Every finding on record at Avera at Home Southwest Minnesota

Based on interview and record review, the agency failed to ensure registered nurse (RN) supervisory visits were made at least every 14 days for 5 of 14 patients (P2, P8, P10, P11, and P14) patients in the sample who received home health aide (HHA) services. --- P2 was admitted for hospice services on 6/4/25, with diagnoses that included gastrointestinal hemorrhage, Alzheimers, vascular dementia, chronic kidney disease, diabetes, and congestive heart failure. The current plan of care indicated P2 received skilled nurse services twice weekly. The plan of care also indicated the patient received home health aide (HHA) services twice weekly to assist the patient with personal cares. P2’s medical record indicated the registered nurse (RN) had completed a supervisory visit on 6/23/25. The HHA visited the patient twice weekly, The RN continued with twice weekly visits, however, there was no supervisory visit completed again until 8/11/25.P8 was admitted for hospice services on 7/15/25, with diagnoses that included pneumonia, dementia, malnutrition, chronic obstructive pulmonary disease (COPD) and osteoporosis. The current plan of care indicated P8 received skilled nurse services twice weekly. The plan of care also indicated the patient received HHA services weekly to assist the patient with personal cares. P8’s medical record indicated the RN had completed a supervisory visit on 8/1/25. The HHA visited P8 weekly, the RN visited twice weekly, however the next supervisory visit was completed on 8/25/25. P10 was admitted for hospice services on 7/23/25, with diagnoses that included COPD, severe protein-calorie malnutrition, anxiety and chronic respiratory failure. The current plan of care indicated P10 received skilled nurse services twice weekly. The plan of care also indicated the patient received HHA services twice weekly to assist the patient with personal cares.P10’s medical record indicated the RN had completed a supervisory visit on 9/2/25. The next supervisory visit was completed on 9/19/25.P11 was admitted for hospice services on 6/30/25, with diagnoses that included senile degeneration of brain, dementia, and osteoporosis. The current plan of care indicated P11 received skilled nurse services twice weekly. The plan of care also indicated the patient received HHA services twice weekly to assist the patient with personal cares.P11’s medical record indicated the RN had completed a supervisory visit on 7/3/25. The next supervisory visit was completed on 7/28/25.P14 was admitted for hospice services on 6/27/25, with diagnoses that included senile degeneration of brain, dementia, basal cell carcinoma, heart failure, and osteoporosis. The current plan of care indicated P14 received skilled nurse services twice weekly. The plan of care also indicated the patient received HHA services twice weekly to assist the patient with personal cares.P14’s medical record indicated the RN had completed a supervisory visit on 8/31/25. P14’s medical record failed to indicate another supervisory visit was completed. When interviewed on 9/23/25, at 2:15 p.m. RN-A stated the supervisory visit doesn’t always trigger to be completed, at some point there was a change, it’s gotten easier to miss the supervisory visits. During an interview on 9/24/25, at 10:08 a.m. RN-B stated every fourteen days there is a task that drops into the system for a supervisory visit to be completed. The task drops after the nurse completed the documentation for their visit. Some nurses don’t use the tasks they just document the supervisory visit in the notes, that won’t trigger a task for the next supervisory visit. The system is “glitchy”. Provider policy Care Assistant/Aide Supervisory Visits policy indicated supervision  of aide services must occur at least every 14 days.