on 4/21/21, at 8:38 a.m. RN-B stated after P1 was found with a burn caused by the space heater placed by staff, she had not completed re-training or communicated with LPN-A directly. RN-B stated she had re-trained RN-A on the use of space heaters and doing "eye on report" with the outgoing nurses at shift change. RN-B acknowledged she did not have any documentation of any training that had been completed for either RN-A or LPN-A. RN-B indicated the agency had not implemented re-training for all staff (licensed and un-licensed), patients and family on the use of space heaters following the incident. RN-B stated the training was going to be completed moving forward since it was a problem surveyor had a concern with. On 4/21/21, at 9:11 a.m. the director of nursing (DON) stated the agency did not have a policy on space heater use. The closest policy they had was the Safety Management Program and she did not see anything addressing the use of space heaters. The DON stated this was an area the agency needed to develop. The DON stated there was an oversight in staff education for the proper use of space heaters following the incident. During interview on 4/21/21, at 10:59 a.m. LPN-A stated she was assigned to P1 on 3/30/21, when the burn was identified by RN-A after she left the home for her shift. LPN-A stated there was nothing out of the ordinary that day with using the space heater as P1 always requested staff to turn on the space heater due to being cold. LPN-A stated the one thing she had not done at the end of the shift on 3/30/21, was she did not uncover P1 to check the skin. LPN-A stated she was not certain if she was the one who had turned the space heater on for P1 or if it was the PCA who assisted with P1's cares that shift. LPN-A stated there was no training that had been provided to her or other staff on the use of space heaters including how close the staff could place it to the patient. LPN-A stated, "Nobody called me after the incident. I have not gotten any training after the incident either." LPN-A stated all the other patients in the home also used space heaters and any of the staff was able to turn on the space heater for them per the patient request. During interview on 4/21/21, at 10:47 a.m. LPN-B stated she worked on 3/30/21, through 3/31/21, the shift after the burn to P1's left hand was identified by RN-A. LPN-B stated during the night shift the patients in the home asked the staff to turn on the space heaters for them including P1. LPN-A stated when P1 requested the space heater, she would set the space heater on top of the stool in the room far from the bed by the window. LPN-B stated she had not received any training on the use of space heaters before or after the incident with P1. LPN-B stated she thought because the incident had not happened when she was working that was the reason she had not been contacted. During review of the medical records of the other patients who resided in the same home with P1, and used space heaters, the following was revealed: P2's POC for certification period 4/6/21, through 6/4/21 included diagnoses of type 2 diabetes, chronic respiratory failure and encounter for attention to tracheostomy. The POC indicated P2 required complex nursing RN/LPN up to 12 hours per day, personal care aide (PCA) up to 12 hours per day and respiratory therapist twice per day. The POC failed to identify the use of the space heaters. P3's POC for certification period 2/26/21, through 4/26/21 included diagnoses of quadriplegia and acute and chronic respiratory failure. The POC indicated P3 required RN/LPN up to 24 hours per day, PCA services provided by secondary agency and respiratory therapist twice per day. The POC failed to identify the use of the space heaters. P4's POC for certification period 3/3/21, through 5/1/21 included diagnoses of muscular dystrophy (a disease that damages and weakens muscles over time), respiratory failure and encounter for attention to tracheostomy. P4 required complex nursing RN/LPN up to 24 hours per day, PCA up to 4 hours per day flexible use and a respiratory therapist twice per day. The POC failed to identify the use of the space heaters. During an interview on 4/22/21, at 10:24 a.m. with the agency administrator, the DON and RN-B, the administrator stated after the concern was brought to their attention about the use of the space heaters, an agency wide audit had been completed for all the patients who received services. The administrator stated there was an additional 14 patients who were identified to have and used space heaters with the assistance of agency staff. The DON stated all the space heaters for the six patients who resided in the group sites had been removed. Also the DON stated for patients in private homes the use of space heaters was on hold until the agency obtained physician signed orders and training on the new policy on space heaters both had to be completed before the use of space heaters would be reinstated for patients to use with staff assistance. The immediate jeopardy was removed on 4/23/21, at 1:00 p.m. after it was verified the agency had physically removed all space heaters until space heaters could be evaluated for safety and staff/patients were educated on proper space heater use. The agency completed a formal re-training on space heater use and neglect of patient with LPN-A and for both RN-A and RN-B re-training was provided on notifying the supervising RN and the physician of an injury immediately respectively. The agency surveyed all patients in the group locations for space heater use and removed them. The agency posted a bulletin on the patient RTask profile to alert staff all space heater use was suspended until further notice and this popped up on all screens as staff completed charting for patient's identified with space heaters. In addition, physician orders for all the patients who used space heaters were initiated through Bridge physician portal and the policy and training module for Environmental Safety: Space Heaters was pushed out for staff to review at the start of their shift starting 4/22/21.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview and document review, the home health agency (HHA) failed to meet the Condition of Participation at 484.60, Care Planning, Coordination of Services, and Quality of Care. The HHA failed to notify the physician timely resulting delayed treatment for 1 of 3 patients (P1) who sustained a burn to the left hand after staff turned a space heater on and placed close to P1. Findings include: Refer to G-590: Based on observation, interview and document review, the home health agency (HHA) failed to notify the physician timely, resulting in delayed treatment for 1 of 3 patients (P1) who sustained a burn to the left hand and was admitted to the hospital burn unit for treatment. An immediate jeopardy was identified for P1, as the agency had failed to ensure action was implemented for nurses related to prompt notification of change of condition to ensure delay of treatment did not reoccur. Refer to G-574: Based on observation, interview and document review, the agency failed to ensure 4 of 4 patients (P1, P2, P3, P4) whose physician order, plan of care (POC) were reviewed, included the use of space heaters for patients. This had the potential to affect an additional 14, (18 total) patients who were identified as patients who used and required staff assistance with use of the space heater and did not have this information included on their POC.

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 observation, interview and document review, the agency failed to ensure 4 of 4 patients (P1, P2, P3, P4) whose physician order, plan of care (POC) were reviewed, included the use of space heaters for patients. This had the potential to affect an additional 14, (18 total) patients who were identified as patients who used and required staff assistance with use of the space heater and did not have this information included on their POC. Findings include: P1's POC for certification period of 4/13/21, through 6/11/21, included diagnoses of dependence on respirator [ventilator], acute respiratory failure, encounter for attention to tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and C-spine quadriplegia. The POC indicated P1 required complex nursing RN/LPN (registered nurse/licensed practical nurse), up to 24 hours per day. The POC failed to identify the use of the space heaters which staff assisted P1 with regularly. An Incident report dated 3/30/21, at 5:30 p.m. indicated P1 was noted with multiple blisters on the left hand which were caused by a space heater. The index finger and the middle finger were all blistered with 3 medium size blisters on top of the left hand. The index finger was 5 centimeters (cm) by 2.1 cm and the middle finger was 6.2 cm by 2.2 cm. During a home visit on 4/20/21, at 11:29 a.m. a black approximately 12-inch-high space heater was observed on the floor by the window about two feet from P1's bed. Also, right next to P1's bed was a black wooden stool which was approximately 15 inches tall. P1 stated at the time of the incident she had asked the staff to set the space heater on the stool after the staff turned it on. P1 stated she did not feel anything during and after when staff identified the burn in her left hand. P1 further stated she always used the space heater with the assistance of the staff as it was cold in her room. On 4/20/21, at 11:50 a.m. registered nurse (RN)-A stated prior to discovering the blisters she had been in P1's room with licensed practical nurse (LPN)-A who worked the day shift, to get report and do a spot check. RN-A stated at that time P1's room felt warm, and she unplugged the space heater off the wall. RN-A stated she returned to the room between 5:30 to 6:00 p.m. and when she uncovered P1 from blankets and discovered the blisters. In addition, RN-A stated all the patients in the home currently had space heaters and used then regularly because they were hot and cold due to having trachs. P2's POC for certification period 4/6/21, through 6/4/21 included diagnoses of type 2 diabetes, chronic respiratory failure and encounter for attention to tracheostomy. The POC indicated P2 required complex nursing RN/LPN up to 12 hours per day, personal care aide (PCA) up to 12 hours per day and respiratory therapist twice per day. The POC failed to identify the use of the space heaters which staff assisted P2 with. P3's POC for certification period 2/26/21, through 4/26/21 included diagnoses of quadriplegia and acute and chronic respiratory failure obtained from the POC for certification period 2/26/21, through 4/26/21. The POC indicated P3 required RN/LPN up to 24 hours per day, PCA services provided by secondary agency and respiratory therapist twice per day. The POC failed to identify the use of the space heaters which staff assisted P3 with. P4's POC for certification period 3/3/21, through 5/1/21 included diagnoses of muscular dystrophy (a disease that damages and weakens muscles over time), respiratory failure and encounter for attention to tracheostomy. P4 required complex nursing RN/LPN up to 24 hours per day, PCA up to 4 hours per day flexible use and a respiratory therapist twice per day. The POC failed to identify the use of the space heaters which staff assisted P4 with. During interview on 4/20/21, at 12:21 p.m. RN-C stated all the patients at the home which included P1, P2, P3 and P4 used space heaters regularly with staff assistance. During an interview on 4/22/21, at 10:24 a.m. with the agency administrator, the DON and RN-B, the administrator stated after the concern was brought to their attention about the use of the space heaters, an agency wide audit had been completed for all the patients who received services. The administrator stated there was an additional 14 patients who were identified to have and used space heaters with the assistance of agency staff. The DON stated all the space heaters for the six patients who resided in the group sites had been removed. Also the DON stated for patients in private homes the use of space heaters was on hold until the agency obtained physician signed orders and training on the new policy on space heaters both had to be completed before the use of space heaters would be reinstated for patients to use with staff assistance. During interview on 4/21/21, at 9:11 a.m. the director of nursing (DON) acknowledged the use of space heaters for patient use with staff assistance was not included in the patients POC. The agency Plan Of Care policy revised 6/25/20, indicated the plan of care was to include any safety measures to protect against injury, other appropriate items, instructions to the client/caregiver as applicable and the POC was supposed to be signed by the physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the home health agency (HHA) failed to notify the physician timely resulting in delayed treatment for 1 of 3 patients (P1) who sustained a burn to the left hand and was admitted to the hospital burn unit for treatment. An immediate jeopardy was identified for P1, as the agency had failed to ensure action was implemented for nurses related to prompt notification of change of condition to ensure delay of treatment did not reoccur. The immediate jeopardy began on 3/30/21, when staff did not notify the physician timely resulting in delayed treatment for P1 who required hospitalization in the burn unit for 9 days and was discharged home with wound care treatment. The agency administrator and case manager registered nurse (RN)-A were notified of the IJ on 4/21/20, at 2:20 p.m. The immediate jeopardy was removed on 4/23/21 at 1:00 p.m. after it could be verified the agency had implemented an acceptable removal plan. Findings include: P1's plan of care (POC) for certification period of 4/13/21, through 6/11/21, included diagnoses of dependence on respirator [ventilator], acute respiratory failure and encounter for attention to tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and C-spine quadriplegia (paralysis of all 4 limbs). The POC indicated P1 required complex nursing RN/LPN (registered nurse/licensed practical nurse), up to 24 hours per day. An incident report dated 3/30/21, at 5:30 p.m. indicated patient was noted with multiple blisters on the client left hand which were caused by a space heater. The index finger and the middle finger were all blistered with 3 medium size blisters on top of the left hand. The index finger was 5 centimeters (cm) by 2.1 cm and the middle finger was 6.2 cm by 2.2 cm. The incident report indicated RN-B was the case management on-call staff and the incident had been reported to her on 3/30/21, at 7:15 p.m. by RN-A. The incident report indicated the actions taken following the incident was to monitor for signs and symptoms of infections, keep dry and clean and no notification was made to the physician. During interview on 4/20/21, at 9:52 a.m. family member (FM)-A stated she did not know the agency staff had not notified the provider and she was present on 4/5/21 when the physician came to do a routine visit and recommended P1 to be sent to the hospital for treatment. During interview on 4/20/21, at 10:14 a.m. RN-D stated she was informed that P1 had sustained a burn on the left hand related to the use of the space heater. RN-D stated she had worked on 4/5/21 when the physician sent P1 to the hospital for burn treatment. RN-D stated the agency policy was the nurses were to update the house case manager and the on-call case manager at the agency and either one was responsible to notify the physician, or whoever answered the on-call would direct the nurses on what needed to happen. During interview and observation on 4/20/21, at 11:29 a.m. P1 stated she had been admitted to the hospital for 9 days for treatment due to the burn she had on her left hand. P1's left hand was observed lying by the edge of the bed on a red blanket and was wrapped in Kerlix and secured with paper tape. P1 stated she did not feel anything during and after when staff identified the burn on her left hand. During interview on 4/20/21, at 11:50 a.m. RN-A stated she identified the blisters and notified RN-B who was the case manager and was also the on-call nurse that evening. RN-A stated prior to discovering the blisters she had been in the room with licensed practical nurse (LPN)-A who worked the day shift, to get report and do P1's spot check. RN-A stated at that time, P1's room felt warm, and she unplugged the space heater off the wall. RN-A stated she returned to the room between 5:30 to 6:00 p.m. and when she uncovered P1 from the blankets, she discovered the blisters. RN-A stated when she notified RN-B on the incident she assumed RN-B was going to notify the physician of the burn because she had sent a picture of it to RN-B. During interview on 4/20/21, at 12:21 p.m. RN-C stated she had sent a text message to RN-B case manager on 4/2/21, asking RN-B if she was aware of P1's burn because the left hand did not look good. RN-C stated the left hand "was big, swollen and the blisters were fluid filled and [P1] said she did not feel any pain." RN-C stated RN-B had sent a message back thanking her for letting her know. RN-C stated she had reported the burn to RN-B because the agency policy was to report any concerns and she assumed by RN-B response, the physician had been notified. RN-C stated all staff were supposed to call the agency on-call manager to inform them of situations or incidents and then the case managers notified the physician. During interview on 4/20/21, at 1:07 p.m. the physician care coordinator (PCC) stated P1's physician had concerns with not being notified about P1's burn promptly which led to P1 being hospitalized in the burn unit for 9 days. The PCC stated P1's physician was concerned no agency nurse had notified the provider when the incident happened and subsequently there was a delay in treatment for 6 days. The PCC stated following the incident the physician's office had contacted RN-B who indicated that several staff had notified her and sent her pictures over the weekend as the nurses were concerned about the left hand burn however, the physician was not contacted. The PCC stated P1 was currently receiving wound treatment with antibiotic ointment. The PCC stated the agency had a communication portal which was used to communicate with the physician however, this was not used for P1's burn incident. The PCC stated there was a concern there was limited access for who used the portal to communicate with the network of physician's who followed several patients in the agency and this had been brought up to RN-B's attention. The PCC stated if there were more nurses who had access to the portal the notification of change issue for P1 could have been prevented. During interview on 4/20/21, at 1:58 p.m. RN-B stated after the burn to P1's left hand was identified, RN-A had called the on-call agency line and she was the on-call staff and she got report about the burn. RN-B stated, "I told her to send a picture to ensure it was intact because if it was not open it was not a wound, to notify the family and to fill an incident report." RN-B stated, "I also instructed to keep the burn clean, dry, to monitor for infections and to let us know if it changed from the current status." RN-B stated the physician was supposed to be notified anytime a patient care plan was off base. RN-B stated she had received picture text messages on 3/30/21, 4/4/21 and 4/5/21 of the burn and to her the burn only looked different from 4/4/21, to 4/5/21 and that was the reason she asked the nurse at the home to have the physician evaluate P1 on 4/5/21 during routine rounds. RN-B stated she did not notify the physician on the burn because it was not open and was not showing any signs and symptoms of infections. RN-B stated depending on the situation during business hours she was P1's case manager to notify the physician and after hours for on-call cases it was different for each patient depending on the physician network system. RN-B acknowledged she was the on-call on 3/30/21, when the incident happened, and she was responsible for notifying the physician. RN-B stated she had Health Insurance Portability and Accountability (HIPPA) concerns with the other staff nurses getting access to the Bridge portal to update the physicians however, the case managers and the director of nursing (DON) all had access. During interview on 4/21/21, at 8:38 a.m. RN-B indicated the agency had not implemented any training on prompt notification of change of condition to prevent delay of treatment for other patients. RN-B stated the training was going to happen because the surveyor had concerns. On 4/21/21, at 9:11 a.m. the director of nursing (DON) stated staff education for the notification of change to the physician did not occur, and this was an over-site. During interview on 4/21/21, at 10:47 a.m. LPN-B stated she worked on 3/30/21, through 3/31/21, the shift after the burn to P1's left hand was identified by RN-A. LPN-B stated when she received end of shift report from RN-A, she was informed by RN-A she had notified the right people that she was supposed to notify. LPN-B stated the nurses were supposed to call the on-call supervisor and to notify them of what was going on and the on-call would give the nurse instructions what needed to be done ,"The first line of communication is the agency on-call." The agency Plan Of Care policy revised 6/25/20, directed professional staff to promptly alert the physician to any changes that suggest a need to alter the plan of care. The agency undated Safety Management Program policy directed staff if an accident involved a client, appropriate actions were to be initiated and the physician was to be notified to obtain specific follow up orders. The immediate jeopardy was removed on 4/23/21, at 1:00 p.m. after it was verified the agency had completed formal re-training for both RN-A and RN-B on notifying the supervising RN and the physician of an injury immediately respectively. In addition, the policy and training module for Coordination of Client Services about notification of change to physician was pushed out for staff to review at the start of their shift starting 4/22/21.

An abbreviated survey was conducted at your agency on 3/16/2021. Provident Home Healthcare was found NOT to be in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. The following complaint was found to be SUBSTANTIATED: H81326019C/MN00070816 with deficiencies issued at G488 and G710. In addition, the Condition of Participation: Skilled Professional Services §484.75 at G700, was found NOT met. As a result an extended survey was completed. The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. Federal Law as specified in 42 CFR 484.80 (f)(3), prohibits any home health agency to offer and/or conduct home health aide training and/or competency testing which, within the previous two years has been subjected to an extended or partially extended survey as a result of having been found to have furnished substandard care.

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 home health agency (HHA) failed to immediately report an incident of a medication error for 1 of 3 patients (P1) to the State Agency (SA) and designated agency personnel reviewed for medication errors. Findings include: P1's plan of care (POC) for the certification period of 2/20/21 to 4/20/21, included P1's diagnoses of chronic respiratory failure and cerebral palsy. The POC indicated P1 required medications be delivered via G-tube (a tube inserted through the wall of the abdomen directly into the stomach) unless otherwise specified by a physician. P1's functional limitations included bowel and bladder incontinence, endurance, ambulation, dyspnea (shortness of breath), and had contracture (a permanent shortening, as of muscle, tendon, or scar tissue, producing deformity or distortion). P1's vulnerability assessment indicated safety measures in place included up to 24 hour supervision by nurse staff along with family in home for supervision and cares. The assessment further indicated all staff were trained to monitor and report any signs of abuse and neglect. P1's facility reported event dated 3/9/21, indicated licensed practical nurse (LPN)-A arrived for her shift on 3/6/21 at 7:00 p.m. and gave P1 medication that were supposed to be administered the morning of 3/7/21, after family member (FM)-A had told LPN-A that P1 did not need any medications for the evening. The following medications were given incorrectly; Baclofen (muscle spasm) 10 mg (milligrams), Banzel (to prevent seizures) 400 mg (10 ml) (milliliters), Bromocriptine (treat high levels of prolactin in the body) 2.5 mg, Ciprofloxacin (antibiotic) 375 mg, Cyproheptadine (allergies) 2 mg, Felbamate (prevent seizures) 540 mg, Keppra (treat seizures) 400 mg, Onfi (treat seizures) 3 ml, Prevacid (treat gastroesophageal reflux disease) 15 mg, and Robinul (treat stomach ulcers) 1.5 mg. During an interview on 3/16/21, at 9:15 a.m. registered nurse (RN)-A indicated on March 6th licensed practical nurse (LPN)-A was told by family member (FM)-A P1 already had his evening medications and P1's morning medications were setup on the counter for FM-A to administer in the morning. RN-A indicated medication error made by LPN-A was not reported by RN-A because she was not the one that made the error and that she felt guilty and should had reported immediately to the on-call nurse. During an interview on 3/16/21, at 9:49 a.m. the assistant director of nursing (ADON) indicated she became aware of the medication error when FM-A called on March 8th. The ADON indicated she was the on-call nurse for the previous weekend and had not received a call about the medication error. The ADON further indicated FM-A had informed her that she had drained P1's stomach contents the evening of March 6th, through P1's G-tube after FM-A was aware that P1 received the medications. The ADON indicated the incident should had been reported right away, especially because of the effects P1 had from the incident. The ADON explained P1 had hypoxia (not having adequate oxygen supply), tachycardia (rapid heartbeat), bloating of the stomach, and increased seizure activity as result of the medication error. During an interview on 3/16/21, at 10:03 a.m. the Director of Nursing (DON) indicated a medication error should be reported immediately and that there is 24 hour RN availability. During an interview on 3/16/21, at 12:30 p.m. LPN-A indicated she arrived at 7:00 p.m. on March 6th, and was helping with another patient. LPN-A further indicated it was about 7:30 p.m. when she went to care for P1 and gave the medication to P1. LPN-A indicated after P1 was given the medications RN-A came and told her that P1 already had his medications. LPN-A then indicated she told FM-A about the medications error. LPN-A indicated she had not reported the incident to anyone because she had never made a medication error before. Review of the Employee Retraining/Warning form dated 3/16/21, indicated that LPN-A failed to document the medication error in an incident report and failed to report to the case manager or on-call nurse at the time of the incident. The agency's undated Provision for 24 hour RN Availability policy directed a registered nurse shall be accessible at all times, 24 hours per day, by telephone and/or pager to meet client needs. The policy further directed all calls are documented on an activity log. The agency's undated Medication Administration Error policy directed all medication errors will be documented on an Incident Report or Medication Error Report form. The policy further directed a complete narrative description is documented by the responsible staff member and reviewed by the supervisor.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. 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 484.75, Skilled Professional Services. The agency failed to ensure medication administration was performed correctly for 1 of 3 patients (P1) who received medications at the wrong time resulting in significant adverse reaction. Findings include: Refer to G710: Based on interview and document review, the home health agency (HHA) failed to ensure medication administration was performed correctly for 1 of 3 patients (P1) when a licensed practical nurse (LPN) administered medications preset up by family, approximately 12 hours prior to scheduled dose time, resulting in significant adverse reaction for P1.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to ensure medication administration was performed correctly for 1 of 3 patients (P1) when a licensed practical nurse (LPN) administered medications preset up by family, approximately 12 hours prior to scheduled dose time, resulting in significant adverse reaction for P1. Findings include: P1's plan of care (POC) for the certification period of 2/20/21 to 4/20/21, included P1's diagnoses of chronic respiratory failure and cerebral palsy. The POC indicated P1 required medications be delivered via G-tube (a tube inserted through the wall of the abdomen directly into the stomach) unless otherwise specified by a physician. P1's vulnerability assessment indicated safety measures in place included up to 24 hour supervision by nurse staff along with family in home for supervision and cares. P1's facility reported event dated 3/9/21, indicated licensed practical nurse (LPN)-A arrived for her shift on 3/6/21 at 7:00 p.m. and gave P1 medication that were supposed to be administered the morning of 3/7/21, after family member (FM)-A had told LPN-A that P1 did not need any medications for the evening. The following medications were given incorrectly; Baclofen (muscle spasm) 10 mg (milligrams), Banzel (to prevent seizures) 400 mg (10 ml) (milliliters), Bromocriptine (treat high levels of prolactin in the body) 2.5 mg, Ciprofloxacin (antibiotic) 375 mg, Cyproheptadine (allergies) 2 mg, Felbamate (prevent seizures) 540 mg, Keppra (treat seizures) 400 mg, Onfi (treat seizures) 3 ml, Prevacid (treat gastroesophageal reflux disease) 15 mg, and Robinul (treat stomach ulcers) 1.5 mg. During an interview on 3/16/21, at 9:15 a.m. registered nurse (RN)-A indicated on March 6th LPN-A was told by FM-A P1 already had his evening medications and P1's morning medications were setup on the counter for FM-A to administer in the morning. RN-A indicated when she punched out for her shift, "I looked and [P1's] morning meds were gone. I asked [LPN-A] if she gave [P1] more medications [meds] and LPN-A said of course." RN-A further stated she told LPN-A P1 already had received medications by FM-A, and that FM-A needed to be told of this error. RN-A indicated medication error made by LPN-A was not reported by RN-A to the on-call nurse because she was not the one that made the error. RN-A indicated a physician was notified the evening of the medication error, an appointment was made for P1 on 3/10/21, and that staff were directed to monitor vital signs every 2 hours for the next 24 hours. During an interview on 3/16/21, at 9:49 a.m. assistant director of nursing (ADON) indicated LPN-A arrived to work Saturday evening of March 6th and received report from FM-A that all medications, cares and treatments were completed for P1. The ADON further indicated FM-A was going to cover cares Sunday March 7th, and had setup P1's morning medications the evening of March 6th. The ADON further explained LPN-A had seen the medications on the counter and gave them to P1. The ADON indicated she became aware of the medication error when FM-A called on March 8th. The ADON indicated she was the on-call nurse for the weekend and had not received a call about the medication error. The ADON further indicated FM-A drained P1's stomach contents the evening of March 6th, through P1's G-tube after FM-A was told about P1 receiving the medications. The ADON indicated the incident should had been reported right away, especially because of the effects P1 had from the incident. The ADON explained following the medication error, P1 had hypoxia (not having adequate oxygen supply), tachycardia (rapid heartbeat), bloating of the stomach, and increased seizure activity. During an interview on 3/16/21, at 10:03 a.m. the Director of Nursing (DON) indicated medication errors should be reported immediately. The DON further indicated nurses should not give medications without ensuring they know what medications they are giving. The DON further indicated LPN-A was removed from the schedule as soon as she was informed of the medication error, until they could make contact with her for follow up education and discipline. The DON indicated LPN-A was scheduled to come in that day and this was the first opportunity they had to meet with her due to her school schedule. During an interview on 3/16/21, at 12:30 p.m. LPN-A indicated she arrived at 7:00 p.m. on March 6th, and was helping with another patient. LPN-A further indicated it was about 7:30 p.m. when she went to care for P1 and gave the medication to P1 that were setup on the counter without checking the medications. LPN-A indicated that she knew she should not have given medications without checking them first. LPN-A indicated after P1 was given the medications RN-A came and told her that P1 already had his medications. LPN-A then indicated she told FM-A about the medications error. LPN-A indicated she had not reported the incident to anyone because she had never made a medication error before. Three attempts to contact FM-A on 3/16/21, by phone were made to obtain an interview, no return call was received. During an interview on 3/16/21, at 1:03 p.m. RN-A indicated that they setup their own medications even if someone presets up medications. RN-A further indicated that even if the medications were preset up she would check the medications prior to giving them. During an interview on 3/16/21, at 1:06 p.m. RN-B indicated medications should be setup and administered by the nurse working and preset up medications should not be given. During an interview on 3/16/21, at 1:08 p.m. LPN-B indicated she would not give medications that had been preset up. LPN-B further indicated she set up her own medications because medications preset up would not be able to be verified. LPN-B then indicated that P1's FM-A would not setup the medications if there was a nurse working that day. During an interview on 3/16/21, at 1:11 p.m. RN-C indicated that she set up her own medications because she would want to know what medications are being given. Review of the Employee Retraining/Warning form dated 3/16/21, indicated that LPN-A failed to document the medication error in an incident report and failed to report to the case manager or on-call nurse at the time of the incident. Furthermore a separate Employee Retraining/Warning form dated 3/16/21, indicated LPN-A was retrained on the five rights and three checks of medication administration. The agency's undated Medication Administration Error policy indicated all medication errors will be documented on an incident report or medication error report form. The policy further indicated that a medication error shall be defined as, but is not limited to: a. Wrong Medication b. Wrong dose c. Extra Dose d. Wrong time e. Wrong route f. Omission of ordered drug In addition the policy directed all medication errors will be documented on an Incident Report or Medication Error Report form.