Every finding on record at St Marys Regional Health Center

A survey with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 6/20/23, through 6/22/23 during a recertification survey. The agency was in compliance with the Appendix Z Emergency Preparedness Requirements.

On 6/20/23 & 6/22/23, a recertification survey was conducted. This resulted in a partial extended survey at Home Health Agency. The agency was found NOT to have met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 24 Total home visits conducted: 03 Parent Location visited, including the addresses as verified while on site: Essentia Health Graceville Home Health 115 West 2nd Street Graceville MN 56240 The agency has no branch offices. Hours of Operation: 8:00 a.m. to 4:30 p.m. total number of records reviewed: 07

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 1 of 7 patients (P4) reviewed, in the sample P4's plan of care (POC) for the certification period 6/1/23 through 7/30/23, indicated a start of care (SOC) date of 2/1/23. Diagnoses included diabetes, kidney disease, chronic obstructive pulmonary disease (COPD), heart disease and Alzheimer's disease. P4's medical recorded identified a referral for home care services dated 1/6/23. P4's Outcome and Assessment Information set (OASIS) and SOC assessment visit was completed on 2/1/23. The medical record failed to identify a reason P4 had not been assessed within 48 hours of the referral date of 1/6/23, and lacked evidence P4's physician was notified of the delay in the SOC date. During interview on 6/21/23, at 2:30 p.m. the agency manager (AM)-A stated the agency does assess patients within 48 hours of referral, however, the referral had been received from the county social services and the agency was waiting for the patient to have a face to face visit from her primary physician, however, P4's medical record identified P4's face to face medical appointment had been completed April 2023, two months after the SOC visit. AM-A stated she knew P4's delay in SOC was discussed with her primary physician, however, was unable to find documentation or verbal order to delay her SOC. The agency's policy Home Care-Provider's Orders, dated 11/18/21, indicated referral orders for admission would be taken from the ordering provider, a nurse on behalf of the ordering provider, or a social worker on behalf of the ordering provider. Verification of verbal orders from the provider would be dated as of the date of when the complete order of the referral was received. Orders that were requested by the provider to start later than 48 hours from the referral date or requested to start by the patient or family later than 48 hours, would have a separate order authorizing the ordered verbal start of care date.

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 each patient had an initial assessment visit within 48 hours of a patient's return home following hospital discharge for 1 of 7 patients (P2) reviewed in the sample. P2's plan of care (POC) 5/27/23 through 7/25/23, identified a start of care (SOC) date 9/29/22. Diagnoses included open wound left hand, diabetes, hemiplegia, hypertension, post traumatic stress disorder, and anxiety. P2's medical record indicated a Hospital Discharge Summary dated 5/15/23, following a hospital stay 5/3/23 through 5/15/23. The discharge summary indicated a call had been placed on 5/12/23 to P2's home care case manager to notify her of plan for P2 to discharge to her home 5/15/23, with home care services. A resumption of care (ROC) visit was not completed until 5/19/23. The medical record failed to identify why P2 had not been assessed within 48 hours of her discharge from the hospital on 5/15/23, and lacked evidence P2's physician had been notified of the delay in her ROC. During interview on 6/21/23, at 2:30 p.m. the agency manager (AM)-A stated she was not sure if the case manager knew for sure the patient had discharged home, however an explanation or verbal order should have been completed to explain the delay in resumption of services. The agency's policy Home Care Certified Program Comprehensive Assessment dated 6/15/23, indicated a ROC visit would follow an inpatient facility stay of greater than 24 hours and must be completed within 48 hours of patient ROC or on ROC date ordered by physician. The initial assessment visit would be completed within 48 hours of the client's return home.