Every finding on record at Recover Health of Minnesota, Inc.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 10/17/22 through 10/20/22, during a recertification survey. The facility was found to be in compliance with the Appendix Z Emergency Preparedness Requirements.

On 10/17/22 through 10/20/22 , a partially extended survey was conducted at your agency. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census: 418 Total home visits conducted: 04 No Branch offices. Hours of Operation: 8:00 a.m. to 4:30 p.m. Total number of records reviewed: 10

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 record review, the agency failed to ensure the patient was consulted and consented to changes in services and care and document in the patient's clinical record whether the patient was informed of and agreed to a change in services for 1 of 10 patients (P8) reviewed for patient participation in care. P8's plan of care (POC) for certification period 8/3/22 to 10/1/22, indicated a start of care date of 6/4/22. Diagnoses included paraplegia, neuromuscular dysfunction bladder and multiple sclerosis. Orders included skilled nurse visits (SNV) one visit per week for eight weeks for various assessments, education, perform monthly catheter changes and medication management. P8 was identified to have a high risk for falls and for hospitalizations. Skilled nurse visits were needed due to P8 continued to have problems with mobility, required catheter change monthly, intermittent assistance with her medications and observation for changes in condition, with changes reported to P8's physician for possible alteration in her treatment plan or additional procedures to stabilize her condition. No discharge plan was anticipated. Review of P8's clinical record indicated a SNV was completed 8/2/22, for recertification and a comprehensive assessment was completed. Documentation indicated P8 continued to need skilled nursing services for medication management and assessment to ensure her safety and monitoring of her co-morbidities to decrease her risk of hospitalization. P8 was noted to continue to have falls in her home and had fallen the day prior. P8's goal was to be able to care for herself and be free from falls and it was noted goals continued to be in progress. The visit note indicated no changes with P8's POC. A verbal order was documented on 8/7/22, which indicated P8 would no longer receive SNV weekly and would be seen monthly instead to perform catheter changes and care. Two as needed visits could be performed if P8's catheter were to become dislodged. The medical record lacked documentation to indicate whether P8 had been informed or agreed to the decrease in her skilled nursing visits. During interview on 10/20/22, at 9:25 a.m. the area vice president (VP) stated there should have been some kind of reference in the skilled nurse visit note regarding decrease visits. She would have expected to see a discussion with the patient regarding changes in services to have been documented in the recertification visit note that had been performed on 8/2/22. The agency's policy Coordination of Client Services dated 2/5/18, indicated the clinical manager would ensure each patient received ongoing education and training regarding the care, training, and education objectives based on the comprehensive assessment, patient centered POC and goals identified. Patient responses and comprehension of the training would be monitored and documented.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to discharge 1 of 3 patients (P10) for appropriate cause, when a patient was discharged from the agency without notice or assistance in identifying other entities in the area that may be able to meet the patient's needs. P10's plan of care (POC) for certification period 4/22/22 to 6/20/22, identified at start of care (SOC) date of 12/23/21. Diagnoses included diabetes, chronic obstructive pulmonary disease, chronic respiratory failure, heart disease, epilepsy, bipolar disorder, adjustment disorder, borderline personality disorder, fibromyalgia, agoraphobia with panic disorder, post traumatic stress disorder, and chronic pain. The POC identified skilled nurse visits (SNV) were ordered one time per week to prefill P10's medication planner. P10 was unable to prefill her own due to the amount of medication she took and anxiety with trying to set up her own medications. Nurse visits were also ordered for various assessments, patient education and monitoring and identified the need for continued services to monitor P10's pain, mental health, respiratory status, diabetic education and monitoring, and education for safety. P10 was identified as a moderate to high risk for hospitalizations. Goals included P10 to administer medications per her medication planner, management of diabetes and respiratory exacerbations, manage pain and to remain safe in her home. No discharge plans were anticipated and the agency would coordinate a discharge with P10 and P10's provider if her needs required a higher level than home care services could provide. Review of P10's medical record 5/5/22 through 6/2/22, identified the following: SNV note dated 5/26/22, registered nurse (RN)-A setup P10's medications in her prefill planner device four times per day for seven days and performed various assessments and observations. The visit note identified no changes were made to P10's POC with frequency or duration of visits, medications or treatments. P10 reported pain in her legs and RN-A identified P10 was taking more ibuprofen and Tylenol as a result. RN-A noted P10 was administering her medications properly as a result of the nurse prefilled planner device. Care coordination was identified as not applicable and anticipated discharge or discharge planning was not identified. SNV dated 6/2/22, identified the purpose of the visit was to discharge P10 from the agency. No significant medication issues were identified and P10 was identified as compliant with all medication administration. The visit note indicated there were no potential significant medication issues identified since P10's SOC and P10 continued to require medication setup by another person. On discharge P10 remained in the community without formal services. Discharge teaching was identified as symptoms to report to her physician and no care coordination was initiated. Non agency caregivers, such as a family member, was identified as currently providing assistance with P9's medications. P9's Discharge Summary Report dated 6/2/22, identified the reason for discharge was P10 no longer required skilled nursing care and was independent in her home. During telephone interview on 10/20/22, at 1:45 p.m. RN-A stated a family member had moved in with P10 and had been known to take P10's medications. The last couple of SNV had identified missing medications and RN-A had notified P10's physician a couple of times regarding the missing medications. RN-A reported during her last visit prior to discharging P9, P9's personal care attendant had set up her medications and that was not allowed, and she was short on her medications again and had to go without. P10's family member had reported P9 had been taking more of the medications on an as needed basis and it was not ordered that way. RN-A indicated she had discussed the case with the clinical manager and it was decided to discharge P9 due to the missing medications and suspicion of med diversion by the family member. P10 was aware there were other resources available, however she had not provided resources or a 10 day notice prior to this discharge. RN-A indicated she thought the family member would take over the medication setup after P10's discharge. An interview with P10 was attempted, however, was unable to reach P10 via telephone. When interviewed on 10/20/22, at 1:30 p.m. the clinical manager indicated P10 was discharged due to non compliance with her medications. P10's primary physician had been notified regarding the suspected diversion of P10's medications by a family member and attempts had been made to limit the family members access to the medications by using a locked pill dispenser to dispense the medications automatically at the times they were due and a locked box to keep her medication bottles in, however, medications continued to be missing when the nurse visited to set them. P10 had not been given a 10 day notice prior to her discharge or a list of alternative agencies or resources to assist her with her medication setup. The agency's policy Transfer, Discharge and Oasis dated 12/2/19, indicated the agency would be required to provide the patient with contact information for other agencies or providers who would be potentially able to provide care following discharge. If the agency terminated a service plan with a patient and the patient continued to need home care services the agency would provide a written notice of termination which included the effective date of termination, the reason for termination, a list of known licensed home care providers in the client's geographic area and a statement the agency would participate in a coordinated transfer of care of the client to another provider. The patient had a right to at least ten days' advance notice of the termination of a service by the provider.

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 ensure unplanned discharge without alternative services and incidents of suspected misappropriation of property was reported immediately to the State Agency (SA) for one of ten patients (P10) reviewed for patient rights. P10's plan of care (POC) for certification period 4/22/22 to 6/20/22, identified at start of care (SOC) date of 12/23/21. Diagnoses included diabetes, chronic obstructive pulmonary disease, chronic respiratory failure, heart disease, epilepsy, bipolar disorder, adjustment disorder, borderline personality disorder, fibromyalgia, agoraphobia with panic disorder, post traumatic stress disorder, and chronic pain. The POC identified skilled nurse visits (SNV) were ordered one visit per week to prefill P10's medication planner. P10 was unable to prefill her own due to the amount of medication she took and anxiety with trying to set up her own medications. Nurse visits were also ordered for various assessments, patient education and monitoring and identified the need for continued services to monitor P10's pain, mental health, respiratory status, diabetic education and monitoring, and education for safety. P10 was identified as a moderate to high risk for hospitalizations. Goals included for P10 to administer medications per her medication planner, management of diabetes and respiratory exacerbations, manage pain and to remain safe in her home. No discharge plans were anticipated and the agency would coordinate a discharge with P10 and P10's provider if her needs required a higher level than home care services could provide. Review of P10's medical record 5/5/22 through 6/2/22, identified the following: Client Coordination Note Report (CCN) dated 5/12/22, indicated a call was made to P10's provider regarding missing medications and indicated P10 would not have enough medications to setup for the month. Provider was asked if wanted to discontinue the missing medication and prescribe something else that would less likely be abused. CCN dated 5/19/22, indicated P10 reported her medications had been set up by her personal care attendant (PCA). P10 was warned the PCA was not allowed to set medications and if occurred again the agency would discharge her. Medications were noted to be missing and the patient would not have enough medications for the month. P10's primary physician was contacted again to clarify how the medications were ordered. CCN dated 5/20/22, indicated P10's physician was notified of missing medications and client report she was taking more often then ordered for pain. SNV dated 6/2/22, identified the purpose of the visit was to discharge P10 from the agency. No significant medication issues were identified and P10 was identified as compliant with all medication administration. The visit note indicated there were no potential significant medication issues identified since P10's SOC and P10 continued to require medication setup by another person. On discharge P10 remained in the community without formal services. Discharge teaching was identified as symptoms to report to her physician. No care coordination was initiated. Non agency caregivers, such as a family member, was identified as currently providing assistance with P10's medications. P10's Discharge Summary Report dated 6/2/22, identified the reason for discharge was P10 no longer required skilled nursing care and was independent in her home. During telephone interview on 10/20/22, at 1:45 p.m. RN-A stated a family member had moved in with P10 and had been known to take P10's medications. The last couple of SNV had identified missing medications and RN-A had notified P10's physician a couple of times regarding the missing medications. Her medications were in a locked box . P10 had one key and the nurse had the second key. The lock box would have been easy to break into by picking the lock. RN-A reported during her last visit prior to discharging P10, P10's personal care attendant had set up her medications and that was not allowed, and she was short on her medications again and had to go without. P10's family member had reported P10 had been taking more of the medications on an as needed basis and it was not ordered that way. RN-A indicated she had discussed the case with the clinical manager and it was decided to discharge P10 due to the missing medications and suspicion of med diversion by the family member. P10 was unable to set up her medications herself. RN-A indicated she thought the family member would take over the medication setup after P10's discharge. RN-A did not file a vulnerable adult report regarding the suspected medication diversion by P10's family member or the discharge from the agency without alternative services for managing her medications. An interview with P10 was attempted, however, was unable to reach P10 via telephone. When interviewed on 10/20/22, at 1:30 p.m. the clinical manager indicated P10 was discharged due to non compliance with her medications. P10's primary physician had been notified regarding the suspected diversion of P10's medications by a family member and attempts had been made to limit the family members access to the medications by using a locked pill dispenser to dispense the medications automatically at the times they were due and a locked box to keep her medication bottles in, however, medications continued to be missing when the nurse visited to set them. P10 had not been given a 10 day notice prior to her discharge or a list of alternative agencies or resources to assist her with her medication setup. A vulnerable adult report had not been filed and should have been due to the discharge for cause as well as for the suspected medication diversion by a family member. The agency's Vulnerable Adult policy with review date 10/10/18, indicated any incident which constituted an occurrence which is non‐routine, and results, or might have resulted, in harm to a client or to the good will of the agency, must be immediately reported as an unusual occurrence, including but not limited to, any suspected maltreatment, any unexplained injury, mistake in therapeutic conduct, accident, inappropriate use of client property and any client self‐abuse or intra‐client abuse. The agency would investigate and forward to the appropriate agencies any and all reports where there is actual, or suspected, abuse or neglect.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications for 1 of 3 patients (P4) whose medications were reviewed during home visits and record review. P4's plan of care (POC) for the certification period 9/16/22 to 11/14/22, identified a start of care (SOC) date 9/21/21. P4's diagnoses included Alzheimer's' disease, dementia, kidney disease, vision loss, depression and history of traumatic brain injury. Skilled nursing visits were ordered one visit per week for seven weeks, then two visits per week for one week to conduct varoius assessments, observation and review and reconciliation of medication s as needed. P4's POC included the following medications: amlodipine-valsartan (a blood pressure medication) 5 milligrams (mg)-150 mg by mouth (po) daily, gabapentin (used for pain) 300 mg po two times (BID) daily, galantamine (to treat dementia) extended release 24 mg po daily, memantine (to treat dementia) 28 mg po daily, pravastatin (for cholesterol) 40 mg po daily, sertraline (an antidepressant) 25 mg po daily, trazadone (to treat depression) 50 mg po daily, and vibryd (antidepressant) 20 mg po daily. During a home visit conducted on 10/18/22, at 10:00 a.m. P4's family member (FM)-A stated she set P4's medications every week and administered his medications to him two times per day. FM-A brought out P4's pill bottles and med set up and reviewed each medication she set up in his med planner. FM-A indicated she set up vitamin E, vitamin D3, aspirin, acetyl L carnitines and alpha lipoic acid tablets daily as well as the prescribed medications listed on P4's POC. The medications were over the counter and she had been setting them up and administering them for years as it had been recommended by P4's neurologist a long time ago to take them for his dementia. During interview on 10/18/22, at 11:30 a.m. registered nurse (RN)-B stated she reviewed P4's medications however, did not do so every visit. His family member set up his medications and FM-A would notify the nurses on their weekly visits if there had been any changes to P4's medications. She had not been aware P4 was taking the over the counter medications. It would be important to have all medications P4 was taking on his POC so the provider was aware as well as to monitor for potential side effects or interactions with his prescription medications. When interviewed on 10/18/22, at 2:20 p.m. the clinical manager (CM)-A stated the agency expected all over the counter medications and supplements to be listed on the patient's POC so they could be monitored for potential interactions or side effects. The agency policy Provision of Medication Management dated 10/10/18, indicated the medication profile record must be current and updated when there are any changes.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure physician orders were followed for 1 of 10 patients (P8) reviewed, P8 had farrow wraps (a type of compression garment for swelling), physical and occupational therapies ordered, but the services had not been provided, and the physician had not been notified the services were not provided. In addition, the agency failed to ensure visits were conducted in accordance with physician orders for 2 of 10 patients (P8, P6 ) when the visits were not conducted according to the plan of care (POC) P8's plan of care (POC) for certification period 8/3/22 to 10/1/22, indicated a start of care date of 6/4/22. Diagnoses included paraplegia, neuromuscular dysfunction bladder and multiple sclerosis. Skilled nurse visits (SNV) were ordered one visit per week for eight weeks for various assessments, education, perform monthly catheter changes and medication management. P8 was identified to have a high risk for falls and for hospitalizations. Skilled nurse visits were needed due to P8 continued to have problems with mobility, required catheter change monthly, intermittent assistance with her medications and observation for changes in condition, with changes reported to P8's physician for possible alteration in her treatment plan or additional procedures to stabilize her condition. No discharge plan was anticipated. P8's medical record identified P8 had made a physician clinic visit on 9/20/22, to follow up with acute changes in condition such as edema (swelling), concerns related to her urinary status and catheter care and a large rectal prolapse (part of the large intestine slips outside the anus). The physician made a referral to the home care agency for nursing to assist with farrow wraps (a type of compression garment to manage edema) as well as physical and occupational therapies. P8's medical record lacked documentation of any additional visits, services or communication to P8 following her physician appointment or new orders on 9/20/22. P8 was discharged from the agency without a nurse visit on 9/29/22, when she was admitted to the hospital. During interview on 10/19/22, at 11:30 a.m. the clinical manager (CM)-A stated she was unable to find any further information or documentation regarding the orders for farrow wraps and therapies ordered on 9/20/22. She could not recall ever having been made aware of the new orders and the physician had not been notified the agency had not complied with the physician orders. P6's POC for the certification period 8/31/22 to 10/29/22, identified a SOC date 8/31/22. Diagnoses included diabetes, venous insufficiency, non pressure chronic ulcer, pain syndrome, polyosteoarthritis and intervertebral disc disorder. Orders for skilled nurse visits two visits per week for one week, four visits per week for one week then three visits per week for seven weeks for various assessments, evaluation, and dressing changes. Physical therapy was ordered one visit per week for five weeks for strengthening, balance and gait training and occupational therapy was ordered to instruct patient on activities of daily living techniques and equipment to increase independence. Review of P6 visit notes indicated physical therapy visits were not conducted as ordered on the weeks of 9/11/22 and 9/18/22. Occupational therapy visits were not conducted as ordered the weeks of 9/11/22 and 9/25/22. When interviewed on 10/18/22, at 3:30 p.m. the clinical manager stated she was unable to find physician notification or orders for the missed visits. When visits were not performed, it was expected to notify the physician to the reason the visits had not been completed. The agency policy Missed Visits dated 1/19/18, indicated the patient's physician provided orders for treatments and services and the orders were the foundation of the plan of care. If the agency missed visits or services it must notify the responsible physician,

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to evaluate the plan of care in partnership with the patient when P8 had acute changes in condition with increase weakness and potential need for increase services to prevent hospitalization. P8's plan of care (POC) for certification period 8/3/22 to 10/1/22, indicated a start of care date of 6/4/22. Diagnoses included paraplegia, neuromuscular dysfunction bladder and multiple sclerosis. Skilled nurse visits (SNV) were ordered one visit per week for eight weeks for various assessments, education, perform monthly catheter changes and medication management. P8 was identified to have a high risk for falls and for hospitalizations. Skilled nurse visits were needed due to P8 continued to have problems with mobility, required catheter change monthly, intermittent assistance with her medications and observation for changes in condition, with changes reported to P8's physician for possible alteration in her treatment plan or additional procedures to stabilize her condition. No discharge plan was anticipated. Review of P8's clinical record indicated a SNV was completed 8/2/22, for recertification and a comprehensive assessment was completed. A notation was documented which indicated P8 continued to need skilled nursing services for medication management and assessment to ensure her safety and monitoring of her co-morbidities to decrease her risk of hospitalization. P8 was noted to continue to have falls in her home and had fallen the day prior. P8's goal was to be able to care for herself and be free from falls and it was noted goals continued to be in progress. The visit note indicated no changes with P8's POC. A verbal order was documented on 8/7/22, which indicated P8 would no longer receive SNV weekly and would be seen monthly instead to perform catheter changes and care. Two as needed visits could be performed if P8's catheter were to become dislodged. The medical record lacked documentation to indicate whether P8 had been informed or agreed to the decrease in her skilled nursing visits. On 8/30/22, an as needed (PRN) SNV was completed on physician request due to P8 was having difficulty and concerns with her catheter. P8's catheter was noted not to be functioning correctly as she was voiding out of her urethra and a urology consult was requested. On 9/12/22, P8's scheduled monthly visit was performed. It was noted P8 had significant lower extremity edema (swelling), foul, odorous and dark urine and was extremely weak and having difficulty ambulating. An ambulance was called and P8 was sent to the emergency room for evaluation. P8 was sent home from the emergency room on 9/12/22 with a follow up physician appointment on 9/20/22. P8's follow up clinical visit note dated 9/20/22, indicated P8 was wheelchair bound due to progressive neurological disorder and she had a large rectal prolapse which made it difficult for her to care for herself. She did not ambulate and continued to have edema in her lower extremities. A referral and order was made to the home care agency for nursing to assist with farrow wraps (a short stretch compression wrap) and physical and occupational therapies. P8's medical record lacked any nurse visit, communication or agency contact following her emergency room visit on 9/12/22, or her physician appointment on 9/20/22 to evaluate her ability to care for herself in her home or need for additional services or increase skilled nurse visits. A transfer summary was completed on 9/29/22, with no visit made. During interview on 10/19/22, at 11:30 a.m. clinical manager (CM)-A stated typically the agency would have made another skilled nurse visit or follow up phone call following an emergency room visit. She was not sure why a visit was not made. When interviewed on 10/20/22, at 9:45 a.m. the area vice president (VP) stated she would have expected some type of follow visit to have been completed following P8's emergency room visit on 9/12/22, due to her acute change in condition and increase weakness. The agency policy Coordination of Client Services dated 2/5/18, indicated the clinical manager would ensure effective integration of services, whether services were provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of car provided by all disciplines.