Every finding on record at The Evangelical Lutheran Good Samaritan Society

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 8/18/25 to 8/20/25 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 8/18/25 to 8/20/25 a recertification survey was conducted. This resulted in a partial extended survey at Good Samaritan Home care Robbinsdale. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 764 Total home visits conducted: 7 List Parent Location visit. 4080 W. Broadway #132, Robbinsdale, MN 55422 List all other branch offices for this agency. no branches List Hours of Operation: 8:00 a.m. to 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 interview and document review the agency failed to encode and electronically transmit completed OASIS assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment of the for 6 of 6(P18, P19, P20, P21, P22, P23) patients reviewed. Findings include: The Center of Medicare and Medicaid (CMS) Outcome and Assessment Information Set (OASIS) Error Detail Report dated 1/1/25 through 8/14/25, identified eleven patients whose OASIS assessment records were submitted more than 30 days after the assessment had been completed. P18's plan of care (POC) identified a start of care date (SOC) of 2/3/25. P18's start of care OASIS assessment with completion date 2/3/25, was submitted to CMS 3/7/25, 32 days after completion of the assessment. P19's POC identified a SOC date of 12/8/24. P19's recertification OASIS assessment with completion date 3/3/25, was submitted to CMS 4/10/25, 37 days after completion of the assessment. P20's POC identified a SOC of 4/6/25. P20's start of care OASIS assessment with completion date 4/6/25, was submitted to CMS 5/15/25, 39 days after completion of the assessment. P21's POC identified a SOC of 1/26/25. P21's start of care OASIS assessment with completion date 1/26/25, was submitted to CMS 5/23/25, over 80 days after completion of the assessment. P22's POC identified a SOC of 3/5/24. P22's discharge OASIS assessment with completion date 3/25/25, was submitted to CMS 5/31/25, 66 days after completion of the assessment. P23's POC identified a SOC of 5/17/25. P23's start of care OASIS assessment with completion date 5/27/25, was submitted to CMS 7/9/25, 38 days after completion of the assessment. During an interview on 8/20/25 at 2:53 p.m., Utilization review (UR) stated they were the staff members who submitted the OASIS to CMS. After the nursing staff completed all the needed information and it was reviewed, the submission would take place. UR reviewed P18 through P23’s OASIS submissions and confirmed they had been submitted after the 30 day limit and stated this happened, "for various reasons." During an interview on 8/20/25 at 3:18 p.m., the administrator stated an expectation UR would review the OASIS information within 48 hours of completion, and if needed to nursing staff would respond to UR's request for further information needed so the OASIS could be submitted to CMS in 30 days or less. Facility policy OASIS- Home Health. last reviewed 7/2025 indicated the OASIS data collection would be updated and submitted within 30 days of the completion of the OASIS completion. The Center for Medicare and Medicaid Services OASIS E Manual, updated 1/1/24, identified OASIS data was collected as part of the comprehensive assessment required by the Medicare Conditions of Participation. The CMS Home Health Conditions of Participation required a home health agency electronically transmit accurate, completed, and encoded OASIS data to a centralized data submission

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 2 patients (P17) with information required related to other available home care providers, at the time of a agency-initiated discharge. Findings include: P17's plan of care (POC) 5/1/25 to 6/29/25, identified a start of care (SOC) 5/1/25. Diagnoses included lymphedema, polyosteoarthritis, hypertension and anxiety disorder. Services included skilled nurse visits (SNV) one time per week for three weeks then two times every thirty days for various assessments and education. Physical therapy (PT) one time per week for four weeks to improve functional mobility and occupational therapy (OT) one time per week for two weeks for strengthening, home exercise program to improve use of upper extremities. P17's OT visit note dated 6/10/25, identified an OT visit was made for a routine visit. Edema management and progression with POC was discussed with P17's caregiver with education and training completed. Documentation included to anticipated discharge from OT soon due to P17's noncompliance with treatment suggestions. P17's OT visit note dated 6/18/25, identified an OT visit was made to discharge patient from the agency due to ongoing refusals and noncompliance with treatment recommendations. P17 signed a Notice of Medicare Non-Coverage (NOMNC), (a written notification to inform Medicare beneficiaries their covered services would be ending) for discharge from the agency effective 6/20/25. P17's SNV note dated 6/20/25, identified a SNV was made to discharge P17 from the agency. The documentation did not identify if P17 had received information for other home care providers in her area that may provide home care services. P17's medical record was reviewed and lacked documentation P17 had received information related to other available home care providers in her area at the time of the agency-initiated discharge from home care services. During interview on 8/20/25 at 3:00 p.m., the administrator stated P17 had been discharged from the agency due to noncompliance with treatment. The administrator stated she was the one who sent out information to patients after discharge, informing them of other agencies available in the area, however, was unable to find if she sent the form out to P17. P17 should have received the list of other agencies available but it had been missed. The agency's Discharge and Transfer policy dated 7/30/24, identified discharge/transfer protocol would be adhered to according to state and federal regulations and the patient would be informed in a timely manner of the impending discharge, continuing care requirements and other available services if needed.

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 for resumption of care within 48 hours of the patient's discharge from the hospital for 1 of 2 patients (P15) reviewed in the sample. Findings include: P15's plan of care (POC) for certification period 5/11/25 to 7/9/25, identified start of care (SOC) was 3/12/25. Diagnoses included stage 4 pressure ulcer, heart and kidney disease, diabetes, hemiplegia and urinary retention. Services included skilled nurse visits (SNV) one time per week for nine weeks for wound care, assess/instruct regarding fall and safety precautions, cardiovascular status and complications, skin care, catheter care, and home exercise program. P15's Hospital Care Management summary dated 5/15/25, identified P15 was hospitalized with planned discharge to home on 5/16/25. A referral and face to face attestation for home health care was completed. The referral identified P15 would require home health services for home infusion therapy for intravenous (IV) antibiotics, physical and occupational therapies for safety, assess equipment needs and fall prevention. The appointment urgency was to resume home care services within one to two days. The document identified the referral was faxed to the home care agency on 5/16/25. Review of P15's clinical record identified P15 was discharged to home on 5/16.25, however, was not readmitted to home care services until 5/19/25. The clinical record failed to identify any reason why P15 had not been assessed within 48 hours of his return home from the hospital, and lacked evidence P15's physician was notified of the delay in the resumption of care (ROC). When interviewed on 8/20/25 at 4:20 p.m., the administrator indicated hospital discharge orders to resume home care services were received on 5/16/25, however, she was unable to find a reason why P15 was not seen prior to 5/19/25. The administrator stated P15's ROC was not completed in the required time frame of 48 hours, and it should have been done sooner. The administrator was unable to find a reason the ROC had not been completed more timely. The agency's policy Admission Process dated 12/12/24, identified patients who were accepted for service 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 ensure medications were reconciled and/or set up as ordered for 2 of 7 patients (P6, P8) whose medications were reviewed during home visits and record review. Findings include: P6 P6’s plan of care (POC) with a certification period of 8/2/25 to 9/30/25, identified a start of care (SOC) date of 8/2/25. Diagnoses included burst fracture first cervical vertebrae, hypertensive heart disease, systolic and diastolic heart failure (a serious condition that occurs when the left ventricle can't pump blood efficiently), dysphagia (difficulty swallowing), emphysema (long-term lung condition that causes shortness of breath) and atrial fibrillation (an irregular heart rhythm). Services included skilled nurse visits (SNV) to evaluate and develop a plan of care, assess and evaluate co-morbid conditions, including hypertension, heart failure, emphysema and other conditions that present themselves during the care episode to identify changes and minimize complications and teaching medications. Occupational therapy (OT) to establish and upgrade a home exercise program and provide therapeutic exercises. Physical therapy (PT) for gait and balance, speech therapy for swallowing. P6’s Patient Instructions for discharge orders dated 7/31/25, identified numerous current outpatient medications ordered which included the following: -acetaminophen 500 milligrams (mg) take 2 tablets three times (TID) per day. -albuterol sulfate inhaler, inhale 2 puffs every hour as needed (PRN) for wheezing or shortness of breath. -calcium carbonate 500 mg 1 tablet every day. -diltiazem 30 mg take 1 tablet TID. -furosemide 20 mg take 1 tablet (20 mg) every morning and ½ tablet (10 mg) daily at noon. -ipratropium-albuterol nebulizer solution, inhale 3 millimeters (ml) every 6 hours PRN for wheezing. -polyethylene glycol 17 grams (gm) take 17 gm daily. However, P6’s POC dated 8/2/25, and P6’s Client Medication Report listed her current outpatient medications ordered which incorrectly listed P6 was to take furosemide 20mg 0.5 mg at noon for edema as well as omitted furosemide 20 mg every morning entirely. P6’s POC and Medication Report also failed to list the ordered albuterol inhaler and ipratropium-albuterol nebulizer solution which was ordered on her 7/31/25 discharge orders. During a home visit on 8/20/25 at 10:30 a.m., P6 stated she took her medications on her own. P6 brought out her medication bottles and cards to review. P6 stated she did not take acetaminophen on a scheduled basis and in fact rarely took the medication at all. P6 reported she used her PRN albuterol inhaler and ipratropium-albuterol nebulizer solution a few times daily. P6 stated she did not have or take calcium or polyethylene glycol and did not have the medications in her home. P6 stated she took diltiazem 30 mg one tablet every day and not three times per day as ordered and furosemide 20 mg one tablet every day however, did not take any additional furosemide including the 10 mg at noon as ordered. During interview on 8/20/25 at 11:30 a.m., registered nurse (RN)-A stated she had not reviewed P6’s medications during her visit the week prior. RN-A stated she needed to draw blood for labs, she was having difficulty with that and with the time constraints, she did not have the time to review medications during that visit. During review of P6’s medications during this week’s visit, her medication list was not accurate or up to date and it should have been. RN-A stated the usual procedure was to go through the discharge medication orders and compare with a patient’s medications in the home on admission. If discrepancies were noted or lack of prescriptions needed in the home, she would notify the primary physician and clarify the orders. RN-A stated the medication report would then be updated, which would generate a physician's order to sign, and she would then assist the patient to obtain any missing prescriptions and educate on current medication regimen. RN-A did not feel a thorough medication reconciliation and review had been completed when P6 was admitted to the agency. The medication discrepancies should have been noted during subsequent SNV, as well and the medication report updated. P8 P8’s POC with a certification period of 7/23/25 to 9/20/25, identified a SOC date of 7/23/25. Diagnoses included hemiplegia following a cerebral infarction, stage 2 pressure ulcer of sacral region, hypertension, malignant neoplasm of the bladder and secondary neoplasm of bone, liver, and brain. Services included SNV to evaluate and develop a plan of care, assess and evaluate co-morbid conditions, including hypertension, pressure ulcer, aphasia, cancer, and other conditions that present themselves during the care episode to identify changes and minimize complications and teaching medications. OT to establish and upgrade a home exercise program and provide therapeutic exercises. Physical therapy (PT) to restore functional strength and range of motion, and speech therapy to establish a treatment plan for the improvement of a cognitive communications/swallow disorder. R8's Discharge Summary dated 7/18/25, identified numerous current outpatient medications ordered which included the following: -enoxaparin (a blood thinner) inject 50 mg subcutaneously (SQ) every 12 hours. -Gabapentin (used to treat seizures or nerve pain) 100 mg TID. -methocarbamol 750 mg 1 tablet every four times per day PRN for muscle spasms. -Tagrisso (to treat lung cancer) 80 mg one tablet daily. -Tylenol 325 mg two tablets every four hours PRN. However, P8’s POC dated 7/23/25, and P8’s Client Medication Report listed his current outpatient medications ordered which listed enoxaparin, Gabapentin, methocarbamol and Tagrisso as dosages per instructions and did not identify the ordered dosages of the medications. Methocarbamol was incorrectly listed four times per day and not PRN as ordered, and Tylenol was incorrectly listed as four times per day and not PRN as ordered. During a home visit on 8/19/25 at 10:15 a.m., family member (FM)-A stated she set up and administered P8's medications daily. FM-A brought out P8's medication bottles and cards to review. FM-A stated P8 does not take methocarbamol anymore, and did not take Tylenol on a scheduled basis. FM-A reported P8's medication dosages remained the same as ordered on discharge and did not change. P8 also took Imodium every three to four days and had been for a long time due to chronic bowel issues. During joint interview on 8/20/25 at 2:00 p.m., with the agency’s clinical manager (CM)-A and administrator, CM-A stated the admitting nurse was supposed to compare the patient’s discharge orders to the medications the patient had in their home as well as the patient’s verbal report of medications. The nurse was to notify the primary physician of any discrepancies noted, clarify the orders, write a verbal order and update the patient's medication report. Both the administrator and CM-A stated the agency had just changed computer programs and staff were all learning the system and could have contributed to the inaccurate patient medication lists, as they may have not been inputted accurately due to the new system. The administrator stated it was the agency’s practice for the nurses to review medications at each visit and update medication lists when needed. The agency policy Medication Management dated 10/18/24, identified at a minimum, medications would be assessed and reviewed at the time of the initial assessment, following provider appointments, after a change in patient condition, at the time of recertification and discharge from agency, when there was a concern about the patient's medications and with every comprehensive assessment. Staff were directed to list all medications a patient was taking including nonprescription medications and clarify all medications, including name, dose and frequency. If a patient identified a dose had been changed or a medication discontinued, staff were directed to call the provider to address the change. All medications orders must include name, dose, frequency and route.

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 observation, interview and document review the agency failed to initiate and provide services as ordered on admission for 1 of 7 patients (P6) whose orders were reviewed during home visits. In addition, the agency failed to ensure medications were administered only as ordered by the provider for 1 of 7 patients (P9) whose orders and medications were reviewed during home visits. P9 P9's plan of care (POC) for certification period 8/16/25 to 10/14/25, indicated a start of care date of 6/17/25. The POC lacked a lidocaine patch listed on the section titled, "Medications." P9's POC for certification period 6/17/25 to 8/15/25, also lacked a lidocaine patch listed in the medications section. P9's home health admission orders dated 6/13/25, indicated P9 had been on a 4% lidocaine patch while at the care center but was scratched through and discontinued at time of discharge from the care center and admission to home health agency. During an observation on 8/19/25 at 2:08 p.m., registered nurse (RN)-B spoke with P9 about trying Lidocaine patches and then proceeded to go into another room for privacy and assisted P9 to place the lidocaine patch P9's body. During an interview on 8/20/25 at 9:04 a.m., RN-B stated she had assisted P9 to place the lidocaine patch. There were orders for the Lidocaine patch that were part of the admission orders when the home health agency started care. The lidocaine patch had been on the original medication profile and medication list. She was not sure why it was not on the most recent POC and medication profile. RN-B stated there was no current order for the lidocaine patch. During an interview on 8/20/25 at 2:18 p.m., the administrator reviewed P9's POC's and acknowledged there were no orders for lidocaine patches to be administered. The home health agency admission orders were also reviewed and acknowledged the orders for lidocaine patches at the care center had been scratched out. The administrator stated an expectation the nursing staff would get orders for new medications and update the profile before setting up or assisting in the administration of those medications. Agency policy Medication Administration, Home Health dated 4/8/25, indicated a provider order was necessary on the POC or interim order sheet for any medication administered by the agency staff. Findings include: P6 P6's plan of care (POC) 8/2/25 to 9/30/25, identified a start of care (SOC) date 8/2/25. Diagnoses included fracture of the first cervical vertebra (located in the neck), chronic combined systolic and diastolic heart failure (serious condition when the heart is unable to pump blood effectively), emphysema (lung disease), atrial fibrillation (irregular heartbeat) and dysphagia (difficulty swallow). Services included on the agency's POC included skilled nurse visits (SNV) one time per week for one week, two times per week for one week and one time per week for three weeks, physical therapy (PT) one time per week for one week, occupational therapy (OT) one time per week for seven weeks and home health aide (HHA) one time per week for four weeks. P6's home care referral faxed to the agency on 7/31/25, identified a Face-to-Face Attestation encounter for home health care had been completed on 7/31/25. Primary services ordered for home care included skilled nurse visits, physical therapy, occupational therapy, home health aide and speech therapy. Review of P6's clinical record identified P6 was discharged to home on 7/31/25 and admitted to home care services on 8/2/25. Services for skilled nurse, PT, OT and HHA had been initiated; however, speech therapy had not been initiated as ordered. The clinical record failed to identify any reason why P6 had not been assessed and evaluated by a speech therapist or if the speech therapist had been notified of the need for services on P6's admission to home care services on 8/2/25. The clinical record also lacked evidence P6's physician was notified of the delay in speech therapy services. During a home visit conducted on 8/20/25 at 11:00 a.m., P6 was observed sitting in a chair with a cervical brace around her neck. P6 stated she had swallowing issues and choked easily. P6 stated no one had offered her speech therapy services since she had returned home. P6 stated she thought it would be a good idea to have a speech evaluation completed though, as she did have swallowing issues. During interview on 8/20/25 at 11:30 a.m., registered nurse (RN)-A stated she reviewed P6's chart and could not find speech therapy had been ordered. The speech referral should have been made on admission and scheduled within one to two weeks of admission, and it had not been done. RN-A would make a speech therapy referral for P6 now. During joint interview on 8/20/25, at 3:00 p.m. with clinical manager (CM)-B and the administrator, CM-B stated the referral to start speech therapy services for P6 must have been missed. CM-B felt it may have been missed due to the agency had just changed to a new computer system and the agency staff were just learning how to work in it. P6 should have received a speech therapy evaluation and CM-B put in an order that day for one to be completed. The agency's policy Treatment and Therapy Management dated 1/2/25, identified all new or modified orders for treatment or therapy should be communicated within 24 hours.

On 4/3/23-4/5/23, a survey for compliance with Appendix Z, Emergency Preparedness Requirements, §483.73(b)(6) was conducted during a standard recertification survey. The facility was in compliance.

On 4/3/23-4/5/23 a recertification and complaint survey were conducted. This resulted in a partial extended survey. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. H8086005 was unsubstantiated, no deficiencies were issued. 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: 819 Total home visits conducted: 7 Good Samaritan Home Care Robbinsdale No branch offices. Hours of Operation: 8:00 a.m. to 4:30 p.m. Total number of records reviewed: 17.

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 observation, interview, and document review the agency failed to ensure medications were administered per physician's orders for 1 of 1 patient (P12) reviewed for medications. Findings include: P12's plan of care (POC) for the certification period 3/12/23 to 5/10/23 included mild cognitive impairment and diagnoses of age-related osteoporosis with current pathological fracture of vertebra(e), Alzheimer's disease, and history of falling. It further included P12 received skilled nursing visits one time a week to review medication list and reconcile. P12's POC included the following medications: Tums chewable tablet 500 milligrams (mg), take 1 tablet by mouth daily at noon and B-6 50 mg, take 1 tablet by mouth daily in the morning. During observation on 4/4/23 at 10:00 a.m., registered nurse (RN)-A assisted P12 to set up her medications into daily pill boxes for the following week (4/5/23-4/11/23). RN-A had a printed medication list and P12 had another list her family had made for her. P12's current medication bottles were compared to the medications listed on the POC, however two of the medications had the incorrect dosage. One of the medications was Tums which indicated the dosage to be 750 mg and the bottle of B-6 which indicated the dosage was 100 mg. During an interview on 4/4/23 at 10:30 a.m., RN-A stated when setting up patient's medications, nurses were supposed to use the physician's orders in the patient's medical record. RN-A further stated nurses are supposed to reconcile medications with every recertification, but he reconciles them each time he visits the patient. P12's physician's orders located in the medical record indicated Tums chewy bites 750 mg, take 1 tablet by mouth daily and B-6 100 mg, take 1 tablet by mouth daily. Both of these OTC medications had a start date of 4/4/23. During an interview on 4/5/23 at 12:50 p.m., the clinical manager stated the nurses should be using the physician's orders in the patients' medical record when setting up their medications and they are responsible for ensuring the bottles of medications match what is in the medical record. The clinical manager also verified the dosages for the Tums and the B-6 were not updated in the medical record and RN-A had failed to reconcile the dosage on the medication bottles with the medical record. During a follow up interview on 4/5/23 at 2:00 p.m. RN-A stated he wasn't aware the dosage of the Tums or B-6 had changed until he arrived to set up P12's medications on 4/4/23. RN-A further stated he should have called the doctor if there was a discrepancy with the medications in the patient's medical record and the medications themselves (dosage, frequency, route, etc.) but he hadn't done that yet. RN-A also stated he updated the start date of P12's Tums and B6 following the medication set up when the surveyor asked about the discrepancy. The agency's policy regarding medication management dated 10/19/22 indicated the purpose of the policy was to ensure medication records accurately reflect the patient's current medication regimen.

On 3/2/22 through 3/3/22, 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: Patient Rights 42 CFR 484.50 at G406 was found not met. As a result a partially extended survey was conducted. The following complaint H8086003C, intake# 62168 was substantiated with additional standard deficiencies issued at G482, and G488 An Immediate Jeopardy (IJ) began on 2/14/22, when staff left P1 alone and unattended in the shower tub after P1 refused to get out of the tub for LPN-A to complete wound care. The agency Administrator was notified of the IJ on 3/2/22, at 4:10 p.m. The immediate jeopardy was removed on 3/3/22 at 12:40 p.m. after it could be verified the agency had implemented an acceptable removal plan.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observation, interview and document review, the home health agency (HHA) failed to meet the Condition of Participation at 484.50, Patient Rights. The HHA failed to ensure 1 of 1 patient (P1) was free from neglect of care when staff left P1 lying at the bottom of the shower tub alone and unattended and was found by another caregiver with water up to his ears, and appeared confused. Refer to G-482: Based on interview and document review, the home health agency (HHA) failed to ensure 1 of 1 patients (P1) was free from neglect of care when staff left P1 lying at the bottom of the shower tub alone and unattended and was found by another caregiver with water up to his ears, and appeared confused. An Immediate Jeopardy was called on 3/2/22, at 4:10 p.m. related to P1 being found on 2/14/22, lying flat on his back in the tub with the water from the shower faucet still running slowly and the water was up to P1’s ears. LPN-A left P1 unattended and left the house. P1 had physical limitations which could have prevented him from removing himself from a serious situation such as drowning or injury, impairment from falling.

Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to ensure 1 of 1 patient (P1) was free from neglect of care when staff left P1 lying at the bottom of the shower tub alone and unattended and was found by another caregiver with water up to his ears, and appeared confused. The Immediate Jeopardy (IJ) began on 2/14/22, when staff left P1 alone and unattended in the shower tub after P1 refused to get out of the tub for LPN-A to complete wound care. The agency Administrator was notified of the IJ on 3/2/22, at 4:10 p.m. The immediate jeopardy was removed on 3/3/22 at 12:40 p.m. after it could be verified the agency had implemented an acceptable removal plan. P1’s plan of care (POC) for certification period of 12/13/21, through 2/10/22, identified diagnoses of Parkinson’s disease, multiple sclerosis, type 2 diabetes, chronic obstructive pulmonary disease, paraplegia, and dementia. The Outcome and Assessment Information Set (OASIS) assessment completed on 2/21/22, indicated functional factors of concern and included weakness, ambulation, transfers, and unwillingness to use assistive devices. The POC further indicated P1 received skilled nursing services three times weekly for nine weeks for wound care to the right posterior thigh proximal and distal, right groin and setting up medications. The POC identified P1 lived at home alone, and the goal was to ensure P1 remained safe at home, free of injury and indicated any signs or symptoms of abuse or neglect including unexplained injuries, bruising, malnutrition, or mood changes were to be reported to the State Agency (SA). P1's OASIS assessment completed on 12/10/21, indicated P1 required intermittent supervision or encouragement or reminders with bathing and transfers and indicated P1 required minimal human assistance or use of assistive devices. P1's Vulnerable Adult Assessment dated 10/13/21, identified P1 was not cooperative/competent with the plan of care at times, was susceptible to abuse by others, was dependent on caregiver, had chronic conditions/illnesses/disability and was considered vulnerable to abuse and neglect. Review of the Minnesota Adult Abuse Reporting Center (MAARC) alleged event date 2/14/22, indicated agency staff was in P1's home to assist P1 with bathing and the staff had gotten frustrated with P1 while P1 was in the bathtub and indicated staff had left the home while P1 was still in the tub with the water running. The report also alleged P1 was unable to shut off the bathtub water on his own and the staff had called P1's caregiver to inform her she was leaving. When caregiver arrived, P1 was still lying at the bottom of the bathtub partly submerged with the water still running and 911 was called to bring P1 to the hospital for evaluation. Review of the agency Home Health Suggestion, Complaint/Concern or Grievance dated 2/15/22, indicated staff had arrived at home for routine wound care visit and had found P1 with diarrhea and stool all over. P1 was lethargic per staff report. Staff did contact FM-A and P1 was brought to the shower but continued stooling, was uncooperative and argumentative. After several attempts, staff left P1 in the tub and left the home. FM-A arrived later and P1 was in the tub lying down and was disoriented. FM-A called 911 and P1 was admitted to the hospital. FM-A was upset that P1 was left alone in the tub and FM-A reported receiving several calls/texts from staff but was shocked that P1 was alone. Review of the Client Compliant Log form provided by the clinical supervisor on 3/2/22, at 11:40 a.m. revealed on 2/15/22, it was documented a complaint had been filed by family member (FM)-A that licensed practical nurse (LPN)-A had left P1 in an unsafe environment. In the resolution column was the comment that the administrator and clinical supervisor discussed with FM-A that the agency would rotate more staff in P1's home. The log lacked evidence of further documentation of the incident or follow up with other staff. Review of the agency internal Investigation Report dated 2/15/22, indicated on 2/14/22, at 8:30 a.m. agency staff had left P1 in the bathroom alone and had not waited for FM-A to arrive. The report also indicated P1 had occasional episodes of similar behaviors of being uncooperative, agitated, refusing cares and demanding staff to leave. The report indicated P1 had increased confusion throughout the morning, and "staff should not have left him alone." The report indicated corrective action of the staff involved, and indicated the clinical supervisor had reviewed the incident and education and coaching was provided. In addition, the report indicated "Not Applicable" for reporting to the State Agency. During interview on 3/2/22, at 11:56 a.m. the clinical supervisor acknowledged she had been informed about the incident by FM-A and said LPN-A should not have left P1 in the tub alone and unattended in the home despite P1 refusing to get out of the tub as P1 had physical and functional limitations and was a vulnerable adult. The clinical supervisor stated after the incident was reported to her by FM-A on 2/15/22, as the incident had happened on 2/14/22, she had called and reviewed the incident with LPN-A and at that time education and coaching was given to LPN-A. The clinical manager stated following the incident with P1, LPN-A had not returned to work with P1 but continued to work with other patients assigned. The clinical manager further acknowledged following the incident, no education had been completed for other staff on neglect of care and dealing with behavioral dementia challenges. During interview on 3/2/22, at 12:30 p.m. FM-A who was P1’s caregiver stated on 2/14/22, LPN-A had informed her P1 had “pooped” all over the place in the bedroom and LPN-A assisted P1 into the shower. FM-A added that she turned around in her car at the time of the call to go to the store to get cleaning supplies, instead of coming to P1’s home. LPN-A had again contacted her to let her know she had left P1 in the tub alone. FM-A stated she had questioned LPN-A about P1 being in the tub as he had never used the tub and would not be physically able to get out of the tub due to physical limitations, but LPN-A still left. FM-A stated when she arrived at the home, she found P1 lying flat on his back on the bottom of the tub with the water from the shower faucet still running slowly and the water was up to P1’s ears. FM-A stated she did not know how long P1 had been lying in that position prior to her arrival. FM-A stated upon seeing P1 in that state she called P1's name several times and had noticed P1 appeared confused, was not making sense through the conversation and his eyeballs were bulging which was not normal. FM-A stated she had assisted P1 physically out of the tub and then called 911 because P1 appeared as though he was going to faint. FM-A then stated she had contacted the agency clinical supervisor and reported the incident and had questioned why LPN-A who had worked with P1 for 2 years had left P1 in the tub alone and if this was normal as she had concerns of P1 drowning or hitting his head if he had attempted to get out and could have sustained a head injury. On 3/2/22, at 1:02 p.m. LPN-A stated after P1 was in the shower, P1 had called for assistance but when she checked with P1, P1 did not say what he needed help with. LPN-A then stated P1 had gotten out of the shower at some point and had a bowel movement on the bathroom floor and went back into the shower then after she had completed setting up the medications, she had checked on P1 and this time she found him lying on his back at the bottom of the bathtub with the water running from the shower and she had turned the water off. LPN-A stated she then asked P1 to come out of the tub/shower so she could perform the wound care but P1 refused. LPN-A then stated she asked P1 to come out several times and P1 told her “Shut up already" and asked her to leave and P1 did not care which was "unusual." LPN-A stated during the visit she felt P1 was “not quite right but could not put my finger to his behaviors” but was not emergent to her so once P1 started moving around she thought P1 was okay. LPN-A stated "I should have followed my gut. I did not think he was not safe. I wanted to respect his wishes. I look back and think I should have called 911 and stayed." LPN-A stated she had called her agency case manager but had no response but did not think of calling the clinical manager to alert them she had to leave P1 alone. When asked what time she had left P1 alone in the home unattended and in the bathtub, LPN-A stated she was not certain, but thought was after 9:00 a.m. LPN-A acknowledged she should not have left P1 alone in the tub despite P1 refusing wound care. LPN-A stated although P1 was able to physically get in and out of the shower independently, she was not sure if P1 would have been able to physically get out of the tub alone and that she was not aware until FM-A had informed her P1 had never used and been in a tub before. LPN-A acknowledged P1 had physical limitations which could hinder him from physically being able to do several things. LPN-A stated following the incident she had been educated who to contact when incidences happened however, she acknowledged no further education had been completed on vulnerable adult, neglect of care and dealing with behavioral challenges related to dementia. LPN-A further stated following the incident she continued to work with other patients but had not worked with P1. On 3/2/22, at 3:35 p.m. the administrator stated at the time the incident occurred they were made aware of the incident but indicated at the time FM-A made it seem like "not a big deal." The administrator stated she and the clinical supervisor had spoken to FM-B who had made it clear she was not very happy about the situation. The administrator stated following the incident at the supervisor meeting held on 2/15/22, there was discussion that in March all the staff were to focus on the process for when to file a vulnerable adult report, documentation of the report and she had sent a policy to staff and indicated the agency was planning to complete the training with the staff in the month of March. The administrator acknowledged no other training had been completed with LPN-A or the rest of the staff immediately following the incident. The administrator stated she was not aware of the details of P1 being found submerged in water in the bottom of the tub. The administrator acknowledged the immediacy of the need of all staff being educated and stated the training was scheduled to be completed on 3/3/22, after the surveyor was on site for the investigation. The immediate jeopardy was removed on 3/3/22, at 12:40 p.m. after it was verified that all agency staff were directed to attend mandatory education and training meeting on 3/3/22 at 9:00 a.m. onsite or via WebEx to address the following items including vulnerable adult (VA) reporting, abuse and neglect, dementia with behaviors, copies of the VA policy were sent out to all staff on reporting of maltreatment of vulnerable adults and the policy was reviewed during 3/3/22 meeting. The agency suspended LPN-A on 3/2/22, pending the investigation outcome, all staff were assigned other training on-line to be completed by 3/31/22, on understanding dementia, communication in people with dementia, behaviors and symptoms, mandated reporting and abuse and neglect of the vulnerable adult. In addition, the agency started to call patients assigned to LPN-A to ask about quality of care/satisfaction of services. The agency Reporting Abuse and Neglect policy revised 11/4/21, defined neglect as "Failure to provide goods and/or services necessary to avoid physical harm, mental anguish or mental illness." The policy directed staff to report any situation that may be considered abuse, neglect or misappropriation of patient/client property immediately to the administrator or designee. In addition, the policy directed "if this is an allegation of employee to patient/client abuse, the employee will be removed from providing services to all patients/clients while the situation is under investigation. Additionally, the employee will be placed on suspension pending results of the investigation. The administrator/designated will notify any designated agencies in accordance with any state abuse and neglect reporting laws..."

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 report immediately to the State Agency (SA) an allegation of neglect of care for 1 of 1 patient (P1) reviewed for patient rights. P1’s plan of care (POC) for certification period of 12/13/21, through 2/10/22 identified diagnoses of Parkinson’s disease, multiple sclerosis, type 2 diabetes, chronic obstructive pulmonary disease, paraplegia, and dementia. The Outcome and Assessment Information Set (OASIS) assessment completed on 2/21/22, indicated functional factors of concern included weakness, ambulation, transfers, and unwillingness to use assistive devices. The POC also indicated P1 received skilled nursing services three times weekly for nine weeks for wound care to the right posterior thigh proximal and distal, right groin and setting up medications. The POC identified P1 lived at home alone, and the goal was to ensure P1 remained safe at home free of injury and indicated any signs or symptoms of abuse or neglect including unexplained injuries, bruising, malnutrition, or mood changes were to be reported to the SA. P1's Vulnerable Adult Assessment dated 10/13/21, identified P1 was not cooperative/competent with the plan of care at time, was susceptible to abuse by others, was dependent on caregiver, had chronic conditions/illnesses/disability and was considered vulnerable to abuse and neglect. Review of the Minnesota Adult Abuse Reporting Center (MAARC) report alleged event date 2/14/22, indicated agency staff was in P1's home to assist P1 with bathing and the staff had gotten frustrated with P1 while P1 was in the bathtub and staff had left the home while P1 was still in the tub with the water running. The report also alleged P1 was unable to shut off the bathtub water on his own and the staff had called P1's caregiver to inform her she was leaving. When the caregiver arrived, P1 was still lying at the bottom of the bathtub partly submerged with the water still running and 911 was called to bring P1 to the hospital for evaluation. Review of the agency Home Health Suggestion, Complaint/Concern or Grievance form dated 2/15/22, indicated staff had arrived at home for routine wound care visit and had found P1 with diarrhea and stool all over. P1 was lethargic per staff report. Staff did contact FM-A and P1 was brought to the shower but continued stooling, was uncooperative and argumentative. After several attempts, staff left P1 in the tub and left the home. FM-A arrived later and P1 was in the tub lying down and was disoriented. FM-A called 911 and P1 was admitted to the hospital. FM-A was upset that P1 was left alone in the tub. FM-A reported receiving several calls/texts from staff but was shocked that P1 was alone. Review of the Client Compliant Log form provided by the clinical supervisor on 3/2/22, at 11:40 a.m. revealed on 2/15/22, it was documented a complaint had been filed by family member (FM)-A that licensed practical nurse (LPN)-A had left P1 in an unsafe environment. In the resolution column was the comment that the administrator and clinical supervisor discussed with FM-A that the agency would rotate more staff in P1's home. The log lacked evidence of further documentation of the incident or follow up with other staff. Review of the agency internal Investigation Report dated 2/15/22, indicated on 2/14/22, at 8:30 a.m. agency staff had left P1 in the bathroom alone and had not waited for FM-A to arrive. The report also indicated P1 had occasional episodes of similar behaviors of being uncooperative, agitated, refusing cares and demanding staff to leave. The report indicated P1 had increased confusion throughout the morning, and "staff should not have left him alone." The report indicated the corrective action of the staff involved and indicated the clinical supervisor had reviewed the incident and education and coaching had been provided. In addition, the report indicated "Not Applicable" for reporting to the State Agency. During interview on 3/2/22, at 11:56 a.m. the clinical supervisor acknowledged she had been informed about the incident by FM-A and LPN-A should not have left P1 in the tub alone and unattended in the home despite P1 refusing to get out of the tub as P1 had physical and functional limitations and was a vulnerable adult. The clinical supervisor stated after the incident was reported to her by FM-A on 2/15/22, since the incident happened on 2/14/22, she had called and reviewed the incident with LPN-A and at that time education and coaching was provided to LPN-A. The clinical manager further acknowledged the agency had not reported the allegation to the SA. During interview on 3/2/22, at 12:30 p.m. FM-A who was P1’s caregiver stated on 2/14/22, LPN-A had informed her P1 had pooped all over the place in the bedroom and LPN-A assisted P1 into the shower. FM-A added that she turned around in her car at the time of the call to go to the store to get cleaning supplies, instead of coming to P1’s home. LPN-A had again contacted her to let her know she had left P1 in the tub alone. FM-A stated she had questioned LPN-A about P1 being in the tub as he had never used the tub and would not be able physically to get out of the tub due to physical limitations, but LPN-A still left. FM-A stated when she arrived at the home, she found P1 lying flat on his back at the bottom of the tub with the water from the shower faucet still running slowly and the water was up to P1’s ears. FM-A stated she did not know how long P1 had been lying in that position prior to her arrival. FM-A stated upon seeing P1 in that state she called P1's name several times and had noticed P1 appeared confused, was not making sense through the conversation and his eyeballs were bulging which was not normal. FM-A stated she had assisted P1 physically out of the tub and had then called 911 because P1 appeared as though he was going to faint. FM-A then stated she had contacted the agency clinical supervisor and reported the incident and had questioned why LPN-A who had worked with P1 for 2 years had left P1 in the tub alone and if this was normal as she had concerns of P1 drowning or hitting his head if he had attempted to get out and could have sustained a head injury. On 3/2/22, at 1:02 p.m. LPN-A stated she should have not left P1 alone and unattended in the tub despite P1 refusing wound care. LPN-A stated although P1 was able to physically get in and out of the shower independently, she was not sure if P1 would have been able to physically get out of the tub alone and that she had not been aware until FM-A had informed her P1 had never used and been in a tub before. LPN-A acknowledged P1 had physical limitations which would hinder him from physically being able to do several things. LPN-A further stated following the incident she continued to work with other patients but had not worked with P1. On 3/2/22, at 3:35 p.m. the administrator stated at the time of the incident they were made aware of the incident but at the time FM-A made it seem like "not a big deal." The administrator stated she and the clinical supervisor had spoken to FM-B who had made it clear she was not very happy about the situation. The administrator stated following the incident at the supervisor meeting held on 2/15/22, there was discussion that in March, all the staff were to focus on the process for when to file a vulnerable adult report and documentation of the report and indicated. The administrator stated she had sent a policy to staff and the agency was planning to complete the training with the staff in the month of March. The administrator stated she was not aware of the details of the P1 being found submerged in water in the bottom of the tub. The administrator stated the incident was not reported to the SA, but the agency had completed the internal investigation. The agency Reporting Abuse and Neglect policy revised 11/4/21, defined neglect as "Failure to provide goods and/or services necessary to avoid physical harm, mental anguish or mental illness." The policy directed staff to report any situation that may be considered abuse, neglect, or misappropriation of patient/client property immediately to the administrator or designee. In addition, the policy directed "if this is an allegation of employee to patient/client abuse, the employee will be removed from providing services to all patients/clients while the situation is under investigation. Additionally, the employee will be placed on suspension pending results of the investigation. The administrator/designated will notify any designated agencies in accordance with any state abuse and neglect reporting laws..."