Every finding on record at Recover Health of Minnesota, Inc

On 1/3/22, 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: Care Planning, Coordination of Services, and Quality of Care 42 CFR 484.60 at G570 was found not met. The complaint H8068006C was substantiated with an additional standard deficiency issued at G590 when the Home Health agency (HHA) failed to ensure timely coordination and communication to the physician to changes requiring a review and/or change of the treatment plan for 1 of 3 patients (P1) reviewed who utilized an indwelling urinary catheter.

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 at 484.60, Care Planning, Coordination of Services, and Quality of Care. The HHA failed to ensure timely communication to the physician for changes requiring a review of treatment options for 1 of 3 patients (P1) who was admitted to the hospital related to a urinary tract infection with sepsis after multiple indwelling catheter changes reviewed for indwelling urinary catheter. Refer to G-590: Based on interview and document review, the home health agency (HHA) failed to coordinate and communicate to the physician to changes requiring a review and/or change of the treatment plan for 1 of 3 patients (P1) reviewed who utilized an indwelling urinary catheter.

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 coordinate and communicate to the physician, changes requiring a review and/or change of the treatment plan for 1 of 3 patients (P1) reviewed who utilized an indwelling urinary catheter. P1's plan of care (POC) for certification period of 11/23/21, through 1/21/22, included diagnoses of other injury of bladder, neuromuscular dysfunction of bladder, neurogenic bowel, quadriplegia, peripheral vascular disease, anxiety and obesity. The POC indicated P1 required skilled nursing three times a week for one week and then once every two weeks for eight weeks. The POC directed the skilled nurse to insert an indwelling Foley catheter every two weeks and one to two times weekly as needed for catheter maintenance, dislodgement, stoppage and obtaining urine specimen as indicated. In addition, the POC indicated P1 used a 20 French with 30 centimeter (cc) balloon but instructed staff to fill the balloon with 10 cc only. Review of the Minnesota Adult Abuse Reporting Center (MAARC) report alleged event date 12/16/2021, agency nurse performed a catheter change for P1 however, the nurse did it “incorrectly again,” which caused damage to P1's urethra. Following the insertion, P1 did not put out any urine but instead was putting out blood through the catheter. The facility staff where P1 resided had noticed there was a problem and had contacted the agency staff who were not able to come back out to see P1. The facility staff then had brought P1 to the nearby hospital on 12/17/21, where P1 was admitted due to sepsis related to a urinary tract infection and was hospitalized in the intensive care unit (ICU) for a couple days before being moved to regular acute care unit for treatment. During review of the medical record the following was revealed: -11/23/21, during the start of care visit registered nurse (RN)-A documented she had attempted to insert a catheter on P1 twice and after the second attempt she was able to advance the catheter with minimal resistance. In addition, RN-A indicated during the two attempts she had attempted to change P1’s position, had rectal stimulation done for P1 and an enema were attempted before the catheter was inserted. -11/25/21, on-call RN-B documented she had been contacted by the facility where P1 resided after the catheter had fallen out and she had completed a skilled visit. RN-B indicated during the visit, after the first unsuccessful attempt to insert the catheter, she had observed the penial area was red and irritated and there was a small amount of bleeding. RN-B then indicated on the second attempt to insert the catheter she had observed bloody urine on the catheter tubing after she had inserted the catheter however, when she attempted to instill saline in the balloon the catheter fell out. RN-B then attempted to insert the catheter a third time and despite resistance when inserting it she was able to advance the catheter and instill 30 cc of saline into the balloon. The catheter was then connected to the night Foley bag. -12/8/21, licensed practical nurse (LPN)-A had gone to complete a home visit, however, P1 refused the catheter change. -12/15/21, LPN-B had completed a skilled nursing visit to change P1’s catheter, however, when she attempted to insert the catheter, she was not successful and thus had left P1 without a catheter that night. During interview on 1/3/22, at 10:25 a.m. RN-B stated she was the on-call nurse on 11/25/21, and had completed a home visit for P1. RN-B stated she had received the call from P1’s facility indicating the catheter had fallen out and at that time she had told P1 and the staff at the facility, she had been informed RN-A had difficulty inserting the catheter a few days prior. RN-B stated during the visit she had attempted to insert the catheter twice without success due to resistance and challenges related to P1’s anatomical characteristics however, on the third time the staff at the facility had assisted to put pressure on P1’s bladder and despite resistance she was able to insert it. RN-B stated she had observed bleeding and irritation of the skin due to the many catheter’s insertion attempts which P1 was frustrated about. RN-B stated on the third attempt she initially did not get anything back except approximately one tea spoonful of blood, but later saw some yellow urine in the tubing. RN-B also stated she had informed the facility staff it was common to have the blood in the urine for up to 24 hours and staff had the 24 hour on-call agency number to call if there were concerns. RN-B then stated after the visit she had sent an e-mail to RN-A who was P1’s case manager and completed the visit documentation which included the difficulty experienced during the catheter insertion. RN-B stated if P1 was her patient she would have notified the physician about the challenges they were experiencing with the catheter and thought RN-A had notified the physician because RN-A had spent four hours at the visit on 11/23/21, attempting to insert the catheter. RN-B further stated she did not recall if the agency had a policy which gave guidance on how many times nurses were to attempt to insert a catheter if they were having trouble. During interview on 1/3/22, at 11:03 a.m. RN-A stated she had completed two home visits for P1. The first one at SOC on 11/23/21, and an as needed visit on 12/16/21, and indicated at both visits she inserted the catheters. RN-A stated, “I was the first person who placed it and everything at first was not going good, but we worked through it and was good when I was leaving and he was happy it had worked. I had trouble inserting it and we had called the previous nurse who helped through it and gave a few tips.” RN-A stated since that visit RN-B and LPN-A had also changed the catheter and they both had difficulty inserting the catheters with RN-B attempting multiple times. RN-A stated there were guidelines provided by the agency on how many attempts a nurse could make with the catheter but thought after two attempts she would certainly reach out to other nurses to see if someone was able to assist. RN-A stated on the 12/16/21, visit she had completed the visit because LPN-A had left P1 without a catheter and she acknowledged she was supposed to update the provider about P1 being left without a catheter on 12/15/21, but had not. RN-A stated she did not know what RN-B had done after her visit and it had not been communicated to her about the difficulty RN-B had. RN-A stated she would have expected the issues to have been communicated to her. RN-A acknowledged she was expected to coordinate and communicate with the physician if there were concerns with the current treatment plan. RN-A stated when she inserted the catheter on 12/16/21, she had further stated she had been informed later after the 12/16/21, visit that P1 had been admitted to the hospital and was being treated for sepsis and that the catheter was not draining. During interview on 1/3/22, at 11:22 a.m. LPN-A stated she had completed a home visit on 12/15/21, and at the visit had tried to place the catheter after removing the old one but had not been successful. LPN-A stated from what she knew several nurses had a hard time inserting the catheter and when she was not able to insert it at her visit another nurse had been sent out to attempt it on 12/16/21. LPN-A stated she had informed the branch clinical manager, RN-C that she was not able to re-insert the catheter and had left P1 without a catheter that evening/night. LPN-A stated she was not aware if the physician had been notified that the nurses before had a difficult time doing it. LPN-A stated she had not attempted a second catheter because she had concerns with maintaining a sterile field during the insertion related to P1’s anatomy, and because P1 did not have sensation, she did not want to cause internal damage to the area. During interview on 1/3/22, at 12:30 p.m. the branch clinical manager RN-C stated she personally had not worked directly with P1, however, she knew at the SOC for P1, RN-A had called her because she had difficulties with inserting the catheter. RN-C stated she had been involved in trouble shooting the situation. RN-C stated on 11/25/21, there had been a standard e-mail which had been sent out by the on-call nurse, RN-B which indicated she had been out to P1’s facility and had replaced the catheter again because it had been dislodged. RN-C reviewed P1’s medical record and verified after the initial visit on 11/23/21, other subsequent visits had been completed by several nurses to change the catheter with multiple attempts, however, no coordination had been initiated to address the catheter insertion difficulties. RN-C stated, “Am going to be honest I was not aware they had tried that many times. My expectation is they are supposed to reach out to the doctor immediately." During interview on 1/3/22, at 1:40 p.m. the agency administrator stated he was made aware P1 had been sent to the emergency room (ER) due to a blockage in the catheter. The administrator stated RN-A had changed P1’s catheter on 12/16/21, and that evening the facility had contacted the agency reporting P1 was experiencing problems and the clinical recommendation given to the facility staff was to bring P1 to ER. The administrator further stated RN-A had reported after the catheter insertion on 12/16/21, P1’s output was approximately five centimeters with sediment and was pink and cloudy. In addition, RN-A did not stay long after inserting the catheter. During interview on 1/3/22, at 2:07 p.m. P1 stated he admitted to the agency on 11/23/21, and since that time there had been several nurses who had made several attempts to change his catheter. P1 stated during the times the staff were doing the catheter insertion, the facility staff had observed the nurses not maintaining the sterile technique. R1 stated on 12/16/21, after RN-A left, he and the facility staff had noticed a lot of discharge in the tubing. He stated later he felt sick and was brought to ER that night. P1 stated during each time the agency nurse came to do the catheter they could not get it in and he was not sure why they were not able. P1 also stated on 12/16/21, after the agency nurse had left there was no urine draining but there was pint drainage which was “translucent was pink.” P1 further stated he was admitted to the hospital for six days and was treated for sepsis due to a bladder infection. During interview on 1/12/22, at 11:14 p.m. P1’s physician stated he would have expected the agency nurses to have notified him to make a recommendation for P1 to make a visit to ER or the clinic for another provider to insert the catheter using “a Coude catheter” (a catheter specifically designed to maneuver around obstructions or blockages in the urethra). The physician also stated the nurses were not supposed to push the catheter through the obstruction but were to attempt gentle insertion 2 times and if not able the nurses were supposed to send P1 to ER. The agency Coordination of Client Services policy dated 05/2018, directed the clinical manager or designee were responsible to coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any) and caregivers as appropriate in the coordination of care activities. The agency assured staff who provided care were communicating any patient concerns and patient progress towards the goals of the plan of care with other involved in the patients care.

An abbreviated survey was conducted on 7/12/21, through 7/14/21, at Recover Health. to investigate a complaint. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. As a result, the following deficiencies are issued: Findings of the complaints were as followed H8068003C (MN74365) was unsubstantiated. H8068004C (MN52157) was unsubstantiated. H8068005C (MN73162) was substantiated with a deficiency cited at G458.

Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure all health care providers responsible for the home health plan of care agreed that the measurable outcomes and goals set forth in the POC had been achieved and the physician responsible for the home health Plan of Care (POC) agreed that the patient (P2) no longer needed home health agency services. Findings include: P2's Home Health Certification and Plan of Care (POC) for the certification period 5/8/21 to 7/6/21, indicated P2's start of care (SOC) date was 9/21/18, and identified diagnoses including diabetes mellitus, hypertension, and low back pain. P2's plan of care (POC) included orders for skilled nurse visits (SNV) one time per week for two weeks for various assessments including to educate on healthy diet, management of diabetes, medication management purpose, effects, time, dose frequency, route and potential side effects of medications. The medication orders included to inject Trulicity (a non insulin anti-hyperglycemic medication) 0.75 milligrams (MG) subcutaneous (under the skin)(SQ) one time weekly with a start date of 4/23/21. The visit summary indicated P2 diabetes treatment plan had recently changed to include weekly injections of Trulicity. P2's goals included blood sugar ranges to remain between 60 and 350, P2 would teach back general diabetic education, and P2 would teach back purpose, time, dose, route, frequency and potential side effects of medications. P2's POC goals were not updated to include his newly ordered weekly Trulicity injections and remained unchanged from his previous certification POC. All goals listed had a target completion date of 5/22/21. P2's SNV notes in the medical record were reviewed and indicated the following: SNV note dated 4/23/21, indicated P2's Trulicity injections were started and client was instructed on how to do the injections, side effects and benefits of the injection. No discharge planning was initiated with the visit and the client was not given notice of discharge. Discharge plans were to discharge when all goals were met. Recertification visit note dated 5/5/21, indicated P2 would be recertified for services for 2 additional weeks with anticipated discharge 5/22/21, when goals/maximum potential were reached by the patient and skilled instruction was still needed. SNV note dated 5/12/21, indicated P2 had needed to bring his Trulicity to the local clinic on 5/7/21, for injection as he had not received assistance with injection the previous week. On 5/12/21, P2 requested nurse to administer his injection during this visit, as he did not know how to do it. The note further indicated P2 was able to inject the medication after receiving verbal instruction and demonstrations two times. The note indicated P2 was progressing toward goals on schedule and no discharge planning had been initiated and patient had not been given notice of discharge. Discharge visit note dated 5/19/21, indicated goals had been met for the planned discharge and condition at discharge was improved. The discharge note did not indicate P2's ability to take his injectable medication and indicated a non-agency was currently providing medication administration assistance to P2, including injectable medications. Review of electronic mail correspondence (email) between P2's visiting Registered nurse (RN)-A, visiting licensed practical nurse (LPN)-A, clinical manager (CM)-A and administrator on 4/19/21, 5/3/21, and 5/4/21, indicated P2's Trulicity injections and ability to administer them were under discussion and some communication had occurred with the diabetic educator and county case worker (CCW)-A. Discharge plans had been delayed due to the need for further instruction related to the Trulicity injections, however, discharge was still planned 5/22/21, if the team believed all goals had been met. The email dated 5/3/21 from LPN-A indicated that although P2 had administered his injection himself the last visit, she did not feel comfortable discharging him quite yet with his injection and wondered if the injection would be a long term medication for P2. When interviewed by telephone on 7/13/21, at 9:00 a.m. P2 stated his diabetic injections have been going good. P2 stated he would never give the injection to himself as he would be to afraid of messing it up. He indicated a nurse from a different agency, was coming in to give him his injections every week. He wasn't sure of her name or on what day she was scheduled. During interview on 7/13/21, at 9:23 a.m. CCW-A stated P2 was not able to understand or remember to do his injections correctly. Recover Home Health Agency (HHA) discharged P2 shortly after initiation of P2's injections and his PCA who did his homemaker tasks tried to give him verbal reminders, but it was not working. Another agency was found to manage P2's medications and injections with two times weekly skilled nurse visits. CCW-A indicated she learned of P2's discharge from the agency when P2's diabetic manager called her on 4/19/21, and notified her of the impending discharge that week. CCW-A indicated she had called the administrator at Recover HHA and discussed with him the need for assistance with the weekly injections. CCW-A stated the administrator was adamant P2 was independent with his injections and there was no skilled nursing need in the home. On 5/5/21, CCW-A stated she had received a call from the Recover HHA administrator to inform her the agency was discharging P2 on 5/17/21 and would call P2 to notify him of the discharge. CCW-A indicated the discharge was real sudden and was at the time P2 had the most skilled need. During telephone interview on 7/13/21, at 9:40 a.m. RN-A stated the agency had only visited P2 a couple of weeks after he was started on the Trulicity injections and she herself had only seen P2 one time. P2 was trained by the diabetic educator on how to do the injections and he had a calendar in his home. His ability to remember the injection was variable but he had a personal care attendant (PCA) that would supervise him. RN-A indicated when she had made the visit on 5/5/21, the injection would have been supervised by the PCA that week so she did not do any supervision of the injection that day. The agency discharged him on 5/19/21, and he was not incredibly receptive with the training. RN-A stated there was nothing else the agency could do for P2 as they did not just go in homes for assessment or supervision, the patients had to have a skilled need. RN-A indicated there was only so much they could teach P2 and he needed to have prompts and reminders. RN-A stated P2 should have been in a skilled nursing facility or assisted living in her opinion, but he refused to go. RN-A stated she had spoken with the diabetic educator who would continue to work with him. During interview on 7/14/21, at 10:00 a.m. the administrator stated clinical leadership had been reviewing P2 regarding what skilled services were being provided and it was felt the agency was not providing any skilled services. The agency planned to discharge and P2 was working with the diabetic educator regarding the injections. A nurse watched P2 a couple of times and felt that he was doing ok and was comfortable with his injections. The agency would provide the patient with resources if the patient felt the need for more care. The administrator indicated he had talked with P2's CCW and the diabetic educator regarding P2's discharge and the care that was coordinated. The administrator stated it was his practice to try to assist the nurses on the discharge piece of it, if the agency was going to discharge and the agency would call around to make sure that everyone was comfortable with the discharge. When interviewed by telephone on 7/15/21, at 12:45 p.m. the diabetic educator stated she had received a call on 5/4/21, from the Recover HHA administrator to inform her P2 was going to be discharged from their agency and the PCA, who was basically only a homemaker would give him verbal reminders related to his injection. The diabetic educator indicated nothing was said about referrals to her. She placed a telephone call to CCW-A because she felt the agency had made a medication error in administering P2's Trulicity injection as it was due on Fridays and had been given on Wednesday. Recover HHA was teaching P2 the injection but she thought the nurses did not understand the mechanism of the medication. The diabetic educator indicated she did not do any further review. P2 would not remember when he took the medication and she notified CCW-A she felt it was a lot of responsibility to leave with a homemaker and the homemaker was only there on Mondays and Thursdays. The diabetic educator stated P2 lived alone and was limited about some of his understanding. The homemaker had reported he will eat eight banana's every day and drink a gallon of chocolate milk in three days. The diabetic manager talked with P2 about his diet, moderation and the need to test his blood glucose testing more frequently and P2 was suppose to follow up with her in a month. The diabetic educator stated P2 was only seen in her office on a monthly schedule. The agency's policy Transfer, Discharge and Oasis, with review date 12/2/19, indicated any revisions related to plans for the patient's discharge must be communicated to the patient, representative and caregiver and all physicians issuing orders for the POC and the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency.