Every finding on record at Sanford Bemidji Home Care and Hospice

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 9/5/23, through 9/7/23, during a recertification survey. The agency is in compliance with the Appendix Z Emergency Preparedness Requirements.

On September 05, 2023 to September 7, 2023, a recertification survey was conducted. This resulted in a partial extended survey at Sanford Bemidji Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency's inability to ensure provision of quality of care. Unduplicated census previous 12 months: 610 Total home visits conducted: 5 Parent Location visited, including the addresses as verified while on site: Sanford Bemidji Home Care and Hospice 3201 Pine Ridge Ave NW STE A Bemidji, MN 56601 Branch Offices for this agency: None

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to complete an initial comprehensive assessment within the required 48 hours after referral for 1 of 9 patients (P10) in the sample. P10's plan of care (POC) for certification date 3/8/23 through 5/6/23, indicated a start of care (SOC) date 3/8/23. Diagnoses included emphysema (lung disease), atrial fibrillation (irregular heartbeat) and ulcerative colitis. The POC included orders for physical therapy (PT) and skilled nurse visits (SN) weekly. P10's Hospital Discharge Summary dated 3/4/23, indicated P10 discharged to home 3/4/23, with orders for home health referral for a physical therapy appointment. The initial comprehensive assessment was not conducted by the physical therapist until 3/8/23, 4 days after his return home. The medical record lacked documentation of the reason P10's initial comprehensive assessment was not completed until 4 days after the agency's receiving his referral as well as physician notification of the delay in P10's SOC. During interview on 9/7/23, at 8:10 a.m. registered nurse (RN)-A stated the referral nurse received referrals, reviewed for eligibility and then routed to the case manager, who was responsible to set up the start of care assessment visit. When interviewed on 9/7/23, at 12:38 p.m. the hospice director (HD) stated she did not know why the SOC for P10 was not done timely. It was the agency's policy to do an initial assessment visit within 48 hours of receiving the referral. The agency policy Admissions Process dated 7/19/23, indicated patients should be admitted into the agency within 48 hours of referral unless otherwise specified by the provider.

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/dosages for 1 of 3 patients (P4) whose medications were reviewed during home visits and record review. P4's plan of care (POC) for certification period 8/16/24 through 10/14/23, indicated a start of care (SOC) date 8/16/23. Diagnoses included arthritis of right knee, right total knee arthroplasty, bipolar disease, epilepsy, kidney disease and asthma. Services were ordered for physical therapy (PT) two times per week for one week, three visits per week for two weeks and two visits per week for two weeks. The POC indicated physical therapy goals included: fall prevention, equipment recommendations, gait training, mobility and transfer training, therapeutic exercises, postural and balance training and manual therapy. The POC synopsis indicated a goal the patient would verbalize/demonstrate the understanding of the importance of physician ordered POC as it relates to their disease process. Interventions included patient would verbalize and demonstrate understanding appropriate management of medications, safety precautions to prevent falls, compliance of the disease and treatments, appropriate depression interventions and improvement of pain. P4's POC included the following medications: acetaminophen 650 milligrams (mg) 1 tablet by mouth (po) every (q) 6 hours (hr) as needed (prn), albuterol inhaler 2 puffs inhalation q 4 to 6 hrs prn, Mylanta 15 milliliters (ml) po q 4 hrs prn, vitamin C 1000 mg po everyday (qd), aspirin 325 mg po qd, Cogentin (to treat involuntary movements) 0.5 mg po qd, clindamycin (an antibiotic) 300 mg po three times per day for 7 days (stop 8/15/23) clonazepam (an antianxiety) 0.5 mg po qd, donepezil (to treat Alzheimer's) 10 mg po qd (stop 8/7/23), Lasix (a diuretic) 20 mg po qd (stop 8/22/23), gabapentin (an anticonvulsant) 300 mg 2 capsules po three times per day, Vistaril (to treat itching) 50 mg q 6 hrs prn, lisinopril (to treat high blood pressure) 20 mg po qd, magnesium oxide 250 mg po qd, melatonin 3 mg po at bedtime prn, methimazole (anti thyroid) 5 mg po qd, mirtazapine (an antidepressant) 15 mg 3 tablets po qd, multi vitamin 1 tablet po qd (stop 8/16/23), nicotine gum 1 q hr prn, olanzapine (an antipsychotic) 20 mg po at bedtime, omeprazole (acid reducer) 20 mg po qd, oxycodone (opioid analgesic) 5 mg 1-2 tablets po q 4 to 6 hrs prn (stop 8/22/23), Miralax 3 teaspoons po qd, pramipexole (to treat restless legs) 0.25 mg po three times per day, Senna-S 1 tablet po qd prn (stop 8/22/23), sertraline (an antidepressant) 100 mg po qd, sertraline 25 mg po qd, simethicone (to treat gas) 125 mg po three times per day, simvastatin (to treat cholesterol) 20 mg po q bedtime, tramadol (an opioid analgesic) 50 mg 1-2 tablets po q 6 hrs prn (stop 8/22/23). During a home visit conducted on 9/6/23. at 9:15 a.m. Physical therapist (PT)-C greeted P4 and reviewed general condition, assessed for pain, use of pain medications and asked patient if any medication changes had occurred since her last visit. P4 denied medication changes and reviewed her pain levels. P4 stated she was not aware of what medications she was currently taking as the assisted living staff administered and managed all her medications. P4's medications were reviewed with nursing staff at the assisted living home where P4 resided. Registered nurse (RN)-B stated the staff administered P4's clonazepam 0.5 mg three times per day, not one time per day as directed on P4's discharge summary. P4 had been receiving the clonazepam dose three times a day for a long time and they were not aware of any changes to the dose. The staff also administered donepezil 10 mg every evening and were not aware the medication had been discontinued. She had never reviewed P4's medication list with the agency's home care staff. The assisted living staff administered P4's medications per her current medication administration report. P4's assisted living current medication administration report dated 9/6/23, included the following medication orders: clonazepam 0.5 mg po daily, give one tablet per day at 9:00 a.m.,1:00 p.m. and 7:00 p.m. not one time per day as ordered on P4's discharge summary, donepezil 10 mg po daily at 7:00 p.m. which was not stopped as ordered, sertraline 100 mg, give one and one-half tablets at 9:00 am. not one tablet as ordered, vitamin c 250 mg po daily at 9:00 a.m. not 1000 mg as ordered, and olanzapine 5 mg po every 4 hrs prn , which was not a current order for P4. During interview on 9/6/23, at 9:00 a.m. PT-C stated she reviewed medications with the patient and staff if applicable. She also reviewed any clinic notes if the patient had any doctor appointments between her visits. If there were changes to medications, she would update the electronic medication list and the patient's copy and update the nursing supervisor (NS)-A, as NS-A reviewed all patient medication orders when it was a therapy only case. When interviewed on 9/7/23, at 9:35 a.m. NS-A stated if a patient was admitted with therapy only, the therapist did the SOC assessment and did the medication reconciliation at that time. NS-A also reviewed the medication list as well for accuracy. The agency's medication list was accurate and no discrepancies were noted when reviewed with P4's discharge summary 8/15/23. She thought when PT-C did P4's SOC assessment visit RN-B was not available, only the medication aide was on duty, which may have been the reason the medication review had not been thoroughly completed. NS-A verified therapy had patient visits documented 8/16/23, 8/18/23, 8/21/23, 8/25/23, 8/28/23, 8/30/23 and 9/1/23, in which medications should have been reviewed to ensure accuracy of medication administration. NS-A stated she had obtained an order today for a skilled nurse visit to reconcile medications for P4 and had a nurse scheduled to go out that afternoon. She would then notify P4's primary physician of any discrepancies found and take action to have them corrected and assure P4 was taking her medications as ordered. The agency policy Medication Management dated 10/29/22, indicated a comprehensive assessment must include a review of all medications the patient was 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 non compliance with drug therapy. Clarify all medications, including name, dose, and frequency. Compare medication orders with medication containers, including dose, frequency, expiration date, and validate patient/caregiver proper administration. Ongoing assessments are completed during visits.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure that a comprehensive assessment was updated and revised, including the Outcome and Assessment Information Set (OASIS) data within 48 hours of return form a hospital for 1 of 3 patients (P1) in the sample, who had been hospitalized. P1's plan of care (POC) 6/24/23 through 8/22/23, indicated a start of care (SOC) date 6/24/23. Diagnoses included attention to artificial opening of urinary tract, malignant neoplasm of left kidney and colon, cancer pain and anxiety. Services ordered for skilled nurse visits every 2 weeks for various assessments and nephrostomy change and home health aide (HHA) visits weekly for bathing, dressing, grooming and hygiene. P1's discharge summary dated 7/13/23, indicated she was being discharged from a 6 day hospital stay for urinary tract infection. Discharge orders included to discharge to home under care of organized home health services. The face to face visit note dated 7/13/23, indicated P1 had a need for intermittent skilled nursing and home health aide services in the home. A clinic referral for home health services was completed. P1's resumption of care (ROC) visit was completed 7/17/23, 4 days after P1 was discharged to her home. P1's medical record lacked documentation to the reason why P1's ROC visit was not completed within 48 hours after her discharge from the hospital, as well as physician notification of the delay in her resumption of care. During interview on 9/7/23, at 11:15 a.m. the nursing supervisor (NS) stated she was not sure why P1's ROC visit was late. NS indicated it was the agency's policy when patients were hospitalized, to complete their ROC visits within 48 hours of their return home. The agency policy Assessments and Reassessments dated 8/3/23, indicated the comprehensive assessment would be updated and revised with patient reassessment within 48 hours upon a patient's return home after an inpatient hospital admission of 24 hours or more.