Bethesda Home Health

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on document review and interview, the agency failed to develop a plan specific to the home care agency and the electronic medical record system implemented by the agency. This had the potential to affect all 146 patients served by the agency. On 3/5/24, at approximately 12:30 p.m. during the entrance interview, a list of Emergency Preparedness policies and procedures was requested from the Director of Home Care. At this time, the Director of Home Care stated they are housed within the Bethesda Campus, and are in included the Emergency Operations Plan for Bethesda, however, the agency has specific policies for the home care agency. Upon review of the facility policies for the Bethesda Campus, specific policies for the home health agency and medical documentation were not included. When interviewed on 3/7/24, at approximately 2:30 p.m. the Director of Home Care stated the medical documentation was completed electronically on an internet-based system. The Director stated all of the staff have the capacity to use the hot spot during visits to allow access to the electronic medical records. A review of additional policies provided specifically to Bethesda Home Health was completed to assess plans for electronic connectivity in the midst of a power outage or electronic access with hot spots. The policy, Bethesda Home Health Loss of Telephone Service Policy and Procedure, identified how access would be managed in the event of extended telephone outage. The policy identified the facility would work with the local Emergency Management Team on a communication system, however, lacked definition as to any pre-established plans as to what was to be done. The policy lacked indication of other methods to access information or maintain a functioning medical record in the absence of phone systems as the use for a hot spot. The information provided lacked any alternate documentation system to be implemented in the event the electronic medical record was unavailable. Additionally, the policy Bethesda Home Health Electrical Power Outage Policy and Procedure, last reviewed 9/23, was reviewed, and identified staff was to assure back up phones were available, however, it lacked identification as to how this was to be maintained in the event of a power outage. The Director stated the agency was supported by the main campus in their ongoing access to the electronic medical documentation system.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to include volunteer staffing guidelines with the Emergency Preparedness plan for the agency. This had the potential to impact all clients served by the agency. On 3/5/24, at approximately 12:30 p.m. Emergency Preparedness policies and procedures were requested from the Director of Home Care. The Director of Home Care stated they are housed within the Bethesda Campus, and were included with the Emergency Operations Plan for Bethesda, however, the agency has specific policies for the home care agency. Upon review of the facility policies for the Bethesda Campus, specific policies for the home health agency and the use of volunteers in an emergency response were not provided. When interviewed on 3/7/24, at approximately 2:30 p.m. the Director of Home Care provided a policy for the campus related to use of volunteers. The Director of Home Care stated there were no additional policies specific to Bethesda Home Health related to volunteer use. The Director identified the home health agency did not use volunteers in any capacity, however, the agency lacked specific policies that reflected that.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on interview and document, the agency failed to develop a plan to maintain communication with both staff, and the people who are served by the agency, in the event of disrupted communication with the telephone system. This had the potential to impact all patients served by the home care agency. On 3/5/24, at approximately 12:30 p.m. during the entrance interview, the Emergency Preparedness policies and procedures were requested from the Director of Home Care. The Director of Home Care stated as the agency was housed within the Bethesda Campus, and were included the Emergency Operations Plan for Bethesda, however, the agency has specific policies for the home care agency. Upon review of the specific policies for the home health agency related to the Communications Policy and Procedures, last reviewed 9/23, it was identified in the event of a power outage, or other circumstances when the agency was out of telephone service, the agency staff were to contact the local Emergency Management Team, Kandiyohi Emergency Operations Center (EOC) who were to assign a communication system. The policy lacked any indication of prior planning, training, or exercising of potential alternate plans of communication. When interviewed on 3/7/24, at approximately 2:30 p.m. the Director of Home Care stated in the event of an emergency, the agency would drive to the individual’s home when needed, however, the policy lacked this information.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on document review and interview, the agency failed to develop an inclusive listing of names and contact information for internal critical contacts for Bethesda Home Health Care. This had the potential to impact all staff working for the home health agency, as well as the patients served by the agency. On 3/5/24, at approximately 12:30 p.m. the Emergency Preparedness policies and procedures were requested from the Director of Home Care. At this time, the Director of Home Care stated although they are housed within the Bethesda Campus, and are included the Emergency Operations Plan for Bethesda, however, the agency has specific policies for the home care agency. Upon review of the facility policies for the Bethesda Campus, specific policies and information for critical contacts for Bethesda Home Health Care was not identified. A review of the Bethesda Home Health Communications Policy and Procedure, last reviewed 9/23, also lacked this information. During interview on 3/7/24, at approximately 2:30 p.m. the Director of Home Care stated in the event of an emergency response, the Bethesda Complex Critical Contacts listing information would be used. The Director stated the chain of command outlined in both the Bethesda Emergency Calling Tree and Incident Command Structure was used in the event of emergency response. A review of both the Bethesda Emergency Calling Tree and Incident Command Structure, undated, were noted to lack any identified staff for the Bethesda Home Health Care in any capacity.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interview and document, the agency failed to develop a plan for alternate communication with both staff, and the people who are served by the agency, in the event of disrupted communication related to telephone or cellular services, or power outage. This had the potential to impact all patients served by the home care agency. On 3/5/24, at approximately 12:30 p.m. the Emergency Preparedness policies and procedures were requested from the Director of Home Care. The Director of Home Care stated as the agency was housed within the Bethesda Campus, and were included the Emergency Operations Plan for Bethesda, however, the agency has specific policies for the home care agency. Upon review of the specific policies for the home health agency related to the Communications Policy and Procedures, last reviewed 9/23, it was identified in the event of a power outage, or other circumstances when the agency was out of telephone service, the agency staff were to contact the local Emergency Management Team, Kandiyohi Emergency Operations Center (EOC) who were to assign a communication system. The policy lacked any indication of prior planning, training, or exercising of potential alternate plans of communication. Additionally, the policy lacked alternate resources explored with the EOC prior to the loss of communication systems. When interviewed on 3/7/24, at approximately 2:30 p.m. the Director of Home Care stated in the event of an emergency, the agency would drive to the individual’s home when needed, however, the policy lacked this information.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on observation, interview and document, the agency failed to ensure medication set up was completed as ordered for 1 of 1 patient (P4) observed with medication set up. This resulted in a period of five days during which medication was not set up, or available, for P4, and related to medications missed and current diagnoses, was classified as a significant error by the provider. P4’s Home Health Certification and Plan of Care (POC) for the certification period from 1/7/24 to 3/6/24, indicated P4’s principal diagnosis was that of malignant neoplasm (a cancerous tumor), with other pertinent diagnoses listing only personal history of traumatic brain injury (an injury to the brain which can cause alteration in mental state such as disorientation, slow thinking, or difficulty concentrating). Although not listed as the primary, or secondary diagnoses, P4 received medications identified as being ordered for aortic insufficiency, elevated cholesterol, muscle spasms, asthma, gastroesophageal reflux disease (GERD), migraine, sleep problems, allergic rhinitis (allergy symptoms which included sneezing, congestion, itchy nose and watery eyes), depression, nerve pain, and diabetes. P4’s order for discipline and treatments identified P4 was followed with skilled nurse visits one time a week effective 1/28/24, one time a week 2/25/24, one time a week 3/3/24. The plan of care indicated the services provided were to include general health assessment and med set up. P4’s goal, identified 11/8/23, was for P4 to administer medications safely. The POC identified the intervention, started 11/8/23, direct staff to assess for safety concerns and teach as indicated. On 3/5/24, at 2:10 p.m. registered nurse (RN)-A was observed as she completed medication set up of the following medications for a four-week rotation, with the exceptions to this time frame as noted: anastrozole 1 mg daily in the morning for breast cancer atorvastatin 40 mg daily in the morning for cholesterol bupropion XL extended release 150 mg daily in the morning for depression bupropion XL extended release 300 mg daily in the morning for depression cetirizine 10 mg daily in the evening for allergies (medications set up for two weeks due to lack of supply) cholecalciferol (Vitamin D3) 2000 international units/50 mcg daily in the morning vitamin D deficiency diltiazem 120 mg daily in the morning for aortic insufficiency escitalopram 10 mg one tablet daily in the morning for depression and anxiety escitalopram 20 mg one tablet daily in the morning for depression and anxiety famotidine 20 mg one tablet daily in the evening for gastroesophageal reflux disorder (GERD) was set up for a daily frequency, as outlined on the Medication Profile, however, the label identified the medication was to be given twice daily. ferrous sulfate 65 mg elemental iron/325 mg one tablet twice daily as a supplement (medications set up from 3/5/24-3/26/24), however, the Medication Profile identified daily administration, as identified with a start date of 3/5/24, the date of visit. RN-A stated this was to be given twice daily, which corresponded to the prescription label filled by the pharmacy. gabapentin capsule 300 mg one capsule in the evening for nerve pain. melatonin 5 mg one tablet daily for sleep. metformin extended release 500 mg two tablets (total 1000 mg) twice daily for diabetes. nortriptyline 10 mg one capsule daily in the evening for prevention of migraines and insomnia. olanzapine 5 mg daily in the morning for depression. omega-3 polyunsaturated fatty acids (fish oil) 1000 mg capsule twice daily as a supplement was set up for one week only due to limited supply (3/5/24-3/11/24). omeprazole delayed release capsule 40 mg one capsule daily in the morning for GERD During the observation of medication set up, and patient interaction, it was observed that all of medications were absent from the medication sets and were identified by RN-A as having been taken correctly by the patient. P4 had stated when she missed medication doses set up, she left them in the med set and did not double up the medications. During the visit, P4 identified she had been sick with nausea, vomiting and diarrhea recently, however stated she was feeling better. P4 stated she had also experienced an episode where she had blurry vision two days prior to visit (3/3/24), however, that had resolved. P4 inquired of RN-A if blood glucoscan (a test to monitor blood sugars in real time) monitoring was indicated as she was on metformin (an oral medication for management of diabetes)? RN-A stated P4 had her Hgb A1C (a blood test which evaluates a time period versus real time results) monitored, however, stated she (RN-A) was going to message the provider to review this. RN-A instructed P4 on the avoidance of foods high in sugar. RN-A assessed vital signs and her blood pressure was 152/88, her pulse was 88 beats per minute, and oxygen saturation level (amount of oxygen in the blood stream) was at 98%. P4 stated she had experienced occasional headaches since the last visit, however, had treated them effectively with Excedrin Migraine, and had not required her Imitrex (prescription medication for migraine headaches). Following the observation of the home visit, a review of the medication set up documentation was completed for the last two four-week cycles. At this time, the time frames medications were set up were from 1/31/24 through 2/28/24, and 3/5/24 through 4/2/24. Upon review of the documentation, it was identified medication set up was lacking from 2/29/24 (Leap year) through 3/4/24, which totaled a period of five days during which medication had not been set up. At no time during the scheduling of visit for observation, provision of profile and POC for observation, or throughout the home visit observation, was it identified there had been a five-day gap where medication had not been set up or available for the time frame from 2/29/24-3/5/24. Additionally, the interview questions, and review of symptoms, and general assessment lacked discussion of the missed medications with the client as to what she had for remaining meds available for use, how she was feeling, or any indicated follow up with the provider. Although a review of the medical record did identify notification of the missed visit was sent to the provider for the visit of 3/1/24, the electronic signature and date created was on 3/5/24, at 1:19 p.m., just prior to leaving for scheduled visit. The information on the communication provided to the provider lacked any additional information aside from a “skilled visit missed, client is sick”. The documentation failed to inform the provider the medication had not been set up for P4, was not available during the time frame from 2/29/24 through 3/4/24, and did not inquire of any follow up indicated due to missed medication for a period of five days. On 3/7/24, at 9:30 a.m. RN-B was interviewed regarding the process of medication set up and interventions in place in the event of a visit cancellation related to patient illness. RN-B first and foremost identified, as nurses, it was often the role of the nurse to see sick patients. RN-B stated dependent on the patient illness, the appropriate personal protective equipment would be implemented, which may have included a mask, face shield, gloves, or gown. RN-B stated social distancing was an effective measure as well. RN-B stated a backup medication set was generally set up for exactly these situations, whether due to illness or weather. RN-B stated the backup set would be rotated through to remain current and prevent outdates with medication. On 3/7/24, at 10:30 a.m. RN-A stated P4’s visit for medication set up had been cancelled on 2/29/24 related to patient illness. RN-A stated she hadn’t wanted to be exposed to illness, and P4 wasn’t up to a visit. RN-A stated she had reached out in follow up to P4 on 3/1/23 to schedule an alternate visit, but P4 had not responded, in follow up to message. RN-A stated the provider was aware of the services provided for P4 and it was “pretty clear if her nurse didn’t visit, she didn’t get meds.” RN-A stated when she spoke to P4 prior to the visit of 3/5/24, P4 stated she had used up some of the previous medications which had been missed earlier and remained in the med set. RN-A stated typically, an additional med set was set up for those with meds set up every two weeks, however, RN-A stated P4 would have become confused with this. Additionally, RN-A stated as P4 often lacked medication supply to set up a four-week rotation, RN-A was uncertain that an alternate week of medication would be available for set up due to history of lack of medications. On 3/7/24, at 2:30 p.m. Director of Home Care stated it was her expectation visits were made to assure available medications were to patients as ordered by the provider. If visits were missed, the provider was to be contacted in follow up and advised of the medications missed and the duration. The Director stated it was common practice to set up a backup week of medications in a med set, so it was available for use in the event of illness, weather, or cancelled visits. On 3/8/24, at 8:41 a.m. a call was received in follow up the primary physician’s nurse, who indicated the physician reviewed the medications P4 received and missing the medications for the period of time identified was concerned a significant medication error. P4 had resumed medications as ordered on 3/5/24. The facility policy, Missed Visits, last reviewed 9/23, identified when a scheduled visit is missed, the agency was to generate a missed visit report in the Electronic Medical Record (EMR) which was to include the date of the missed visit, reason for missed visit, and documentation for any other action was needed. The facility policy, Development of the Individualized Medication Management Plan (IMMP) and Individualized Medication Administration Record (MAR), last reviewed 9/23, indicated the plan should include the following: Any client-specific requirements relating to documentation of medication administration, verification that all medications are administered as prescribed, and monitoring of medication use to prevent possible complications or adverse reactions. The policy lacked specific direction to the staff as to how to ensure the medication set up process include a plan to prevent missed doses in the event of missed visits.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview and document review the agency failed to show tracking and trending of quality indicators that could improve health outcomes with the Quality Assessment Performance Improvement (QAPI) program. On 3/7/24 at 2:20 p.m., the administrator stated the purpose of the QAPI program was to identify trends problems quality. She stated “we talk about admissions, client issues, falls, reportable incidents. The administrator denied keeping a log of grievances. On 3/7/24 at 3:41 p.m., the administrator stated there were no current performance improvement projects the QAPI committee was working on. A facility document, Meeting Minutes, dated 11/3/23. Agenda consisted of new EMR (electronic medical record) concerns, on-call schedule, admin sheets, admissions/census, staffing concerns. The document lacked evidence of internal audits, tracking/trending of incidents, infections, or concerns. The document lacked evidence of PIPs. The attendees listed did not include a representative of therapy or the medical director. A facility document, Nurse meeting notes, dated 9/8/23 were not indicated as a QAPI meeting. The agenda indicated review of new EMR. The document lacked evidence of internal audits, tracking/trending of incidents, infections, or concerns. The document lacked evidence of PIPs. The attendees listed did not include a representative of therapy or the medical director. A facility document, email from administrator to medical director, dated 3/7/24 at 3:05 p.m., with subject line of quarterly QAPI on 11/3/23, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, falls, complaints, staffing concerns and new software were discussed at the meeting. A facility document, email from administrator to medical director, dated 3/7/24 at 3:12 p.m., with subject line of QAPI meeting September 2023, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, and encouraging clients to get flu shots in October. The facility policy, Quality Management Plan, dated 9/2023, directed the home care director/registered nurse (RN) will develop a continuous quality improvement and management program to maintain the agency’s continuous performance improvement efforts, consistent with current professional standards and the highest quality services for clients. All staff will be involved in the implementation of performance improvement efforts. 1 The Home Care Director/RN will establish a quality management program to develop and maintain the agency’s continuous performance improvement efforts. 1 1. The Home Care Director/RN will establish a quality management program to develop and maintain the agency’s continuous performance improvement efforts. 2 2. The Home Care Director/RN will establish a quality council made up of key staff to develop and implement the agency’s quality management program. 3. The quality council meetings will be held at least quarterly to identify and review dashboard and other quality measures, set goals and identify needed changes in procedures or training for staff. 4. Data and information that will be evaluated by the quality council include: a. complaints and feedback from clients, clients’ representatives, clients’ families and agency staff; b. vulnerable adult reports made to the common entry point; c. incident reports; d. medication errors; e. results of audits of client records; f. results of audits of personnel files; g. current data on dashboard measures; h. results of MDH (Minnesota Department of Health) regular surveys and OHFC (Office for Health Facility Complaints) surveys of our agency; and i. other relevant information. 5. Minutes of the quality council meetings will be summarized for all staff to review. The minutes are intended to inform staff of monitoring results and trends, the focus of improvement efforts and quality goals. 7. Improvement projects will be assigned to project teams or individuals by the council.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on interview and document review the agency’s Quality Assessment Performance Improvement (QAPI) committee failed to track and analyze patient concerns and events. On 3/7/24 at 2:20 p.m., the administrator stated the purpose of the QAPI program was to identify trends problems quality. She stated “we talk about admissions, client issues, falls, reportable incidents. The administrator stated there was a recent complaint where a patient was dissatisfied with the lack of service a homemaker was providing. The administrator stated the agency lacked a tracking system for complaints. The administrator stated the most recent QAPI committee meeting was held 11/3/23. On 3/7/24 at 3:41 p.m., the administrator stated there were no current performance improvement projects the QAPI committee was working on. A facility document, Meeting Minutes, dated 11/3/23. Agenda consisted of new EMR (electronic medical record) concerns, PT, on-call schedule, admin sheets, admissions/census, staffing concerns. The document lacked evidence of internal audits, tracking/trending of incidents, infections, or concerns. The document lacked evidence of PIPs. A facility document, Nurse meeting notes, dated 9/8/23 were not indicated as a QAPI meeting. The agenda indicated review of new EMR. The document lacked evidence of internal audits, tracking/trending of incidents, infections, or concerns. The document lacked evidence of PIPs. A facility document, email from administrator to medical director, dated 3/7/24 at 3:05 p.m., with subject line of quarterly QAPI on 11/3/23, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, falls, complaints, staffing concerns and new software were discussed at the meeting. A facility document, email from administrator to medical director, dated 3/7/24 at 3:12 p.m., with subject line of QAPI meeting September 2023, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, and encouraging clients to get flu shots in October. The facility policy, Quality Management Plan, dated 9/2023, directed the home care director/registered nurse (RN) will develop a continuous quality improvement and management program to maintain the agency’s continuous performance improvement efforts, consistent with current professional standards and the highest quality services for clients. All staff will be involved in the implementation of performance improvement efforts. 3. The quality council meetings will be held at least quarterly to identify and review dashboard and other quality measures, set goals and identify needed changes in procedures or training for staff. 4. Data and information that will be evaluated by the quality council include: a. complaints and feedback from clients, clients’ representatives, clients’ families and agency staff; b. vulnerable adult reports made to the common entry point; c. incident reports; d. medication errors; e. results of audits of client records; f. results of audits of personnel files; g. current data on dashboard measures; h. results of MDH (Minnesota Department of Health) regular surveys and OHFC (Office for Health Facility Complaints) surveys of our agency; and i. other relevant information.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and document review the agency’s Quality Assessment Performance Improvement (QAPI) committee failed to identify performance improvement projects with the potential to improve quality of care. On 3/7/24 at 2:20 p.m., the administrator stated the purpose of the QAPI program was to identify trends problems quality. On 3/7/24 at 3:41 p.m., the administrator stated there were no current performance improvement projects the QAPI committee was working on, as there were no areas of identified concerns. A facility document, Meeting Minutes, dated 11/3/23. Agenda consisted of new EMR (electronic medical record) concerns, PT, on-call schedule, admin sheets, admissions/census, staffing concerns. The agenda did not include any patient outcome-based improvement projects. A facility document, Nurse meeting notes, dated 9/8/23 were not indicated as a QAPI meeting. The agenda indicated review of new EMR. The content provided included an overview of the new EMR software program. A facility document, email from administrator to medical director, dated 3/7/24 at 3:05 p.m., with subject line of quarterly QAPI on 11/3/23, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, falls, complaints, staffing concerns and new software were discussed at the meeting. The email did not include any improvement projects. A facility document, email from administrator to medical director, dated 3/7/24 at 3:12 p.m., with subject line of QAPI meeting September 2023, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, and encouraging clients to get flu shots in October. The email did not include any identified improvement projects. The facility policy, Quality Management Plan, dated 9/2023, directed the home care director/registered nurse (RN) will develop a continuous quality improvement and management program to maintain the agency’s continuous performance improvement efforts, consistent with current professional standards and the highest quality services for clients. All staff will be involved in the implementation of performance improvement efforts. 1 1. The Home Care Director/RN will establish a quality management program to develop and maintain the agency’s continuous performance improvement efforts. 3. The quality council meetings will be held at least quarterly to identify and review dashboard and other quality measures, set goals and identify needed changes in procedures or training for staff. 4. Data and information that will be evaluated by the quality council include: a. complaints and feedback from clients, clients’ representatives, clients’ families and agency staff; b. vulnerable adult reports made to the common entry point; c. incident reports; d. medication errors; e. results of audits of client records; f. results of audits of personnel files; g. current data on dashboard measures; h. results of MDH (Minnesota Department of Health) regular surveys and OHFC (Office for Health Facility Complaints) surveys of our agency; and i. other relevant information. 5. Minutes of the quality council meetings will be summarized for all staff to review. The minutes are intended to inform staff of monitoring results and trends, the focus of improvement efforts and quality goals. 7. Improvement projects will be assigned to project teams or individuals by the council.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to follow infection control practices for 2 of 3 patients (P2 and P3) observed home health visits to prevent the transmission of infections and communicable diseases. P2’s Plan of Care dated 2/19/24, for certification period 2/19/24 through 4/18/24, indicated he had diagnoses of occlusion and stenosis (blockage) of the right carotid artery, hypertension, atherosclerosis of autologous artery coronary artery bypass graft (build up on the artery walls of a bypass created from the same individual) with angina pectoris (chest pain), dilated cardiomyopathy (enlarged left ventricle of the heart), chronic kidney disease, malignant neoplasm (cancer) of the prostate, malignant neoplasm of the bladder. Discipline orders for P2 direct skilled nursing five times a week for urostomy (a tube that drains urine from the body) tube flush and dressing change and medication set up. On 3/5/24 at 3:04 p.m., licensed practical nurse (LPN)-A completed a nephrostomy (tube that drains the kidney) flush for P2. LPN-A used alcohol wipes to cleanse the tubing of a thick gelatinous substance. LPN-A placed both contaminated alcohol wipes directly on P2’s kitchen table. Once flush was completed, LPN-A removed the soiled alcohol wipes from the table and discarded into the trash can. LPN-A did not clean the table. LPN-A performed hand hygiene then removed a blood pressure cuff, oximeter, and stethoscope from her backpack, laying those items directly on the kitchen table, where the soiled alcohol wipes had been placed. LPN-A placed the oximeter on several of P2’s fingers before getting a reading of his pulse and oxygenation level. LPN-A then placed the oximeter back into her backpack, without performing hand hygiene and without sanitizing the oximeter. LPN-A placed the blood pressure cuff on P2’s right upper arm, applied the stethoscope to her ears and the bell of the stethoscope to P2’s arm. After completing his blood pressure check, LPN-A removed the stethoscope from her ears and placed it directly on the table. LPN-A then removed the blood pressure cuff from P2’s arm and placed it directly on the kitchen table. LPN-A then placed the BP cuff and stethoscope into her backpack, without performing hand hygiene or cleaning the items. On 3/5/24 at 3:33 p.m., LPN-A stated she was unaware hand hygiene was indicated prior to reaching into her backpack. LPN-A stated she cleaned her equipment in the evening at home, as she felt it was rude to clean it in front of the patient. P3’s Plan of Care dated 1/9/24, for certification period 1/14/24 through 3/13/24, indicated he had diagnoses of alcohol dependence with alcohol-induced persisting dementia. Discipline orders direct home health aide (HHA) five times weekly. Interventions for HHA include check pulse, check respiratory rate, shower, shampoo, brush hair, clean nails, and to apply lotion. On 3/6/24 at 8:24 a.m., HHA-A assisted P3 into his wheelchair, then reached into her bag to retrieve her iPad without performing hand hygiene. On 3/6/24 at 8:26 a.m., HHA stated she was aware that hand hygiene was indicated prior to reaching into her bag. On 3/6/24 at 11:26 a.m., administrator stated she expected staff to clean equipment between patient use and conduct hand hygiene before and after patient care. On 3/7/24 at 10:31 a.m., RN-A stated she would expect all surfaces used during patient visits to be cleaned, barriers to utilized under equipment for infection control purposes. The facility policy, Disposal of Contaminated Material and Equipment, dated 9/2023, directed after completing any task that results in contaminated material, such as a wound dressing change, contaminated material must be disposed properly. The facility policy, Standard (Universal) Precautions for Infection Control, dated 9/2023, directed Standard precautions apply to all staff when working with all home care clients, regardless of the clients’ diagnosis or presumed infection status. Standard (universal) precautions are used when coming in contact with blood; body fluids, secretions, and excretions except sweat (regardless of whether they contain visible blood); non-intact skin; and mucous membranes. 1. Handwashing is crucial. Staff will wash hands: after touching blood, body fluids, feces, or contaminated items (regardless of whether or not gloves are worn) and as necessary, between tasks and procedures on the same client to prevent cross-contamination of different body sites, and between all patient contacts. 5. Staff will use care in handling client-care equipment or linen soiled with blood, body fluids, or feces in order to prevent skin and mucous membrane exposure, contamination of clothing, and transfer or microorganisms to other patients or environments. Ensure that reusable equipment (e.g., blood pressure cuffs, etc) and environmental surfaces are appropriately cleaned and reprocessed prior to use on another client and that single-use items are properly discarded. The facility policy, Standard (Universal) Precautions for Infection Control for Supplies, dated 9/2023, directed standard (universal) precautions apply to all staff when working with all home care clients, regardless of the clients’ diagnosis or presumed infection status. Standard (universal) precautions are used when coming in contact with blood; body fluids, secretions, and excretions except sweat (regardless of whether they contain visible blood); non-intact skin; and mucous membranes. Equipment 1. All equipment will be cleaned with an agency approved cleaner after each use or client contact. The facility policy, Disinfecting Reusable Equipment and Environmental Surfaces, date 9/2023, directed reusable equipment and environmental surfaces will be properly disinfected after use. 1 1. After using reusable equipment, the equipment must be cleaned and returned to the placed that it is stored. 2 2. Environmental Services a a. Environmental surfaces must be disinfected after use. The facility policy, Handwashing/Hand Hygiene, dated 9/2023, directed Hand washing shall be performed between client cares and whenever direct physical contact with a client takes places. The policy directed hand washing to occur before and after direct contact with a client, after contact with environmental surfaces or equipment in the vicinity of the client, before and after assisting a client with personal cares. The policy directed in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub containing 60-95% ethanol or isopropanol acceptable for the following situations: before and after contact with clients, after handling contaminated equipment.”

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This Element is not met as evidenced by: Based on interview and document review the agency failed to conduct a thorough investigation in response to an alleged misappropriation of patient’s money for 1 of 1 patients (P8) reviewed. P8’s plan of care indicated she had homemaker visits scheduled once weekly to assist with light housekeeping that may include vacuuming, dusting, dishes, laundry, shopping, meal preparation, and nutritional support. Homemaker may also perform errands at request of client. On 3/7/24 at 8:57 a.m., the administrator stated the alleged perpetrator (AP) no longer worked at the agency at the time P8 reported missing money. The administrator stated the AP was only seeing two clients at the time she was employed by the agency. The administrator stated she did not remember if she interviewed any other clients at the time the report was made but there were no other complaints of missing money. The administrator stated she did not interview other staff members as the AP was the only staff member who had worked with P8. A facility document complaint form indicated P8 made a report on 10/7/21 of missing money from her home. The document indicated P8 was not sure how long the money had been missing but she had kept cash in an envelope in her dresser drawer for emergencies. When P8 went to look for the money, $400 was missing. P8 reported she had two $2 bills and four $100 bills in the envelope. The $2 bills were still in the drawer, but the $100 bills were missing. P8 reported she had never had any concerns about the staff but she had not had anyone else in her apartment except for family and didn’t believe her family was in her bedroom. The document indicated the report was reported to law enforcement and a vulnerable adult report was filed. The document indicated the AP denied taking the cash when she was interviewed. The document indicated the findings of the investigation were inconclusive due to not having a clear time frame and staff no longer working at the agency. A facility document, Complaint Policy and Procedure, dated 9/2023 directed Every effort is made to appropriately receive, investigate, and resolve complaints and to avoid any form of retaliation. The RN in charge investigates all complaints and provides a response within five business days to the person who originated the complaint. A facility document, Vulnerable Adult Reporting and Investigation Policy, dated 9/2023 directed Suspected abuse, neglect or financial exploitation will be investigated by the RN in coordination with the home care director. 3. Internal investigation process: a. Home care director is responsible for investigating reported incidents and documentation for any incident of suspected maltreatment. The RN will coordinate with the home care director regarding the investigation of any incident and implementation of any necessary steps to reduce the risk of other similar incidents. The investigation will begin as soon as a report is received by the RN or home care director. b. Internal investigation. As part of the internal investigation, the RN, in coordination with the home care director, will: i. Interview witnesses or persons who may have information concerning the incident and will document the witnesses’ statements concerning the incidents”

“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 medication regimen review, and reconciliation of medications, was completed to ensure medications identified on the plan of care (POC) were available and were set up as ordered by physician, for 1 of 1 patient (P4) observed with a home visit for medication set up. P4’s Home Health Certification and Plan of Care (POC) for the certification period from 1/7/24 to 3/6/24, indicated P4’s principal diagnosis was that of malignant neoplasm (a cancerous tumor), with other pertinent diagnoses listing only personal history of traumatic brain injury (an injury to the brain which can cause alteration in mental state such as disorientation, slow thinking, or difficulty concentrating). There were no additional diagnoses listed for P4 under the diagnoses listing heading. P4’s orders for discipline and treatments identified P4 was followed with skilled nurse visits one time a week effective 1/28/24, one time a week 2/25/24, one time a week 3/3/24. The plan of care indicated the services provided were to include general health assessment and med set up. On 3/5/24, at 2:10 p.m. registered nurse (RN)-A was observed as she completed medication set up using the medication profile dated 3/5/24, for set up of medications for a four-week rotation. As medications were set up it the following discrepancies were identified: The medication famotidine 20 mg was listed on the Medication Profile as ordered one tablet daily in the evening for gastroesophageal reflux disorder (GERD). This medication was set up as daily, as per the medication profile, however, the label identified the medication was to be given twice daily. RN-A stated she had not noticed there was a discrepancy in the direction on the label compared to the Medication Profile. RN-A stated P4 also received omeprazole, and that it why the frequency was reduced, however, this was not reflected on the pharmacy label. The medication ferrous sulfate 65 mg elemental iron/325 mg was identified on the medication profile to be set up one tablet daily as a supplement. The Medication Profile identified the start date of this order was 3/5/24. RN-A stated she had received a call mid-January from the provider to increase this to twice daily, however, she had not processed the order, by entering it into the electronic medical record (EMR). The order for ferrous sulfate was not identified on the Medication Profile until the start date of 3/5/24 and the frequency was identified as daily. The prescription label on the medication bottle, with a dispense date of 1/8/24, directed staff to administer ferrous sulfate twice daily. Upon observation of med set up, RN-A set up ferrous sulfate twice daily in the medication sets. During the home visit, the PRN (as needed) medications were reviewed, and available supply was verified. Upon review of the PRN medications, the medication prochlorperazine, 10 mg tablet was ordered every six hours as needed. RN-A reviewed the current supplies available identified the medication expired 11/1/23. RN-A stated this should have been identified earlier with medication review and a new supply ordered. Additional medications were observed on the table where medication was set up, as well as within the open cupboard next to the table. Upon review of the medications observed sitting out, a container of Nystatin powder 100,000 units/gm, ordered every eight hours as needed under breasts which, was dispensed 2/7/23. This order was not identified on either the Medication Profile or POC. A box containing Monistat 3, prefilled applicators, was identified as being outdated in 2016. RN-A was unaware of either medication, and the POC and Medication lacked orders for use. In addition to the above listed discrepancies, the following medications were present within the bottles of prescriptions to be set up, however, no current orders were present either in the Medication Profile or POC: A prescription of hydrochlorothiazide 12.5 mg, one tablet in the morning, was present and was identified as last being set up on 12/31/23. RN-A stated this was discontinued on 1/3/24. A bottle of Oxycodone 5 mg, with directions to take one tablet every six hours as needed was observed within the prescription bottles, however, the Medication Profile and POC lacked current orders for this. A bottle of fexofenadine (Allegra) 60 mg tablets, with directions to take every 12 hours as needed, was also present within the prescription bottles. P4 also had an order in place for cetirizine 10 mg daily for allergies. During medication set up, RN-A stated although the medication profile identified the ferrous sulfate 325 mg was ordered daily, the order had been increased to twice daily via a phone call from the provider sometime in January. RN-A stated she had not integrated the orders into the patient’s records at the twice daily dosing. RN-A stated this was also not reflected in the medication set up documentation, however, stated she had corrected the frequency of the medication and it had been set up as twice daily. The prescription bottle of ferrous sulfate 325 mg, dispensed on 1/8/24, indicated the frequency for administration was twice daily. A review of the medication profile indicated a start date of the ferrous sulfate as 3/5/24, with the frequency listed as daily. During observation of medication, the frequency set up for P4 was twice daily. RN-A stated she was aware that the meds no longer used/ordered, were to be separated from the other medications. RN-A stated all medications were to be reviewed for accuracy of orders and dates of expiration, however, she tried to keep length of time for the visit limited, as P4 is paying for visits privately. RN-A stated medications in the open cupboard should have been reviewed when setting up medications. RN-A was unaware of order/use of Nystatin; and she was unsure if this was indicated at this time. During a follow up interview on 3/7/24, at 10:30 a.m. RN-A stated she had entered the order for the ferrous sulfate on the medication profile on 3/5/24, prior to the observation of home visit, so it would be reflected on the medication profile. RN-A stated the orders would need to be amended to reflect the new directions desired at twice daily. RN-A stated since the order for ferrous sulfate had not been implemented until 3/5/24, there would be no documentation to reflect that ferrous sulfate was set up for P4 in January and February. RN-A indicted she had been setting up the ferrous sulfate twice daily since early January. The policy, Bethesda Home Health Policies and Procedures Medication Management, reviewed 9/23, identified when setting up medication for later administration, the RN (registered nurse) or LPN (licensed practical nurse) were to verify the dose and quantity of medications was consistent with the prescription. The staff was also to review and evaluate the use of PRN (as needed) medications. If any discrepancies or concerns were identified, the nurse was to follow up appropriately and document the results of follow up. The policy lacked indication as to what was to be done with outdated or discontinued medications, or over the counter prescriptions, which had expired. On 3/7/24, at 2:30 p.m. the Home Care Director stated it was her expectation when staff were completing medication set up, all medications were reconciled to assure the medications set up for patients were as ordered by the provider, and no discrepancies were identified. The Director stated the medications which were no longer ordered, or had expired, were not to be kept with current prescriptions.”

“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 interview and document review, the agency failed to include all necessary components within the Home Health Certification and Plan of Care (POC) to reflect a comprehensive plan of care based on patient assessment, which included patient diagnosis, risk of emergency room visits/hospitalization, supplies and equipment required for care, and patient-specific interventions with measurable outcomes and goals for 2 of 4 patients (P1 and P4) seen with home care visits? P1’s Plan of Care dated 2/9/24, for the certification period 2/13/24 through 4/12/24, indicated P1 had diagnoses of an unstageable (full thickness of the skin tissue) pressure ulcer to the sacral region (between the hips on the back of the pelvis), diabetes, dementia, and obesity. DME (durable medical equipment) and supplies listed: hospital bed, hoyer lift (full body mechanical lift to assist with patient transfers), shower chair, wheelchair, wheelchair cushion, wound care supplies. Discipline orders indicated skilled nurse one time per week for 9 weeks, with 6 additional visits as needed, for wound care. Patient and family goals indicated skin integrity impaired: started 10/16/2023- in process patient’s comfort will be maximized. Intervention indicated: started 10/16/2023 – evaluate patient/patient caregiver’s abilities to manage wound care. The plan of care lacked specific interventions for weekly wound care, location of the wounds, and type of supplies required. The plan of care lacked measurable outcomes and goals for the wound care. The plan of care lacked educational interventions for the patient/patient caregiver. The plan of care lacked the evaluation of progress toward patient-specific goals. P1’s Plan of Care dated 12/14/23, for the certification period 12/15/23 through 2/12/24, indicated P1 had diagnoses of an unstageable pressure ulcer to the sacral region, diabetes, dementia, and obesity. The plan of care lacked any DME or supplies. Discipline orders indicated skilled nurse one time per week for 8 weeks for wound vac (vacuum-assisted closure method of decreasing air pressure to assist the healing process of a wound) dressing change. Patient and family goals indicated skin integrity impaired: started 10/16/2023- in process patient’s comfort will be maximized. Intervention indicated: started 10/16/2023 – evaluate patient/patient caregiver’s abilities to manage wound care. The plan of care lacked specific interventions for weekly wound care, location of the wounds, and type of supplies required. The plan of care lacked measurable outcomes and goals for the wound care. The plan of care lacked educational interventions for the patient/patient caregiver. The plan of care lacked the evaluation of progress toward patient-specific goals. P1’s Plan of Care dated 10/13/23, for the certification period 10/16/23 through 12/14/23, indicated P1 had diagnoses of an unstageable pressure ulcer to the sacral region, diabetes, dementia, and obesity. The plan of care listed the following DME and supplies: hospital bed, shower chair, EZ stand (mechanical device to assist with patient transfers) and ramp. Discipline orders indicated skilled nurse one time per week for 8 weeks for comprehensive assessment of wound, wound care as ordered by MD (medical doctor) or WOCN (wound, ostomy, and continence nurse). The plan of care lacked specific interventions for weekly wound care, location of the wounds and type of supplies required. P1’s Plan of Care dated 8/17/23, for the certification period 8/17/23 through 10/15/23, indicated P1 had diagnoses of an unstageable pressure ulcer to the sacral region, diabetes, dementia, and obesity. The plan of care listed the following DME and supplies: wheelchair, hospital bed, shower chair, EZ stand and ramp. Discipline orders indicated skilled nurse 3-4 times weekly to provide comprehensive assessment of wound, wound care as ordered by MD or WOCN. The plan of care lacked specific interventions for weekly wound care, and type of supplies required. On 3/7/24 at 10:31 a.m., registered nurse (RN)-A stated she was the case manager for P1. RN-A stated P1 received wound care once weekly by the home care agency. RN-A stated the plan of care should include diagnoses, medications, goals, discharge plans, functional status, allergies. RN-A stated she wounds for P1 were ongoing. RN-A stated the agency’s new EMR (electronic medical record) system does not allow them to specify the goals as they had been able to in their previous system. RN-A stated the orders for P1’s wound changed frequently, so she was intentionally vague on the plan of care. A facility policy, Development of the Individualized Treatment and Therapy Plan (ITTP) and Individualized Treatment Administration Record, dated 9/2023, directed the RN ensures that each client’s IITP is kept-up-to-date and consistent with prescriber’s orders and in conjunction with the needs and preferences of the client. The policy also directs any changes to the client’s treatment or therapy will be addressed in the client’s treatment record and communications to all appropriate staff. P4’s Home Health Certification and Plan of Care (POC) for the certification period from 1/7/24 to 3/6/24, indicated P4’s principal diagnosis was that of malignant neoplasm (a cancerous tumor), with other pertinent diagnoses listing only personal history of traumatic brain injury (TBI-an injury to the brain which can cause alteration in mental state such as disorientation, slow thinking, or difficulty concentrating). Under the heading of other pertinent diagnoses, there were no additional diagnoses listed, however, P4 received medications identified as being ordered for aortic insufficiency, elevated cholesterol, muscle spasms, asthma, gastroesophageal reflux disease (GERD), migraine, sleep problems, allergic rhinitis (allergy symptoms which included sneezing, congestion, itchy nose and watery eyes), depression, nerve pain, and diabetes. The POC identified the following under Goals/Rehabilitation Potential/Discharge Potential: Discharge plans discussed with client. Rehab potential is good. Discharge plans discussed with client. Rehab potential is good. (These statements were included twice under the heading identified.) The POC identified under Patient/Family Goals: Started 11/8/23--In Process Pt./PCG (patient caregiver) able to administer medications safely, however, does not establish parameters to identify if this is achieved. The interventions, with a start date of 11/8/23, directed staff to assess for safety concerns and teach as indicated, however, failed to identify teaching or reinforcement completed. The POC identified that P4’s risk for hospital and ER (emergency room) was that P4 lived in an apartment with teenage son. The plan of care lacks indication of potential risks related to malignant neoplasm, TBI, depression, muscle spasms, GERD, migraine, sleep problems, allergic rhinitis, depression, nerve pain or diabetes.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and document review, the agency failed to include all patient care orders in the plan of care for 1 of 11 patients reviewed for comprehensive plan of care. (P1) P1’s Plan of Care dated 2/9/24, for the certification period 2/13/24 through 4/12/24, indicated P1 had diagnoses of an unstageable (full thickness of the skin tissue) pressure ulcer to the sacral region (between the hips on the back of the pelvis), diabetes, dementia, and obesity. Discipline orders indicated skilled nurse one time per week for 9 weeks, with 6 additional visits as needed, for wound care. Patient and family goals indicated skin integrity impaired: started 10/16/2023- in process patient’s comfort will be maximized. Intervention indicated: started 10/16/2023 – evaluate patient/patient caregiver’s abilities to manage wound care. The plan of care lacked specific interventions for the weekly wound care, location of the wounds, and type of supplies ordered by the provider. P1’s Plan of Care dated 12/14/23, for the certification period 12/15/23 through 2/12/24, indicated P1 had diagnoses of an unstageable pressure ulcer to the sacral region, diabetes, dementia, and obesity. Discipline orders indicated skilled nurse one time per week for 8 weeks for wound vac (vacuum-assisted closure method of decreasing air pressure to assist the healing process of a wound) dressing change. Patient and family goals indicated skin integrity impaired: started 10/16/2023- in process patient’s comfort will be maximized. Intervention indicated: started 10/16/2023 – evaluate patient/patient caregiver’s abilities to manage wound care. The plan of care lacked specific interventions for the weekly wound care, location of the wounds, and type of supplies ordered by the provider. P1’s Plan of Care dated 10/13/23, for the certification period 10/16/23 through 12/14/23, indicated P1 had diagnoses of an unstageable pressure ulcer to the sacral region, diabetes, dementia, and obesity. Discipline orders indicated skilled nurse one time per week for 8 weeks for comprehensive assessment of wound, wound care as ordered by MD (medical doctor) or WOCN (wound, ostomy, and continence nurse). The plan of care lacked specific interventions for weekly wound care, location of the wounds and type of supplies required. P1’s Plan of Care dated 8/17/23, for the certification period 8/17/23 through 10/15/23, indicated P1 had diagnoses of an unstageable pressure ulcer to the sacral region, diabetes, dementia, and obesity. The plan of care listed the following DME and supplies: wheelchair, hospital bed, shower chair, EZ stand and ramp. Discipline orders indicated skilled nurse 3-4 times weekly to provide comprehensive assessment of wound, wound care as ordered by MD or WOCN. The plan of care lacked specific interventions for weekly wound care, and type of supplies required. P1’s wound care order dated 3/5/24, directed to cleanse wounds with mile soap and water. Flush areas of depth with saline. Pat dry. Apply Calazime (topical cream with zinc oxide to treat skin irritation) to peri wounds. Coccyx (tailbone area): apply thin layer of Flagyl gel (medicated cream) for odor. Place Purachol Ag (containing hydrated silver chloride compound to promote healing) followed by one strip of Iodoform (an antiseptic) packing (gauze-like). Apply adapt ring (specialized round dressing to protect the skin) to distal edge of wound to help keep packing in place. Cover with sacral border dressing. Right hip: apply Purachol Ag to tunnel. Cover with sacral border dressing. P1’s wound care order dated 2/20/24, directed right hip: cleanse wound with mile soap and water. Flush with saline. Apply Purachol Ag collagen to wound followed by one strip of ¼ inch Iodoform. Calazime to peri wound. Cover with Mepilex sacral border dressing. Coccyx: cleanse wound with mild soap and water. Flush with saline. Apply Flagyl gel to wound bed for odor control followed by one strip of ¼ inch Iodoform. Cover with sacral border dressing. Keep dry with bathing. Continue to change dressings Fridays. WOCN to see patient Tuesdays. P1’s wound care order dated 2/6/24, directed right hip and coccyx wounds: cleanse wounds with mild soap and water. Apply Calazime to peri wounds. Apply Purachol Ag collagen into both wounds. Apply one strip ¼ inch Iodosorb (topical amicrobial gel) into hip wound. Apply one strip therahoney mesh (mesh dressing impregnated with honey to promote debridement) into coccyx wound with tail for easy removal. Cover both wounds with sacral bordered foam dressings. Cover with bathing. Dressings to be changed twice weekly- by WOCN on Tuesdays and by home care on Fridays. P1’s wound care order dated 1/16/24, directed right hip and coccyx wounds: cleanse wounds with mild soap and water. Apply Calazime to peri wounds. Apply Purachol Ag collagen follow by one strip into each wound with tail for ease of retrieval. Cover with sacral bordered foam dressings. Cover with bathing. If dressings are saturated, please revert to previous plan of care with wound care. P1’s wound care order dated 12/15/23, directed right hip and coccyx wounds: continue with vac orders to the right hip and coccyx. Please add one piece of Mepitel Ag mesh (mesh dressing), due to tendon presence, to the hip wound by wrapping it around the granuform (specialized dressing). There is one piece of Mepitel Ag mesh currently in the wound-please make sure to retrieve the strip with vac removal. On 3/7/24 at 10:31 a.m., registered nurse (RN)-A stated she was the case manager for P1. RN-A stated P1 received wound care twice weekly, once by the wound care nurse at the clinic and once by the home care nurse. RN-A stated the plan of care should include diagnoses, medications, goals, discharge plans, functional status, allergies. RN-A stated she intentionally left the wound care orders vague on the plan of care due to the frequent changes to the wound care orders. RN-A stated the agency’s new EMR (electronic medical record) system does not allow them to specify the location or specific treatments for the wounds. The facility policy, Development of the Individualized Treatment and Therapy Plan and Individualized Treatment (IITP) Administration Record, dated 9/2023, directed the RN ensures that each client’s IITP is kept-up-to-date and consistent with prescriber’s orders and in conjunction with the needs and preferences of the client. The policy also directs any changes to the client’s treatment or therapy will be addressed in the client’s treatment record and communications to all appropriate staff.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and document review, the agency failed to assure orders received verbally via a phone call from the provider were documented in the patient’s clinical record, and subsequently implemented, for 1 of 1 patient (P4) observed for medication set up. On 3/5/24, at 2:10 p.m. registered nurse (RN)-A was observed as she completed medication set up of a four-week rotation of medication set up. The RN-A was using the Medication Profile, printed 3/5/24 at 1:24 p.m. The medication set up was initiated and RN-A was observed as she set up ferrous sulfate 65 mg elemental iron 325 mg, one tablet twice daily, as a supplement, however, the Medication Profile indicated the medication was to be given daily. The Medication Profile for ferrous sulfate identified the start date of 3/5/24, however, the prescription label on the ferrous sulfate label, dispensed by pharmacy on 1/8/24, directed staff to set up twice daily. RN-A stated although the medication profile identified the ferrous sulfate 325 mg was ordered as daily, the order had been increased to twice daily via a phone call from the provider sometime in January. RN-A stated although she had not integrated the orders into the patient’s records as the twice daily dosing, she had been setting the ferrous sulfate up on a twice daily basis. RN-A stated the set-up of ferrous sulfate at a twice daily frequency would not be reflected in the electronic documentation as the Medication Profile did not reflect the order for twice daily. The documentation of medication set up is done so in coordination with the Medication Profile. During a follow up interview on 3/7/24, at 10:30 a.m. RN-A stated she had initially entered the order for the ferrous sulfate on the medication profile on 3/5/24, prior to the visit, so it would be reflected on the medication profile during the observation of medication set up. RN-A stated the orders should have been initiated when the order was received, prior to initiation of therapy. RN-A stated the dosing of ferrous sulfate should have been amended to reflect the directions as twice daily at the time that phone call was received. RN-A stated since the order for ferrous sulfate had not been initiated at a daily frequency until 3/5/24, there would be no documentation to reflect this was set up for P4 in January and February. RN-A indicted she had been setting up the ferrous sulfate twice daily since early January, however, acknowledged this will not be reflected in the documentation. A review of the medication documentation was completed for the prior four week set up period, dating 1/3/24 through 1/30/24, lacked any indication of set up of ferrous sulfate 325 mg (65 mg elemental iron), either daily or twice daily. A review of the documentation for the four weeks of medication set up observed for the four-week time frame from 3/5/24-4/2/24, reflected five entries on 3/5/24, which were identified as follows: AM, As needed, HS, Noon, and PM. There were no further entries to identify ferrous sulfate 325 mg was set up for 3/6/24 through 4/5/24. On 3/7/24, at 2:30 p.m. the Home Care Director stated it was her expectation when staff received a verbal order from the provider, this would be transcribed into the medical record, with the updates made to the Medication Profile and subsequent Home Health Certification and Plan of Care (POC) to ensure the patient was receiving the medications as ordered by the provider. A review of the facility policy, Implementation of Medication Prescriptions, last reviewed 9/23, indicated prescriptions for medications must be implemented as quickly as possible. The policy identified the RN is responsible for assuring that the prescriptions and orders have been implemented appropriately. The policy identified this process included adding the order or prescription to the client record, in the appropriate place, an update of the service plan, care plan, medication record/MAR or other documents as necessary to reflect any changes in prescriptions or orders.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and document review the agency failed to notify the provider when services required by plan of care were not performed for 3 of 8 patients reviewed for missed services. (P3, P5 and P11) P3’s Plan of Care dated 1/9/24, for certification period 1/14/24 through 3/13/24, indicated P3 had diagnoses of alcohol dependence with alcohol-induced persisting dementia. Discipline orders direct home health aide (HHA) five times weekly. Interventions for HHA include the following tasks to be completed every visit: check pulse, check respiratory rate, shower, shampoo, brush hair and apply lotion. HHA visit note on 3/5/24 indicated the following tasks were not applicable to the visit: check pulse, respiratory rate, and shower. HHA visit note on 3/4/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 3/1/24 indicated the following tasks were not applicable to the visit: check pulse and check respiratory rate. HHA visit note on 2/29/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/28/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/27/24 indicated the following tasks were note applicable to the visit: check pulse, respiratory rate, shampoo, and shower. HHA visit note on 2/26/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/22/24 indicated the following tasks were not applicable to the visit: check pulse, respiratory rate, shampoo, and shower. HHA visit note on 2/21/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/20/24 indicated the following tasks were not applicable to the visit: check pulse, respiratory rate, shower, and shampoo. HHA visit note on 2/19/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/16/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/15/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate, shampoo, and shower. HHA visit note on 2/14/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/13/24 indicated the following tasks were not applicable to the visit: check, respiratory rate, shower, and shampoo. HHA visit note on 2/12/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/9/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. Registered Nurse (RN) supervisory note on 2/8/24 indicated HHA follows POC (plan of care). HHA visit note on 2/7/24 indicated the following tasks were not applicable to the visit: check pulse and respiratory rate. HHA visit note on 2/6/24 indicated the following tasks were not applicable to the visit: check, respiratory rate, shower, and shampoo. P3’s chart lacked documentation of missed services notification to the primary care provider. P5’s Plan of Care dated 2/28/24, for certification period 2/28/24 through 4/27/24, indicated P5 had diagnoses of chronic heart failure, fracture at the lower end of the right ulna (arm bone between elbow and wrist), weakness and diabetes. Discipline orders directed skilled nurse visits every other week for general health assessment and aide supervision and home health aide (HHA) three times per week. The plan of care directed the HHA to complete the following interventions at every visit: foot care, check blood pressure, check blood sugar, check pulse, check respiratory rate, assist with ambulation, assist with transfer, brush/style hair, light housekeeping, medication reminder, shampoo, apply lotion and shower. The plan of care directed clean nails and shave once weekly. On 3/4/24 the HHA visit note indicated the following interventions scheduled for every visit were not applicable to the visit: foot care, check blood pressure, check blood sugar, check pulse, check respiratory rate, skin care: apply lotion. The visit note lacks documentation to the RN case manager or supervisor of incomplete tasks. The chart lacked documentation of physician notification of missed services. P11’s chart indicated there were no homemaker visits documented for the week of 2/28/24. P11’s Plan of Care dated 11/8/23, for certification period 11/1/23 through 10/30/24, indicated P11 had a primary diagnosis of atherosclerosis (build up or narrowing of the artery) of coronary arterial bypass graft (heart bypass surgery). The physician signed plan of care directed homemaker visits once weekly. P11’s plan of care interventions directed the HHA to change bedding/make bed every visit, clean bath/shower surfaces/fixatures, clean stove/oven/microwave, clean surfaces/counters/cupboards, remove garbage every visit, sweep/mop every visit, vacuum floors, wash clothing/bedding every visit, wash dishes every visit, wash towels/miscellaneous. On 3/7/24 at 2:20 p.m., administrator stated P11 recently filed a complaint regarding the HHA “not doing what they though they should do.” Not providing as many tasks as they thought the HHA should. The administrator stated she talked with the patient and replaced with a different staff person. On 3/7/2024 2:41 p.m., the staffing coordinator stated P11 called to notify her that she needed to get her someone else, or she didn’t want anyone at all. I don’t remember the date. I sent a text to the aide, on 2/21/24 telling her do not go to P11’s house. P11 said she needed more help than the HHA gave her. Scheduling coordinator confirmed 3/1/24 visit was in “scheduled” status but was not completed. She confirmed there was no note for the missed visit, therefore no physician notification of the missed visit occurred. The staffing coordinator stated she replaced the HHA with another HHA. The staffing coordinator stated on 3/6/24 she learned P11 had been hospitalized but was unsure when P11 went to the hospital. On 3/7/2024 at 2:59 p.m., the staffing coordinator stated she spoke to the HHA who was scheduled to visit P11 on 3/1/24. The staffing coordinator stated, “The aide said she went there last week. She knocked and the dog barked. Client did not come to the door, so the aide left.” She stated the aide did not document the missed visit and did not communicate to anyone else in the agency. She stated usually the staff would send a text her if a visit was missed. The staffing coordinator stated she was off work the week of 2/28/24, so she wasn’t sure if anyone else received communication regarding the missed visit for P11. Record review indicated a note was entered in P11’s chart on 3/7/24 at 2:14 p.m., by the staffing coordinator indicating P11 did not want the aide she filed the complaint on to return to her home. On 3/7/24 at 10:31 a.m., RN-A stated she was the case manager for P3 and P5. RN-A stated she was not notified the tasks were not all completed per the plan of care by the HHA on a regular basis for P3. RN-A stated the new EMR system will not allow for her to make the pulse and respiratory rate tasks for P3 weekly. RN-A stated she was not aware the pulse and respiratory rate were not routinely completed for P3. RN-A stated she was not notified the tasks were not all completed per the plan of care by the HHA on 3/4/24 for P5. RN-A stated she would not expect to be notified of all missed tasks. RN-A stated the HHA’s do not complete blood sugar checks but can report what the patient or family find when they check the patient’s blood sugar. RN-A stated she did not realize the HHA care plan became a part of the plan of care, signed by the physician. The facility policy, Missed Visits, dated 9/2023, directed in the event that a client misses a scheduled visit the agency will complete the following steps: 1. Notify staff of cancellation of visit 2. Generate a missed visit report from the EMR (electronic medical record) including the date of the missed visit, reason for the missed visit and document if any other action was needed 3. Missed visit report will be faxed to PCP (primary care provider) in compliance with physician notification regulations 4. Monthly report of agency missed visits will be generated and client charts audited to ensure that all missed visit reports are completed The facility policy, Development of the Individualized Treatment and Therapy Plan and Individualized Treatment (IITP) Administration Record, dated 9/2023, directed the RN ensures that each client’s IITP is kept-up-to-date and consistent with prescriber’s orders and in conjunction with the needs and preferences of the client. The policy also directs any changes to the client’s treatment or therapy will be addressed in the client’s treatment record and communications to all appropriate staff.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on interview and document review the agency failed to include the medical director in the agency’s Quality Assessment Performance Improvement (QAPI) program. On 3/7/24 at 2:20 p.m., the administrator stated the purpose of the QAPI program was to identify trends problems quality. The administrator stated her supervisor, the campus administrator, and senior management were invited to come to the QAPI meetings. The administrator stated sometimes the medical director will attend virtually. The administrator stated the medical director did not attend the last two meetings. A facility document, Meeting Minutes, dated 11/3/23 did not list the medical director as a participant. A facility document, Nurse meeting notes, dated 9/8/23 did not list the medical director as a participant. A facility document, email from administrator to medical director, dated 3/7/24 at 3:05 p.m., with subject line of quarterly QAPI on 11/3/23, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, falls, complaints, staffing concerns and new software were discussed at the meeting. A facility document, email from administrator to medical director, dated 3/7/24 at 3:12 p.m., with subject line of QAPI meeting September 2023, informed medical director of meeting minutes from quarterly meeting. The email also indicated admissions, discharges, and encouraging clients to get flu shots in October. A facility document, Quality Management Plan, dated 9/2023 directed the home care director/RN will develop a continuous quality improvement and management program to maintain the agency’s continuous performance improvement efforts, consistent with current professional standards and the highest quality services for clients. All staff will be involved in the implementation of performance improvement efforts. 2. The home care director/RN will establish a quality council made up of key staff to develop and implement the agency’s quality management program.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, interview, and document review the agency failed to ensure the home health aide followed the plan of care and provided only services for which they are trained for 1 of 11 (P3) patients reviewed for following the plan of care. P3’s Plan of Care dated 1/9/24, for certification period 1/14/24 through 3/13/24, indicated he had diagnoses of alcohol dependence with alcohol-induced persisting dementia. Discipline orders direct home health aide (HHA) five times weekly. Interventions for HHA include: every visit check pulse, every visit check respiratory rate, every visit shower, every visit shampoo, every visit brush hair, once weekly clean nails, and every visit apply lotion. On 3/6/24 at 8:08 a.m., HHA-A stated she had been caring for P3 for years and his routine had not changed. HHA-A state, “I don’t know what the medications are. His daughter sets them up. I just know there’s supposed to three pills.” On 3/6/24 at 8:12 a.m., P3’s family member (FM)-A stated the agency assist P3 with his showers, getting him breakfast, giving him his medications, and getting him on the bus every morning. FM-A stated she set up P3’s medications. FM-A stated the morning medications included fish oil 1000mg, vitamin B12 1000mcg, and quetiapine 50mg. On 3/6/24 at 8:15 a.m., HHA-A was observed opening the medication planner for Wednesday morning, placing the medications in a plastic medication cup, and then handing the medications and a cup of water to P3. P3 was sitting in his chair and proceed to consume the medications with HHA-A’s prompting. On 3/6/24 at 12:15p.m., the administrator stated “Our aides will not take meds out and give them to the patient. They can only provide med reminders. They cannot physically take a pill and give it to them.” She added, “it’s ok as long as they are not dispensing the meds from the bottle, and as long as they are not doing any set up. The aides are not in charge of the pills. Aides are not responsible to know what the pills are.” The administrator stated medication administration should be directed by the patient’s care plan/485. On 3/6/24 at 1:40 p.m., the administrator stated, “We would only administer medications if it’s ordered.” The administrator stated the aides are trained in medication reminders and administration, but they do not offer the service of medication administration. She stated, “The aides can ask the patients if they have taken their medications, but they cannot actually dispense the pills.” On 3/7/24 at 9:03 a.m., RN-B stated the HHA’s cannot administer medications, but they can do reminders. She stated a medication reminder was asking a question, “not opening the medication”. On 3/7/24 at 10:31 a.m., RN-A confirmed that she was the case manager for P3. RN-A stated the aides are expected to perform the tasks indicated on their plan of care. RN-A stated the HHA’s could provide medication reminders but could not perform medication administration. RN-A stated she was not aware a HHA was performing medication administration. The facility policy, Medication Reminders, dated 9/2023, directed prior to providing any medication reminders, a registered nurse must conduct a nursing assessment of a client’s functional status and need for medication reminders or other medication management services. In the client’s medication management plan, the RN will describe how the medication reminder will be provided, for example, visual or verbal reminder over the telephone or in person, and whether other tasks will be provided in conjunction with the reminder, such as bringing the client water or juice. A facility document, Delegation of Nursing Tasks, Treatments or Therapy Tasks, dated 9/2023 directed delegation occurs when the RN transfers the responsibility for the performance of a nursing task in a specific situation to another nursing staff member who is competent to perform the task, while ethe RN retains the accountability for the outcome. Using his/her professional judgment, the RN may delegate nursing tasks to LPNs or unlicensed personnel, consistent with the Nurse Practice Act, the MN home care requirements, accepted nursing practice and the five rights of delegation: · Right task to be delegated · Under the right circumstances · The right person to do the task · The right directions and communication · The right supervision to ensure the task is carried out safely 1. Qualifications for unlicensed personnel who perform delegated nursing tasks, delegated treatments, or assigned therapy tasks. A registered nurse may delegate nursing services, or an authorized licensed health professional may delegate treatments or assign therapy tasks, to unlicensed personnel that: a. Have successfully completed training required for the unlicensed personnel under MN statutes 144A.4795, subd.3,(b). b. Have been trained in the services to be provided, c. Have demonstrated to the RN or licensed health professional the ability to competently follow the procedures for the client and possess the knowledge and skills consistent with the complexity of the tasks. 2. Steps prior to delegating a nursing task: a. Completing a nursing assessment of the client’s functional status and need for nursing services; b. Developing a service plan for providing the services according to the client’s needs and preferences; c. Determining that the unlicensed person is trained and competent and has been instructed in the proper methods to perform the procedures with respect to the specific client; d. Including the written instructions for performing the procedure for the client in the client’s record; and e. Orienting the staff to the client either in writing, in person or orally. 3. Steps prior to delegating medication administration: a registered nurse may delegate medication administration to unlicensed personnel only after the RN has: a. Instructed the unlicensed personnel in the proper methods to administer the medications and the unlicensed personnel has demonstrated the ability to competently follow the procedures; b. Develop specific written instructions for each client and documented those instructions in the client’s medication record/MAR; and c. Communicated with the unlicensed personnel about the individual needs of the client. 6. System to track competencies of unlicensed staff. The RN will establish, implement and update a system to communicate up-to-date information to the RN or licensed health professional regarding the current available staff and their competencies so the RN or licensed health professional has sufficient information to determine the appropriateness of delegating tasks to meet the individual client’s needs and preferences. The facility policy, Treatment and Therapy Management Services, dated 9/2023, directed the home care director will determine which treatment and therapy services our agency will offer. The RN is responsible for our agency’s medication management policies and procedures. Based on the nursing assessment, the RN will develop an individualized treatment and therapy management plan for each client receiving any type of treatment and therapy management services, consistent with current practice standards and guidelines, and will develop specific procedures for treatment and management service that staff will provide. The RN will assure that unlicensed personnel are trained, competent and oriented to the client whenever unlicensed personnel are to perform treatment and therapy management services for the client. Medication administration competency documentation for HHA-A was requested, but not provided, as the administrator stated the HHA’s do not perform medication administration in interview.”