Every finding on record at St. Mary's Regional Health Center

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 3/9/26 through 3/12/26 during an extended recertification survey. The facility is found to be in compliance with the Appendix Z Emergency Preparedness Requirements.

On 3/9/26 through 3/12/26, a recertification survey was conducted. This resulted in an extended survey at Essentia Health 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. The Condition of Participation: Care Planning, Coordination and Quality of Care at 42 CFR 484.60 at G574 was found not met. 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: 1310 Total home visits conducted: 7 Parent Location visited: Essentia Health Home Care West 114 Frazee Street East Detroit Lakes, Minnesota (MN) 56501 Branch locations: Essentia Health Home Care West 900 Hilligoss Boulevard SE Fosston, MN 56542 Essentia Health Home Care West 3362 35th Avenue South Fargo, North Dakota, 58104 St Mary’s Home Health 201 9th Street West Ada, MN, 56510 Branch locations visited: Essentia Home Health Fargo, North Dakota St Mary’s Home Health Ada, MN Hours of Operation: 8:00 a.m.- 4:30 p.m. List total number of records reviewed: 17

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on documentation and interview, the facility failed to report all Outcome and Assessment Information Sets (OASIS) data collected in accordance with federal regulations for timely submission. The total number of records submitted beyond the 30 days after completion of M0090 (the date the assessment was completed) was 25 for the period of 1/1/25 through 12/31/25, with 15/25 being submitted late for reasons other than payor change. Findings include: On the HHA Error Summary by Agency report period of 1/1/25-12/31/25, the agency had an error code of -3330: record submitted late. The description included the submission was more than 30 days after completion on the new record. The total number of records submitted beyond the 30 days within that period was 25. During interview on 3/12/26 at 11:00 a.m., with director of nursing (DON) and clinical supervisor (CS)-B, OASIS oversight, DON stated the OASIS submission was completed daily, Monday through Friday. A review was completed of the identified late submissions as compiled by agency. Upon reviewing the information, it was noted 15/25 late submissions were for reasons outside of change of payor source. DON stated the OASIS guidance indicated the guidance for completion of the discharged patient must be completed by the last clinician, and at times there is miscommunication as to who is the last person providing services was, which had caused delays or errors in completion. CS-B stated all OASIS came to a work queue, and were assigned to staff by supervisors for the staff. A discussion was held at the Interdisciplinary Team (IDT) meetings to determine the last person who had seen the patient to determine who was to complete the OASIS and to review errors identified. IDT meetings were held weekly in some offices, and every two weeks in others. The facility policy, Home Care Certified Programs Comprehensive Assessment, last reviewed 6/15/23, and identified the OASIS data set requires timely completion and must be completed by the fifth day after the start of care. The policy identified the OASIS must be submitted through the iQIES system within 30 days.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to complete a comprehensive reassessment the last 5 days of each 60-day certification period, beginning with the start of care (SOC), for 1 of 1 patient (P4) who received skilled home care services. P4's plan of care (POC) 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included for skilled nurse visits (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. Review of P4's clinical record lacked any reassessments completed since the SOC on 1/9/26. A skilled nurse visit was on P4's visit schedule to complete a SNV for an Outcome and Assessment Information Set (oasis) recertification, however, a visit had not been completed. During interview on 3/11/26, at 12:08 p.m. the director of nursing (DON) stated she was aware P4 did not receive her scheduled nurse visit. P4's primary nurse was on vacation and P4 would not allow another nurse to make the visit. The DON stated normally she would expect a skilled nurse visit (SNV) within the five days required time frame for recertification a patient for continued home care services. A visit would be made when P4's primary nurse returns from her vacation, and the agency would submit a late oasis. It was not the agency's practice to discharge the patient and do a new SOC when a SNV could not be made to recertify the patient for home care services, they just submitted the oasis late. The agency policy Assessment, Reassessment and Coordination of Patient Services Home Care dated 4/26/24, identified patient assessments were completed by all professional staff within the home health care department. A comprehensive assessment was completed on patients every 55 to 60 days when the plan of care was reviewed and updated or on a resumption of care.

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 the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: G570 at 42 CFR 484.60, Care Planning, Coordination, Quality of Care. The agency failed to ensure code status was correctly identified on patient's plan of care and/or transfer summary for 4 of 17 patients (P4, P12, P13, P14) whose medical records were reviewed. Findings include: Refer to G574: Based on interview and record review the home health agency (HHA) failed to ensure the plan of care (POC) included all required components accurately for 4 of 17 patients (P4, P12, P17, P13) whose records were reviewed for code status.

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 the plan of care (POC) included all required components for 5 of 17 patients (P4, P12, P17,P13, and P8) whose records were reviewed. P8 P8's plan of care (POC) 3/4/26 to 5/2/26, identified a start of care date 2/27/26. Services included skilled nurse visits (SNV) one time every two weeks for nine weeks for assessment and education. Additionally, the plan of care identified P8 was to receive home health aide (HHA) visits, one time per week for one week and two times per week for eight weeks to aid with personal needs. The diagnoses included trigeminal neuralgia (a chronic pain disorder which causes intense pain attacks to one side of the face), hypertension (high blood pressure), age-related osteoporosis (bone disease with weak or fragile bones) without current fracture, and bilateral hip replacements. P8's POC listed durable medical equipment (DME- medically necessary devices and equipment designed for long-term use at home to help manage medical conditions) used for P8 as a walker, wheelchair, and grab bars. During observation on 3/10/26, at 2:30 p.m., HHA-B was observed as she assisted P8 to set up and complete her shower. HHA-B stated the plan of care identified P8’s personal needs. The plan of care was accessed online with the use of an agency telephone. P8 was noted to have a wheeled walker in place, as well as a wheelchair. During observation of shower, it was noted P8 had grab bars in the shower. P8 was also noted to have a removable raised toilet seat with arm rests in place, as well as a shower chair, and handheld shower in the shower enclosure. During interview on 3/12/26 at 9:00 a.m., the director of nursing (DON) stated the DME information included on the POC was to include all equipment used in the home. DON stated this was important to alert staff what was currently being used, and stated it was also important to have accurate information in the event a transfer was indicated so the appropriate equipment was available for P8. The facility policy, Home Care Clinical Record Closure and Retention, last reviewed 11/25/25, identified “when care was provided to the client (patient), documentation in the clinical record as a whole shall reflect the client’s physical condition, psychosocial status, safety measures to protect the client from injury, and medical care provided, as applicable, from admission to discharge.” Findings include: P4 P4's plan of care (POC) dated 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included skilled nurse visit (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. The POC identified P4's code status (a medical instruction that identified to healthcare providers what emergency interventions a patient would want if their breathing and heart stopped) as prior. A code status history was listed for three previous code status orders. The first, with inactive date 12/27/25, as full code (the patient wants all life saving measures, including cardiopulmonary resuscitation). The second, with inactive date 11/24/25, as full code. A third code status was listed DNR (the patient does not want CPR or life saving measures initiated) inactive date 10/9/25. P4's Service Plan dated 1/9/26, identified P4 had not completed a Provider Orders for Life-Sustaining Treatment form (POLST) but wished to be DNR. P4's POLST signed by P4 and dated 1/9/26, identified P4's wished to be DNR with physician signature 1/20/26. During interview on 3/11/26 at 8:56 a.m., the director of nursing (DON) stated P4's code status identified her as a full code and that was not correct. There was a DNR POLST and order in P4's medical record. There would be a potential for the staff to attempt to resuscitate P4 if P4's heart were to stop when they were conducting a SNV. During telephone interview on 3/11/25 at 10:09 a.m., registered nurse (RN)-C stated there was a blank POLST form in the patient admission packet. The admitting nurse assisted the patient to fill out and then the nurse brought the form back to the office to be signed by the patient's provider. If the POLST indicated DNR, it would be returned to the patient after the physician had signed and it had been scanned in the medical record. The POC identified the patient's current code status. If the POC identified, "prior," as code status, that meant in the orders their previous choice would show up and would be the chosen code status. RN-C was not P4's primary nurse but he could potentially see her when he filled in for other nurses. RN-C reviewed P4's POC and medical record. RN-C stated P4 was listed as a full code and had orders that identified a full code. If RN-C were conducting a SNV with P4 and her heart were to stop, he would call 911 and start CPR. During telephone interview on 3/11/26 at 11:15 a.m., P4 stated she had DNR ordered in her medical record. P4 did not have a POLST form in her home or on her refrigerator that directed health care providers she was DNR, but she wanted to be DNR and had signed something which indicated DNR in her health record on file at the agency. P4 stated she would not want CPR done for her at all. P12 P12's POC 2/1/26 to 4/1/26, identified a SOC 8/5/25. Orders included SNV one every two weeks for eight weeks for various assessments and medication management. Diagnoses included hypertension (high blood pressure), heart disease, depression, chronic obstructive lung disease (COPD) and dependence on oxygen. The POC identified P12's code status as full code. P12's Service Plan dated 8/7/25, identified P12 had a completed POLST form. P12's POLST, signed by P12 and dated 6/10/25, identified P12's wishes were to be DNR with physician signature 6/19/25. During a home visit on 3/10/26 at 12:00 p.m., P12 stated he wished he, "could just die." P12 stated he was tired of living the way he was, unable to do anything he used to do and just wished it would be over. During interview on 3/11/26 at 10:30 a.m., the DON stated therapy had admitted P12 to home care services in June of 2025 and at that time P12 was DNR. When nursing admitted P12 on 8/5/25, he wanted to be full code. The DON could not find documentation in the medical record to indicate code status had been discussed with P12 or that P12 had indicated he wanted to change his code status from DNR to full code. The DON stated a blank POLST form was always in the admission packet and should always be completed with admissions. One had not been completed when the agency nurse had admitted P12 on 8/5/25, and the only advanced directive was the POLST completed on 6/10/25. During telephone interview on 3/11/26 at 11:20 a.m., P12 stated he had a signed POLST on file that indicated he was DNR. P12 did not remember if he had signed a POLST form with the home care agency but he knew he was DNR on his medical records. P12 stated he had been exposed to agent orange during his service and had a lot of health problems. He would never want anything done to resuscitate him. P12 stated he did not have a POLST form in his home or on his fridge which showed he did not want CPR done but he knew it was listed in his medical records. P17 P17's POC 12/19/25 to 2/16/26, identified a SOC date 12/19/25. Orders included SNV one time per week for nine weeks for various assessments and medication management. Physical therapy visits were ordered one time per week for one week, one time every two weeks for two weeks then one time per week for two weeks for treatment with gait, transfers, mobility and balance. Occupational therapy was ordered one time per week for six weeks to increase P17's independence with activities of daily living (ADLs). Diagnoses included polymyalgia rheumatica (an inflammatory condition that causes pain in joints and muscles), low back pain, hypertension, cellulitis and depression. P17's POC listed code status as DNR. P17's Service Plan dated 12/19/25, identified P17 did have a completed POLST form. P17's POLST, signed by P17 and dated 12/19/25, identified P17's wishes were to be a full code with physician signature 12/23/25. P17's Transfer Summary dated 1/12/26, identified P17 was being transferred to an inpatient facility with code status listed as DNR. During interview on 3/12/26 at 1:15 p.m., the DON stated P17 had a signed POLST dated 12/19/25, on file that identified her wishes were to be a full code. P17's POC dated 12/19/25 identified P17 was a DNR. They were direct opposite of the other. DON was not sure why they were different and felt maybe the nurses were trying to get through their paperwork too quickly and made an error. During telephone interview on 3/12/26 at 1:30 p.m., RN-E stated she completed the admission visit for P17. When she admitted a patient to home care services, she would have the patient sign all the loose papers in the admission packet, which would include the blank POLST form. RN-E would explain what the POLST was and what each choice on the POLST meant. If the patient chose to fill it out, she would review their choices with them, have them sign and she would sign the back of the form. RN-E brought all the signed paperwork back to the office and the POLST would get sent to the physician for signature and scanned in to the patient's electronic health record (EHR). RN-E would get the form back on her desk to return to the patient at her next visit. RN-E reviewed P17's POC and stated the code status identified DNR and that was the direct opposite of the POLST P17 had signed. RN-E could not think of how the DNR code status had been entered on P17's POC and was sure she had not entered DNR as P17's code status. RN-E was unsure why the POC was not matching the POLST and felt it was a serious matter. RN-E then reviewed all her patient charts to check each had a correct code status listed on the POC and stated all her other patient's POC code status were correct. RN-E planned to try to find out how P17's POC identified the incorrect code status. P13 P13's POC 11/11/25 to 1/9/26, identified a SOC date 11/11/25. Orders included SNV one time per week for nine weeks for various assessments and diabetes management. Physical therapy visits were ordered one time per week for three weeks for treatment with gait, transfers, mobility and balance. Diagnoses included diabetes, Parkinson's disease and dementia. Code status was listed as, "prior." A code status history was listed for three previous code status orders. The first, with inactive date 8/13/25, was for full code. The second, with inactive order date 8/11/25, was for full code and the third, with inactive order date 8/11/25, was for full code. P13's Service Plan dated 11/11/25, identified P13 had not completed a POLST but had the information if needed. P13's Provider Order dated 11/13/25, identified an order for P13 to be a full code with physician signature dated 11/21/25, however P13's POC with code status, "prior," was not updated to reflect her current code status ordered. During interview on 3/11/26 at 8:56 a.m., the DON stated the computer program EPIC that was used by the agency would wipe out patient code status any time they had an encounter in the emergency room, clinic or hospital. The system automatically input, "prior," as the patient's code status and so the agency nurses would have to go into the patient's chart and enter in the patient's code status each time. The agency nurses were supposed to look for a patient's POLST, write an order to reflect the patient's code status. If the physician had not signed the code status order, the POC would identify code status as, "prior," until it was signed by the physician. The POLST should be returned to the patient after the first visit and put on the patient's refrigerator. Until a POLST was signed, that identified DNR, every patient was considered a full code. The agency nurses were supposed to put the correct code status in the POC as soon as they were able. Several times, patients would have the POLST on their refrigerator. The nurses would bring the POLST back to the office and get it signed again and then an order would be generated and would reflect in the POC. The nurses would go by the POLST in the home, but DON was not able to ensure every patient would have their current POLST on their refrigerator. It was potentially possible, a nurse would do a full code on a patient that had a DNR POLST if the POC identified, "prior," for code status. The nurses were able to see a patient's code status during any of their visits by checking the patient's EHR notes in the home. The agency nurses were well aware the code status was not pulling forward correctly. During telephone interview on 3/11/26, at 10:25 a.m. RN-B stated the nurses put patient code status in the orders tab and generally ask each patient to put their POLST on the refrigerator. Patients did not always keep them there. Nurses could quickly look up a patient's code status in the home by looking in the EHR, under the, "orders," tab during visits. The orders would either indicate full code or DNR. The nurses discussed code status with patients yearly. Sometimes a POC would list code status as, "prior." RN-B was not sure why that was but would then just have to do a new order for the code status. If a code status was identified as, "prior," RN-B would look in the medical record for an advanced directive or POLST. Keeping code status updated and accurate was very important. If a POLST or advanced directive could not be found and the POC listed, "prior," as code status, RN-B stated she would likely initiate CPR. The agency policy Uniform Code Level Directive for CPR dated 2/24/25, identified every patient had the right to appropriate medical treatment that would maximize the opportunity of the prolongation of life in a meaningful way. In recognition of this fact that every individual also had the right to death with dignity. All patients of the agency would be presumptively coded as level one (full code) unless a specific order was written by a physician. Code level 2 (DNR) would be ordered on the attached form or on the POC. If a patient was code level 2 (DNR) they would be provided a photocopy of the form and the original copy of the form would be retained on the patient's medical record. Staff were directed to review with the patient and family uniform code level directives and to make sure a copy of the directive form was in sight at all times.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to provide home health aide, occupational and physical therapy services as ordered on referral or notify physician when the services were not needed for 1of 17 patients (P4) reviewed for referrals. The agency failed to ensure visits were conducted in accordance with physician orders for 1 of 17 patients (P4) and failed to notify the physician when the visits were not conducted according to the plan of care (POC). In addition, the facility failed to assure orders for frequency of skilled nurse visits and wound care orders appropriately reflected what was currently in place for 1 of 1 patients (P7) observed for wound care. P7 P7's plan of care (POC) 3/6/26 to 5/4/26, identified a start of care date 1/5/26. P7’s diagnoses included hypertensive heart disease with heart failure (a condition caused to the heart from years of unmanaged or undermanaged high blood pressure), paroxysmal atrial fibrillation (irregular heart rhythm), atherosclerotic heart disease (narrowing or blockage of the arteries), venous insufficiency (decreased blood flow to the extremities), chronic obstructive pulmonary disease (COPD-an ongoing lung condition), and encounter for change or removal of nonsurgical wound dressing. P7 was to receive skilled nurse visits (SNV) one time every two weeks for eight weeks for INR (International Normalized Ratio) (a standardized blood test to measure of how long blood takes to clot) management and assessment. Although not identified in the SNV order, the narrative under Current Status, identified the orders were for “Medication, education, management and assessment of effectiveness, Disease education, management, and assessment, Pain management-instruct on pain relief measures and assess pain levels each visit and Wound management.” The POC outlined the following treatments to bilateral lower legs: Ammonium lactate 12% lotion to affected areas two times a week with wrap/dressing changes for venous dermatitis.Eucerin Cream apply to affected area (legs and feet) for skin irritation. The SNV POC identified under the heading of Goal the following entry: SNV to perform dressing change to left and right stasis ulcers twice weekly. The nurse was to remove old dressing, soaking with saline as needed to remove dressing. Nurse was directed to cleanse area with soap and water, and to apply Vaseline and triple layer short stretch compression. This intervention did not list a start date. The duration for this was six weeks. Under the intervention, identified as having started 1/20/26, staff were to cleanse lower legs with soap and water and cleanse off slough (dead tissue). The nurse was then to apply zinc barrier cream to lower legs, apply Mepilex to weeping areas, and wrap with calamine wrap, covered with compression wrap two times weekly. Although the directions for wound care were outlined in two different fashions under both goal and intervention in care plan, the medication listing and listing for durable medical equipment lacked any of this information and lacked clarification as to which was to be completed, or at what frequency as the frequency for nurse visits in the POC effective 3/6/26 to 5/4/26 indicated frequency of SNV to be completed every 2 weeks. A review of the physician orders dated 1/20/26, identified the treatment above in a modified fashion. The order identified the nurse was to cleanse the right and left lower leg with soap and water and cleanse off slough. The order then directed the nurse to apply hydrofera (a type of dressing) to the open area on the right leg. Zinc barrier cream was to be applied to lower legs, followed by compression wraps. The order directed the registered nurse (RN) to change the dressings weekly, and P7 was to go into the clinic for a second weekly change. On 3/9/26 at 1:30 p.m., a home care visit observation was completed with RN-B in P7’s home. Upon arrival, P7 was sitting in recliner, with legs unwrapped, and towel laid on the floor. RN-B assembled supplies for wound care. Once set up, RN-B initiated wound care implementing hand hygiene and glove usage appropriately throughout process. Lower legs were cleansed and slough removed. RN-B applied ammonium lactate to bilateral lower legs. Calamine wrap was then applied and subsequently secured with compression wrap. Following visit, RN-B confirmed the current process was different than what was identified on the POC, which was completed on 3/2/26. A review of subsequent orders entered on 3/9/26, at 2:45 p.m. indicated wound care was to be completed each visit, effective 1/20/26, as followed: RN was to cleanse lower legs with soap and water and cleanse off slough. Ammonia lactade [sic] was to be applied to lower legs. Wrap with calamine wrap covered with compression wrap twice weekly by RN or Physical Therapy (PT). A subsequent order was entered on 3/10/26, at 1:16 p.m, which added one SNV every week for 8 weeks from 3/8/26 to 5/2/26. P7’s prior POC from 1/5/26-3/5/26 identified orders for SNV one time every week for nine weeks. Orders were changed to twice weekly for six weeks from 1/25/26 to 3/5/26. The orders also reflected five visits as needed from 1/11/26 to 3/5/26. A review of the weekly schedules identified the visits were completed at a frequency of twice weekly during this time frame. The POC was updated with date of assessment being 3/2/26. At that time the frequency changed to once every two weeks for the period of 3/6/26 to 5/4/26. P7 was seen with a SNV on 3/2/26 and 3/4/26 within the last certification period. SNV was again completed on 3/9/26. During interview on 3/10/26 at 9:15 a.m., RN-B acknowledged orders were changed on 3/9/26, after observation had been completed and orders had been noted to vary from POC. On 3/10/26 at 10:49 a.m., the director of nursing (DON) stated the POC information was to reflect the most current orders at the time of the assessment. DON stated if there were changes to the treatment, the current orders were to reflect this and were to be documented/transcribed as orders and integrated into the plan of care. A review of the facility policy, Home Care-Provider’s Orders, las reviewed 6/25/25, identified “Interim Orders” were to be generated and sent for provider signature for any change in the plan of care for changes in orders that include care of disciplines, orders, and changes of frequencies. Findings include: Referral P4's plan of care (POC) 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included skilled nurse visits (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. P4's Referral for Home Care Services, dated 1/7/26, identified the reasons for the referral included home health nursing, physical therapy, occupational therapy and home health aide. P4's SOC skilled nurse visit (SNV) note dated 1/9/26, identified an assessment visit was made for a SOC with further visits planned. P4's rehabilitation potential was listed as good to remain in her home with the assistance of home health. P4 had functional limitations of endurance, ambulation, shortness of breath with exertion and was oxygen dependent. P4's goals were to regain strength and prevent hospitalizations. The visit note lacked documentation if therapies or the need for home health aide services had been assessed, discussed and/or offered to P4. Review of P4's medical record lacked documentation why therapy or home health aide services had not been discussed or offered to P4 or if the need for the services had been assessed. The record also lacked documentation if the physician had been notified physical therapy, occupational therapy and home health aide services were not initiated for P4 as ordered on the referral. During interview on 3/11/26 at 11:59 a.m., the director of nursing (DON) stated when a patient had a referral for therapies and/or home health aid and the service was not started, the nurse would generate an order to discontinue the service. The agency did consider a referral as initial orders for services. The agency policy Home Health Admission Process dated 7/26/23, identified a referral was communicated to the home health agency for new SOC, resuming care for client on services or changing or increasing services. Patient needs would be reviewed and verification of staff availability. The agency policy Assessment, Reassessment and Coordination of Patient Services Home Care dated 4/26/24, identified the initial assessment was generally for the purpose of determining the patient's need for care and the type of services required. The initial referral for additional services (therapy, speech or social worker) would be received via provider order. A referral order must be confirmed by completing a written or electronic order that would be signed by the provider. Missed Visits P4's plan of care (POC) 1/9/26 to 3/9/26, identified a start of care (SOC) date 1/9/26. Orders included for skilled nurse visits (SNV) one time per week for nine weeks for various assessments and medication administration. Diagnoses included peritoneal abscess (a localized collection of pus in the abdominal cavity) with infection, emphysema (a chronic lung condition), history of bariatric surgery and dependence on oxygen. Review of P4's electronic health record (EHR) indicated SNVs were completed weekly from SOC 1/9/26 to 2/28/26, however no visits had been completed 3/1/26 to 3/12/26. P4 was due for a SNV recertification for home care services that would need to be completed within the last five days of her 60-day certification period 3/5/25 to 3/9/26, however no visit was completed. This had a potential for discharge of the patient from home care services as P4 would not have the required physician orders for services when her certification period ended on 3/9/26. Review of P4's EHR failed to include documentation to P4's physician to notify a SNV for recertification for home care services had been missed. During interview on 3/11/26 at 12:08 p.m., the director of nursing (DON) stated she was aware P4 did not receive her scheduled nurse visit. P4's primary nurse was on vacation and P4 would not allow another nurse to make the visit. DON stated normally she expected a skilled nurse visit (SNV) within the five days required time frame for recertification for continued home care services. A visit was planned when P4's primary nurse returned from vacation. P4's medical record lacked documentation the physician had been notified of the missed visit and there should have been notification to P4's physician the visit had not been completed. The agency policy Missed Visit Documentation dated 9/11/24, identified notification was required to be sent to the ordering provider when visits were not performed per order. Notification of the visit must include the clinical impact of the missed services or treatment.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to maintain a clinical record that contained current information for every patient receiving home health services for 2 of 17 patients (P6, P14) whose records were reviewed. Findings include: P6 P6's plan of care (POC) 3/3/26 to 5/1/26, identified a start of care date 3/3/26. Services included skilled nurse visits (SNV) two times per week for one week, one time per week for one week and two times per week for seven weeks for various assessments, teaching and health care coordination. Diagnoses included hypertension (high blood pressure), encounter for attention to colostomy, and chronic obstructive pulmonary disease. P6's POC listed P6's code status (a medical instruction that identified to healthcare providers what emergency interventions a patient would want if their breathing and heart stopped) as a full code (the patient wants all life saving measures, including cardiopulmonary resuscitation (CPR). P6's Service Plan dated 3/27/26, identified P6 had completed a POLST form to identify his wishes for code status. P6's POLST was not located during record review. During interview on 3/11/26 at 9:00 a.m., the director of nursing (DON) stated she was unable to locate a completed POLST form scanned into P6's medical record but would continue looking. On 3/11/26 at 10:30 a.m. a copy of P6's POLST was provided. The POLST identified P6 wanted a full code (CPR) and was signed by P6 on 3/27/26. During interview on 3/11/26 at 10:33 a.m., the DON stated she had found the POLST P6 had completed on admission. It was in a pile of paperwork in one of the branch offices. The form should have been scanned into P6's medical record and she had instructed the branch office they needed to scan in the document as soon as possible. P14 P14's POC 1/14/26 to 3/14/26, identified a SOC date 1/14/26. Services included SNV one time per week for eight weeks for various assessments, medication management and teaching. Physical therapy was ordered one time per week for six weeks for for treatment with gait, transfers, mobility and balance. Occupational therapy was ordered one time per week for one week to increase P14's independence with activities of daily living (ADLs). Diagnoses included fracture of left femur, bipolar disorder, anxiety disorder, malnutrition and history of falls. The POC identified P14's code status was a DNR (the patient does not want CPR or life saving measures initiated). P14's Service Plan dated 1/14/26, identified P14 had completed a POLST form to identify his wishes for code status. P14's POLST was not located during record review. During interview on 3/11/26 at 2:30 p.m., the DON stated she was unable to locate P14's POLST form in his medical record. There was no POLST on file that she could find or any documentation of which code status P14 had identified. The DON expected, when a patient identified they had a POLST, the agency staff would obtain that POLST for the patient's medical record or have them complete a new one. The DON stated P14's Service Plan on admission identified a POLST was on file at another health care facility but upon review of the indicated chart, DON was unable to find one. The admission nurse should have asked P14 to complete a new POLST on admission. On 3/11/26 at 2:30 p.m., a copy of P14's POLST was provided. The POLST identified P14 wanted a DNR and was signed by P14 on 1/14/26. During interview on 3/11/26 at 2:33 p.m., the DON stated she had found the POLST P14 had completed on admission. It should have been scanned into his home health medical record, and it had not been. It was important the patient's POLST was scanned into the medical record as soon as possible to show it was addressed with the patient and correctly identified the patient wishes for code status. The agency policy Uniform Code Level Directive for CPR dated 2/24/25, directed staff if a patient chose a code level 2 (DNR) code status, staff would provide a photocopy of the advanced directives to the patient. The original copy of the form would be retained on the patient's medical record at the clinic or the hospital. If no copy was available from the client, the clinic or hospital would be requested to send a copy.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 7/10/23, through 7/12/23, during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On July 10, 2023 to July 12, 2023, a recertification survey was conducted. This resulted in a partial extended survey at Essentia Health Home Care West. 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: 597 (1078 including Fargo ND branch) Total home visits conducted: 6 Parent Location visited, including the addresses as verified while on site: Essentia Health Home Care West 114 Frazee Street East Detroit Lakes MN 56501 Branch Offices for this agency: 1) St. Mary's Home Health (visited during survey) 201 9th street west Ada MN 56510 2) Essentia Health Home Care West 3362 35th Ave South Fargo ND 58104 3) Essentia Health Home Care West (visited during survey) 900 Hilligoss Blvd SE Fosston MN 56542 Hours of Operation: 8:00 a.m. -4:30 p.m. Total number of records reviewed: 13

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 ensure 1 of 13 patients (P8) was informed or consented to services or care being provided, including any ongoing changes in services. P8's plan of care (POC) for the certification date 5/28/23 to 7/26/23, identified a start of care (SOC) date 5/28/23. Diagnoses included ventricular tachycardia, heart disease, acquired absence of right upper limb, and left and right below the knee amputations. The POC indicated P8 received skilled nurse visits (SNV) two times per week for eight weeks and one time per week for one week. A physical therapy (PT) one visit was ordered to evaluate and treat. A PT evaluation visit was conducted on 7/5/23. The physical therapist sent physician communication identifying a POC for PT visits two times per week for three weeks. An occupational therapy (OT) visit was conducted on 7/5/23. The occupational therapist sent physician communication identifying a POC for OT two times per week for one week, then one time per week for two weeks. P8's medical record indicated a Patient Service Agreement was dated and signed by P8 on 5/28/23, which indicated P8 had been advised and consented to SNV two times per week and for PT and occupational therapy (OT) to do evaluation visits. A second Patient service agreement dated 6/30/23, indicated P8 had been advised and consented to a change in SNV to two times per week for one week then one time per week weekly. PT and/or OT visits were not included on the service agreement. No other service agreements were documented in P8's medical record to reflect the initiation of PT and OT therapy services after his therapy evaluation visits 7/5/23. During interview on 7/12/23, the agency's manager (AM) verified P8's medical record lacked a service agreement for the initiation of therapy services on 7/5/23. AM stated it was the agency's practice to complete a patient service agreement when there were changes in a patient's services. The agency's policy Certified Program Comprehensive Assessment dated 10/1/14, indicated if a client requires ongoing services under a new payer the case manager must complete a new service plan with the client. A policy was requested regarding service agreements with change in services, however, none were received.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure each patient had an initial assessment visit within 48 hours of the referral date for 2 of 13 patients (P9, P14) reviewed, in the sample. P9's plan of care (POC) for certification period 7/9/23 to 9/6/23, indicated a start of care (SOC) date 11/11/22. Diagnoses included localized edema, tremor and nonpsychotic mental disorder. P9's clinical record, identified a referral for home care services on 11/2/22. P9's start of care assessment visit was not completed until 11/11/22. The clinical record failed to identify any reason P9 had not been assessed within 48 hours of the referral date of 11/2/22 and lacked evidence P9's physician was notified of the delay in the SOC date. P14 plan of care (POC) for certification period 1/4/23 to 3/4/23, indicated a start of care (SOC) date 1/4/23. Diagnoses included secondary malignant neoplasm of liver and intrahepatic bile duct, malignant neoplasm of unspecified ovary, hypertensive heart disease without heart failure and pleural effusion. P14's clinical record, identified a referral for home care services on 12/16/22. P14's start of care assessment visit was not completed until 1/4/23. The clinical record failed to identify any reason P14 had not been assessed within 48 hours of the referral date of 12/16/22 and lacked evidence P14's physician was notified of the delay in the SOC date. When interviewed on 7/12/23, the agency manager stated it was their policy to admit/assess patients within 48 hours of referral. She stated if the patient was not assessed within 48 hours, there should be notes in the clinical record indicating the reason for delay and communication to the provider. She could not locate any reason for delay in the clinical record. She stated she would ask the Ada branch manager for any information regarding P9 and P14. The agency manager stated she would email the information to the surveyor within three days if anything was identified. The surveyor did not receive any further information.

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 the plan of care (POC) included durable medical equipment (DME) used by 6 of 13 patients (P2, P6, P9, P10, P13, P14) who had documented medical equipment and supplies being used in the home. In addition, the agency failed to include accurate information on the POC related to advanced directives for 4 of 13 patients (P8, P12, P13, P14) reviewed during record review. P6's plan of care (POC) for certification period 6/15/23 through 8/13/23, identified a start of care (SOC) date 2/15/23. Diagnoses included diabetes, hypertension, schizoid personality disorder, depression, dementia, psychotic disturbance, and post traumatic stress disorder. The POC indicated P6 received skilled nurse (SN) and home health aide (HHA) services. P6 had moderate cognitive impairment, allergies to dust mite and smoke, diabetic diet and safety measures included an adequate emergency plan, adequate lighting, bathtub safety bars, needle precautions, phone access, no stairs, smoke detectors and life alert button. Durable medical equipment was listed as none on file. On 7/11/23, a home visit was conducted. P6 was observed to have an automatic blood pressure cuff, glucose monitoring device, an automatic medication dispensing machine, and a box of needles to use on his insulin pens. P6 had a bath bench in his tub. P6 stated he obtained his supplies from the veterans administration. P6's POC lacked documentation of the durable medical equipment observed in P6's home. The functional assessment of the POC for P6 listed a cane and walker, however did not list all the supplies observed in P6's home. When interviewed on 7/12/23, the agency manager stated the agency listed some of the durable medical equipment under the functional assessment of the POC. The agency manager indicated there were system issues with the computer program the agency used. The nurse entered the supplies under a supply tab and the program did not pull that information to the POC as it should. It would be important to have the supplies listed on the POC in case there were issues with obtaining supplies and so staff would know what supplies the patient had in the home. P8's POC for the certification date 5/28/23 to 7/26/23, identified a SOC date 5/28/23. Diagnoses included ventricular tachycardia, heart disease, acquired absence of right upper limb, and left and right below the knee amputations. The POC indicated P8 received SNV two times per week for eight weeks and one time per week for one week. A physical therapy (PT) one visit was ordered to evaluate and treat. P8 was orientated and forgetful, rehab potential was fair and discharge plan was to discharge when goals were met. P8's code status was listed as prior. P8's medical record indicated P8 had completed Provider Orders for Life-Sustaining Treatment (POLST) document indicating he wished to have cardiopulmonary resuscitation (CPR) in event he had no pulse and was not breathing. P12's POC for certification dates 3/30/23 through 5/28/23, identified a SOC date 3/30/23. Diagnoses included encounter for orthopedic care following surgical amputation, acquired absence of other right toes, osteomyelitis, cellulitis, diabetes and bipolar disorder. The POC indicated P12 received SNV one time per week. P12 was orientated, rehab potential was poor and discharge plan was to discharge when family could resume care or when P12 could care for herself. P12's code status was listed as prior. P12's medical record indicated P12 had completed a POLST document indicated she wished to have CPR in event she had no pulse and was not breathing. When interviewed on 7/12/23, the agency manager stated she had never seen prior listed in the code status section of the POC. It was the agency's practice to send a physician order indicating a patient's code status. It was a problem with the computer program used by the agency. The information was inputted correctly however was not getting pulled over to the POC correctly. A patient's code status should be listed on the POC. A code status policy was requested, however was not received. P2 -SOC date of 4/14/23. Diagnoses of venous insufficiency, heart failure, and depression. POC dates 6/13/23 to 8/11/23. SN one visit every two weeks for assessment and medication management. No DME listed on POC. P2 utilized 4 wheeled walker, lift chair and scooter. P9-SOC date of 11/11/22. Diagnoses of localized edema, tremor and cognitive deficits. POC dated 7/9/23to 9/6/23. SN one visit weekly for assessment and home health aide one visit weekly to assist with bathing and personal cares. No DME listed on POC. P9 utilized four wheeled walker, incontinent briefs. P10- SOC date of 1/19/22. Diagnoses of Alzheimer’s and depression. POC dated 5/14/23 to 7/12/23. SN visit one visit weekly for assessment and medication management, home heath aide weekly to assist with personal cares. No DME listed on POC. P10 utilized medication boxes and walker. P13- SOC date of 3/19/23. Diagnoses of spinal stenosis, encounter for other orthopedic aftercare and anxiety disorder. POC dated 3/19/23 to 5/17/23. SN one to two visits weekly for assessment, PT one to two visits for three weeks to assist with home exercise program, OT two visits weekly for two weeks to assist with home exercise program. No DME listed. P13 utilized four wheeled walker and wound care supplies. P14-SOC date of 1/4/23. Diagnoses of secondary malignant neoplasm of liver and ovary, hypertensive heart disease and pleural effusion. POC dated 1/4/23 to 3/4/23. SN one to two visits for three weeks for assessment, PT one visits weekly for five weeks to establish home exercise program and OT one visit weekly for three weeks to assist with home exercise program. No DME listed on POC. P14 utilized four wheeled walker and medication boxes.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation, interview and document review, the agency failed to assess 1 of 14 patients (P6) for diabetic management, compliance and response with treatment, medications, potential side effects of disease as ordered for a patient who's primary diagnosis was diabetes. P6's plan of care (POC) for certification period 6/15/23 through 8/13/23, identified a start of care (SOC) date 2/15/23. Diagnoses included diabetes, hypertension, schizoid personality disorder, depression, dementia, psychotic disturbance, and post traumatic stress disorder. The POC indicated P6 received skilled nurse (SN) and home health aide (HHA) services. P6 had moderate cognitive impairment, diabetic diet and safety measures included an adequate emergency plan, adequate lighting, bathtub safety bars, needle precautions, phone access, no stairs, smoke detectors and life alert button. P6 had a number of medications ordered, which were set up by his skilled nurse. These medications included Jardiance (a medication to lower blood sugar) 25 milligrams (mg) by mouth (po) every morning, novolog insulin 10 units subcutaneous injection (SQ) two times per day, novolog insulin 6 units SQ at supper time, Lantus insulin 40 units SQ at bedtime and Metformin (to control high blood sugar) 1000 mg po every day. P6's order for consult for skilled home care services dated 5/31/23, indicated skilled nursing was being ordered to instruct/supervise P6's diabetes and provide diabetic management, instruction and supervision of medications, assessment of systems, instruct on disease, post hospital management, diabetes and assess adequacy of home environment and patient's ability to provide care. On 7/11/23, a home visit was conducted. P6 complained of feeling ill and stated he did not feel right when he awoke. P6 was observed to have pale color to his face, and slightly sweaty appearance. P6 stated he felt weak. P6 indicated he had checked his blood glucose level when he awoke and it indicated he was "LO". He drank two glasses of milk and rechecked his blood glucose, which he indicated was 164. P6 indicated he had a "LO" blood sugar the afternoon before as well. P6's medical record indicated he had SNV on 6/14/23, 6/21/23, 6/28/23, and 7/5/23. SN visit documentation lacked evidence a diabetic assessment, blood glucose evaluation, compliance with diabetic medications, or diabetic diet had been assessed during each visit or if education regarding diabetes management and side effects had been attempted. During interview on 7/12/23, the hospice manager stated diabetic symptoms and medications should be assessed at every visit and education ongoing, especially if it was a primary diagnoses on the POC. The agency policy Assessment, Reassessment, and Coordination of Patient Services Home Care dated 5/11/21, indicated the scope and frequency of patient reassessment was determined by the patient's diagnosis, condition, response to previous care, circumstances within the home setting, and patient wishes. A focused reassessment was completed by professional staff during each home visit and was documented ont eh visit information record. The focused reassessment generally pertained to the primary purpose of the visit but may be expanded as patient need required.

An abbreviated survey was conducted at your agency on 2/22/21, 2/23/21 and 3/1/21 to conduct a complaint investigation. Essentia Home Health Care West 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 UNSUBSTANTIATED: H8052001C (MN69806) H8052002C (MN49320) H8052003C (MN70357) However deficient practice was identified and cited at G468 and G488. The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on interview, and document review, the agency failed to provide 1 of 3 patients (P5) with information required related to other available Home Care providers, at the time of a facility initiated discharge. Findings include: P5's 485 Certification period 12/2/20-2/9/21, identified diagnosis of pressure ulcer of left buttocks, pressure ulcer of other site, stage 3, pressure ulcer of other site, unstageable, type 1 diabetes mellitus with hyperglycemia (high blood sugar levels), chronic kidney disease, major depressive disorder, encounter for attention to colostomy (surgical hole in the abdomen to allow for bowel movements). P5 is to have skilled visits 2 times a week for 9 weeks. Skilled nursing was to provide wound care, monitor for risk of infections, and overall status. After Visit Summary dated 1/29/21, indicated patient continued to be upset with nurse, 8/14/21 very short during visit. Patient continues to state he was in a bad mood. Patient continues to state that it's the nurse's fault he is in a bad mood because of the shared risk agreement. At the end of the visit P5 asked if he could punch nurse in the face. Nurse felt threatened for safety, patient safe in bed, nurse left premises. After Visit Summary dated 1/29/21, communication notes indicate, contacted patient about concerns regarding bodily threats to RN staff of "punching you in the face" approx. 1 hour ago. Unable to reach via phone. Patient notified via voicemail that he is discharged from home health services immediately because threatening bodily harm to staff, and because threatening bodily harm to staff, and because of zero tolerance policy of violence, he is immediately discharged from services. Providers notified, and Clay county Social worker Sara, notified. Voicemail also notified patient that providers have been notified as well. Compassion care staff also notified home health RN, that patient had threw feces at staff recently. Physician conversation with P5 dated 1/27/21, at 7:22 p.m. indicated the following, " I was contacted by home health that you are not allowing care and not doing what you need to do to keep yourself healthy. This is your last hope and opportunity to have any help at all. Everyone else has signed off due to your behavior and noncompliance. I wanted to continue to help you and try to help you have the best life you can but this is not going to help anything and will leave you in a mess. Why are you choosing to do this? Please give me some insight into what you are thinking". During interview with 2/23/21, at 8:56 a.m. The director stated if someone gets violent or threatens staff they are terminated from services. Director stated they do not give a 10 day notice and will send them a letter stating why they are terminated, however they do not send additional resources during this situation, however, they do send a message to the county worker who can help them find additional services. During interview on 2/22/21, at 12:59 Clinical supervisor-B stated when P5 was terminated from services they called the patient, provider, and county worker, however, they did not send him out any additional resources. During interview on 2/23/21, at 8:05 a.m. Clinical supervisor-B stated that she did not send any agencies resources to P5 after terminating him, however she will plan to send him one. During interview on 2/23/21, at 8:28 a.m. with Clinical supervisor-A stated when someone is terminated they should be notified of reason why they are terminated and also should receive a copy of other agencies available in their area. Discharge/Termination or Transfer from Services policy revised 1/11/2018, "Non-Alignment between agency services and client needs: b) provides the client, the client's representative, the client's case manager or care coordinator, as appropriate, with a written summary of the concerns. d) Provides reasonable assistance to the client, the client's representative and care coordinator as appropriate in obtaining and coordinating any additional services from another provider that will address the client's needs. Discharge procedure a) The organization will verbally notify the client of the decision to terminate or reduce services within one (1) visit prior to the time the change in service is to occur (i.e. prior to the last scheduled visit)). b) Prior notice will not be necessary when services re discontinue by the client or physician; however, action take must be documented in the clinical record and a discharge summary completed. C) An update to the comprehensive assessment, including required OASIS data elements, will be completed as required by regulations. d) For a client requiring continuing care, assistance will be given to the client and family/caregiver in order to manage continuing care needs after the organizations's services are discontinued. Discharge instructions and medication list are provided. e) Discharge is done with final visit by RN, PT, SLP, or OT. Only exception is if discharge is unexpected. f) Appropriate discharge form (i.e. NOMNC etc) are completed as required by regulations. g) Discharge summary completed by discharging professional or case manager. Chart closure is completed by clinical supervisor."

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 immediately report an allegation of misappropriation of property for 2 of 4 patients (P1, P2) reviewed for reporting requirements. Findings include: P1's 485 Certification 1/17/21 to 3/17/21, identified diagnosis of panlobular emphysema (lung disorder), hypertension (high blood pressure), alcohol abuse, in remission, schizophrenia, and obsessive-compulsive personality disorder. mental status; oriented, forgetful, depressed, and has anxiety. MAARC report dated 2/8/21, identified non agency member filed a report regarding P1 having narcotics missing and reported incident to the facility. P1 identified alleged perpetrator (AP) as an agency registered nurse (RN)-C. No reports from agency noted. During interview on 2/22/21, at 11:01 a.m. registered nurse (RN)-A stated he delivered 90 tablets of oxycodone and a few days later received a message from P1 stating medications were missing and she only had a handful left. RN-A stated agency was notified regarding medications missing. RN-A stated allegations of abuse should be reported immediately and was told the agency would handle this. RN-A stated he completed a RL6 which was the internal formal complaint form. During interview on 2/22/21, at 11:43 a.m. RN-C denied allegations of taking narcotics from P1's home. RN-C denied being at P1's home outside of work status. During interview on 2/22/21, at 11:47 a.m. clinical manager (CM)-C stated all allegations of abuse were to be reported immediately and they were currently working with their human resource department, director and employee relation and was never directed to file a MAARC report. CM-C further stated that they did not file a police report as P1 stated she did not want to be a narc. CM-C stated abuse should be reported immediately. During interview on 2/22/21, at 2:44 p.m. CM-B stated allegation of narcotic theft should be brought to the supervisor, remove alleged perpetrator from the client's home and then be investigated. CM-B stated they would file a VA report and report to law enforcement. During interview on 2/23/21, at 8:18 a.m. CM-A stated all abuse should be reported immediately, but they try to investigate and interview the patient to find out what happened first. CM-A stated they would bring the information to human resources and the director and determine if a MAARC report is necessary. During interview on 2/23/21, at 8:56 a.m. the Director stated if made aware of abuse they would gather details about the incident. The director stated with P1 she did not mention who the person was initially and didn't want to report him. The director further stated P1 refused to have law enforcement notified and that they did not file a MAARC report as they did not have concrete information. P2's plan of care dated 8/5/20 to 11/24/20, indicated client is alert and oriented, independent with ambulation, and is able to cook for himself. P2's diagnosis include metastasis prostate cancer, Bone metastasis (cancer of the bone), and arteriosclerotic heart disease. P2's facility MAARC report dated 2/23/21, indicated the allegation took place on December 10th when P2 stated to RN-B that RN-C may have taken his pain medication. The report further indicated this was reported to the agency in February. During interview on 3/1/21, at 12:04 p.m. RN-B stated in December during a narcotic count that P2 had more Percocet missing from his bottle than the previous week. RN-B stated P2 had stated that AP had been coming to his house during off hours and he wanted to see his pain medication bottles. RN-B stated P2 told her that if she reported this incident he would deny the allegation. RN-B further stated she did not say anything about this to anyone until recently. During interview on 3/1/21, at 12:13 p.m. CM-C stated RN-B came to her either on 2/18/21 or 2/19/21 and reported the allegation of P2's medication missing. CM-C stated she did not report the allegation right away due to an investigation that was currently going on with RN-C and wanted to talk with employee relations first. CM-C further stated all allegations should be reported immediately. CM-C stated that the allegation is still be reviewed, they have not had contact with RN-C since he took a leave of absence. CM-C stated that they were waiting on employee relations and that RN-C's access to records have been deactivated and they are planning on terminating him and reporting the allegation to the board of nursing. During interview on 3/1/21, at 1:22 p.m. the director stated they were educating their staff to report all allegations or suspicions right away, even if a client states they will deny the allegation. Director stated incidents need to be reported for the safety of their clients and so they are able to conduct a thorough investigation. Vulnerable adult and Vulnerable Child Reporting policy revised 5/1/19 identified any person who required to report shall immediately but no longer than 24 hours from the time he/she became aware of the incident. Reports can be made internally or externally. The home care manager/supervisor is mandated to report any abuse/neglect or exploitation of a vulnerable adult or minor by agency personnel to the Minnesota Department of health survey and compliance section and to the county social services Department and law enforcement agency or to the north Dakota department of health.