Presbyterian Homes Home Care

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure the start of care packet contained all of the required elements for the state and federal combined bill of rights (BOR). This had the ability to affect all clients receiving services from the agency. During an observation on 8/31/26, the agency-provided start of care packet contained a document, Minnesota Home Care Bill of Rights dated 2/20/26, which didn’t display all of the required elements for the state and federal combined BOR, including contact information for the Office of Ombudsman. During an interview on 9/2/26 at 3:07 p.m., the home health director (HHD) stated in February when the new Minnesota (MN) Bill of Rights (BOR) came out they made the assumption it covered both federal and state, so since February 20th they were giving the new one which they assumed was a combined one. The HHD stated they do have an additional hand outs in the welcome file regarding additional resources, but it didn’t contain contact information for the Office of Ombudsman.”

“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 ensure individualized patient plan of care included information related to patient’s advanced directives for 2 of 17 records (P2, P9) reviewed for components of the care plan. Findings include: P9’s plan of care (POC) dated 8/4/26 to 10/2/26, identified a start of care (SOC) 8/4/26. Ordered services included skilled nurse (SN), Physical therapy, Occupational therapy and speech therapy. Diagnoses included stage two pressure ulcer of sacral region, abdominal aortic aneurysm, congestive heart failure, intracranial injury, atrial fibrillation and long-term use of anticoagulants. The POC listed provider orders for life sustaining treatment (POLST) under the advanced directives section, however, lacked identification of what the POLST included. When interviewed during a home visit on 9/1/26, at 10:00 a.m. occupational therapist (OT)-A stated she was unsure of what POLST on P9’s POC meant and would have to check with her supervisor. P9’s medical record was reviewed and lacked documentation of a POLST form. During interview on 9/1/26, at 3:30 p.m. the administrator stated the agency did not track down a patient’s POLST or advanced directive even when a patient identified having one. The administrator was not sure if POLST, identified on P9’s POC would mean cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR). During interview on 9/2/26, at 8:15 a.m. the home health director (HHD) stated the team had been discussing patient advanced directives, but at this time, it was not the agency’s practice to search for them to add to the patient’s home care medical record. The agency’s undated Advanced Directives/Self Determination policy identified clients on admission would be asked if they have an advanced directive or living will. If the client has an advanced directive or living will, it would be photocopied and appended to the client’s record. If the client did not have an advanced directive, it would be noted in the clinical record.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure home health aide supervisory assessment of services was completed every 14 days for 1 of 5 patients (P12) reviewed for home health aide services. Findings include: P12’s plan of care (POC) 8/6/26 to 10/4/26, identified a start of care (SOC) 8/6/26. Services included physical therapy (PT), occupational therapy (OT) and home health aide (HHA) services. Orders for HHA services were effective 8/9/26, for one time per week for four weeks and tasks included to assist with personal care and activities of daily living (ADLs) due to P12’s functional limitations. Diagnoses included osteoarthritis and history of falls. Review of P12’s medical record 8/1/26 through 9/1/26, identified the HHA completed one visit on 8/20/26. The medical record lacked documentation if the HHA competed all four weeks of visits or if the visits were missed. P12’s medical record lacked HHA supervisory visits or documentation. During interview on 9/2/26, at 3:07 p.m. the home care director (HHD) stated attempts had been made to complete HHA visits on teh weeks of 8/9/26 and 8/23/26, however the patient had refused them. The HHA had not documented the missed visits in the patient visit notes, as was the agency’s practice. The physical therapist had just completed a home health supervisory assessment during his visit on 9/1/26, however, had not completed any HHA supervisory assessments prior to that. The therapist should have reviewed HHA services with the patient by day 14 of the HHA services being initiated. There was no HHA supervision documentation other than the one completed on 9/1/26. The agency policy Home Health Aide Supervision dated 3/24/26, identified for skilled care a home health aide supervisory assessment would be conducted at least every 14 days by a qualified professional. Documentation would review the POC and HHA written instructions and any changes communicated and implemented.”