White Earth Home Health

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure adequate cause for discharge, failed to provide appropriate notice prior to discharge and failed to make efforts to resolve concerns prior to discharging 1 of 1 patient (P1) from the agency. Findings include: P1’s Vulnerable Adult Assessment dated 2/8/24, identified an assessment area titled, Indirect indicators of Vulnerability. Indicators included: Displays combative or aggravating behavior likely to involve retaliation. Area was not identified as a concern. Evidence of alcohol or drug abuse in family and/or patient. Area was not identified as a concern. Assessment area indicated not applicable. The assessment indicated P1 had no vulnerabilities. P1’s Home Health Care Certification and Plan of Care for certification period 3/18/24 through 5/16/24, identified diagnosis that included heart disease, depression, anxiety, and pain. The care plan indicated P1 received skilled nurse visits one time per week and home health aide (HHA) visits twice weekly. The plan of care indicated HHA services included assistance with bathing, dressing, and grooming. The plan of care identified Ozempic 0.25- .5 milligram dose pen subcutaneously weekly. P1’s Home Health Safety Contract dated 2/2/21, indicated an effort to provide a safe and hazard free work environment for staff and the patient, White Earth Home Health is informing of specific situations in which the agency would discontinue services. Inappropriate communication including sexual content, verbal attacks and/or threats, threat of physical assault or unwanted physical contact, sexual harassment, visible abuse of illegal or non-prescribed drugs at the home, failure to comply with healthcare professional request to eliminate perceived threat. An untitled, undated document written by home health aide (HHA)-A indicated when she arrived to P1’s home on 4/15/24, P1 was in the bathtub drinking a beer. HHA-A wrote, in the first 10 minutes of the visit she had noticed something on P1’s slippers and thought she saw something move. HHA-A went to check the bed and found bed bugs covering the pillowcase. P1 stated she did not want HHA-A to call anyone and said she was aware of the agencies policy. HHA-A told P1 she needed to finish the bath and leave the house and P1 told HHA-A she could wait until P1 was done reading her f****** chapter in her book and asked for another beer and a cigarette because she was stressed out. P1 stated she did not have bugs on her, and HHA-A was not going to get them. P1 was very stubborn and ignoring HHA-A, cutting HHA-A off when speaking, yelling, and demanding another beer. When the bath was finished and the tub was draining, P1 was yelling and swearing “about the drain” and swatted at HHA-A a few times with the washcloth and hit HHA-A once with the cloth. HHA-A reported telling P1 she could not do that and P1 replied she had been teasing but continued to yell and swear and swat the washcloth around. HHA-A reported she felt disrespected and indicated the situation was uncomfortable. HHA-A further reported in the past P1 had made her feel uncomfortable when she made derogatory comments regarding Native Americans. P1’s Visit Report dated 4/15/24, indicated a phone call was placed to P1 to provide local pest control contact information. An attachment undated, indicated phone call placed to P1 in regard to “bed bug situation” discovered by HHA-A. Explained to P1 staff could not go into the house until treatment was completed. Told patient she had enough medication set up through 4/25/24, and next medication set-up could be done outside the home if she was unable to get pest control treatment before her medication set was empty. P1 was upset and asked who would be doing her bath and was told family would have to complete. P1 was upset and stated she did not have bed bugs on her. Nurse explained that staff being in the home was a public health risk. P1 stated something in an “aggressive” tone and hung up. Untitled facility document dated 4/18/24, indicated the director of nursing (DON) called P1 to discuss the interaction that was reported by HHA-A and nurse on 4/15/24. P1 indicated HHA-A was “rude, rough and disrespectful.” The things that were addressed with P1 were the verbal abuse (by P1) that had been taking place during visits, the wet washcloth that was swung at and hit HHA-A during incident on 4/15/24, and the tone and negativity displayed by P1 in regard to the tribe and Native Americans in general that was unacceptable. The report indicated the DON told P1 it was concerning that P1 requested HHA-A to get her a beer while P1 smoked and read a book in the bathtub to which P1 replied, she had a right to relax in her own home. The DON told P1 verbal abuse was another violation of the contract. The DON told P1 the contract had been violated and the agency would no longer be in the home to provide services. P1 expressed concern about her shot (Ozempic) and who would administer it. P1 was very frustrated with the removal of services. Untitled facility document dated 4/18/24, indicated the DON sent a text message to P1’s family member (FM)-A requesting call back related to services provided to P1. FM-A returned call and DON ran through reported events and the phone call between P1 and the DON. Explained to FM-A that P1 was in the bathtub and the HHA saw a bug and determined it was bed bugs. HHA had called the nurse for further direction and was told to finish P1’s cares and leave the home. It was reported by HHA-A that P1 drank three beers in the tub and wanted to finish reading the f****** chapter in her book. HHA-A also reported while waiting for the tub to drain, P1 was swinging a wet washcloth and had hit HHA-A with it. The DON told FM-A the agency was discharging P1 from services in the home due to safety contract violations. During interview on 5/1/24 at 10:24 a.m., HHA-A stated she had shown up to P1’s home for a normal visit and said P1 was already in the tub reading a book when she got there. HHA-A stated she saw something on P1’s slippers, “spots or bugs or something.” HHA-A said she thought she saw something move on P1’s bed so she called the nurse to find out how to proceed. HHA-A stated the nurse told her to get P1 safely out of the tub and leave the home. HHA-A stated P1 told her she could wait until she finished the chapter in her book and asked for another beer. HHA-A stated after she was able to finish getting P1 washed, she hit the drain in the tub and said the tub drained slow and P1 got mad because it was so slow. HHA-A said P1 was swatting a washcloth at her and hit her with it once. HHA-A said P1 “was like, I was just teasing.” HHA-A said P1 had tried hitting at her before, but she had never reported it and said, “that’s just her personality.” HHA-A stated she did not know whether P1 was trying to hurt her or just making a point. HHA-A stated P1’s home definitely had bed bugs. An invoice from Prairie Pest Control dated 4/22/24, indicated the company went to P1’s home to treat for bed bugs. The invoice indicated “no evidence of bed bugs.” During interview on 5/1/24 at 12:38 p.m., registered nurse (RN)-A stated she provided weekly service for P1 that included medication set up and administration of her Ozempic. RN-A stated on 4/15/24, she had received a call from HHA-A who reported she had seen bed bugs in P1’s home and had told HHA-A to finish with care and leave the home. RN-A stated HHA-A reported she did not feel safe being there and said there had been comments made in the past by P1 that were racist. RN-A further stated she had been caring for P1 for approximately four years and had not had any incidents and was not aware of incidents with any other staff. RN-A said sometimes P1 kind of yells but nothing that would have been documented. RN-A said the incident reported on 4/15/24, was the first time she had heard of P1 being behavioral toward staff. During interview on 5/1/24 at 1:25 p.m., family member (FM)-A stated the DON called her and told her they were discontinuing services for P1 because of her actions and verbalizations. FM-A stated she was told by the DON the services provided to P1 were free and if she had to go another agency she would have to pay for services. FM-A said they called P1 on Thursday (4/18/24) and said they were discontinuing services and said she felt the agency could have handled it differently. FM-A said she did not understand what P1 did that was so bad. During interview on 5/1/25 at 12:53 p.m., the DON stated P1 had reported on 4/15/24, that HHA-A had been rushing her and she had explained to P1 HHA-A had been directed to finish cares and leave the home. The DON said she told P1 she would address HHA-A. The DON stated P1’s services had been terminated because she violated the safety contract. When asked if P1 had been swearing at HHA-A or just swearing in general the DON replied, “I have no idea, I did not clarify.” The DON stated the decision to terminate P1’s services was made by the interdisciplinary team which included herself and the interim health director (HD) among others. In regard to hitting HHA- A with the washcloth, the DON said HHA-A did say P1 said she had been joking when she hit her with the washcloth. The DON said she had a conversation with P1 about swearing and P1 said she had been angry and upset. The DON said she told P1 she could not verbally harass or verbally abuse staff per the safety contract. The DON said P1 asked why no one had talked to her and begged not to have her services discontinued. The DON acknowledged there was no evidence of previous behaviors from P1 and confirmed that no effort had been made to resolve the concern prior to discharging P1 from services. The DON stated at “at any point we have the right to discharge her from services.” The DON said she provided P1 a list of other agencies but said she had not provided a seven-day notice prior to discontinuing services. During interview on 5/1/24 at approximately 3:00 p.m. the interim director (HD) stated P1’s behavior fell outside the safety contract guidelines. The interim HD said anytime staff felt their safety was at risk the agency could choose to discharge a patient from services. When asked what behavior was perceived as a threat to HHA-A, the interim HD said the washcloth incident and the substance use (alcohol), even though there was no evidence P1 abused alcohol, nor did the agency policy identify use of legal substances as a reason to terminate services. Facility policy Safety Contract- Risk Management dated 1/25/23, indicated if a client failed to adhere to the safety contract and/or the client’s home was deemed unsafe for staff to continue services the agency would initiate the discharge process. The steps included the client and responsible party will be given a seven-day notice of the impending discharge. Facility policy Discharge of Clients dated July 2021, indicated clients would be discharged under the following circumstances: Foals Attained Enters a hospital/inpatient facility or orders expire Moves off the White Earth Reservation Services are refused by client Agency unable to provide services Client dies Client choice The policy indicated clients being discharged still needing home care services will be given a proper notice and provided with a list of other agencies in the area.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on interview and document review, the facility failed to notice the provider of intent to discharge 1 of 1 patient (P1) reviewed who was discharged from the agency without appropriate notice. Findings include: P1’s Home Health Care Certification and Plan of Care for certification period 3/18/24 through 5/16/24, identified diagnosis that included heart disease, depression, anxiety, and pain. The care plan indicated P1 received skilled nurse visits one time per week and home health aide (HHA) visits twice weekly. The plan of care indicated HHA services included assistance with bathing, dressing, and grooming. The plan of care identified Ozempic 0.25- .5 milligram dose pen subcutaneously weekly. P1’s Home Health Safety Contract dated 2/2/21, indicated in an effort to provide a safe and hazard free work environment for staff and the client, White Earth Home Health is informing of specific situations in which the agency would discontinue services. Inappropriate communication including sexual content, verbal attacks and/or threats, threat of physical assault or unwanted physical contact, sexual harassment, visible abuse of illegal or non-prescribed drugs at the home, failure to comply with healthcare professional request to eliminate perceived threat. Untitled facility document dated 4/18/24, indicated the director of nursing (DON) called P1 to discuss the interaction that was reported by HHA-A and nurse on 4/15/24. P1 indicated HHA-A was “rude, rough and disrespectful.” The things that were addressed with P1 were the verbal abuse (by P1) that had been taking place during visits, the wet washcloth that was swung at and hit HHA-A during incident on 4/15/24, and the tone and negativity displayed by P1 in regard to the tribe and Native Americans in general that was unacceptable. The report indicated the DON told P1 it was concerning that P1 requested HHA-A to get her a beer while P1 smoked and read a book in the bathtub. The DON told P1 verbal abuse was another violation of the contract. The DON told P1 the contract had been violated and the agency would no longer be in the home to provide services. P1 expressed concern about her shot (Ozempic) and who would administer it. Untitled facility document dated 4/18/24, indicated the DON sent a text message to P1’s family member (FM)-A requesting call back related to services provided to P1. FM-A returned call and DON ran through reported events and the phone call between P1 and the DON. Explained to FM-A that P1 was in the bathtub and the HHA saw a bug and determined it was bed bugs. HHA had called the nurse for further direction and was told to finish P1’s cares and leave the home. It was reported by HHA-A that P1 drank three beers in the tub and wanted to finish reading the f****** chapter in her book. HHA-A also reported while waiting for the tub to drain, P1 was swinging a wet washcloth and had hit HHA-A with it. The DON told FM-A the agency was discharging P1 from services in the home due to safety contract violations. During interview on 5/1/24 at 1:25 p.m., FM-A stated the DON called her and told her they were discontinuing services for P1 because of her actions and verbalizations. FM-A stated she was told by the DON the services provided to P1 were free and if she had to go another agency she would have to pay for services. FM-A said they called P1 on Thursday (4/18/24) and said they were discontinuing services and said she felt the agency could have handled it differently. During interview on 5/1/25 at 12:53 p.m., The DON stated P1’s services had been terminated because she violated the safety contract. The DON stated the decision to terminate P1’s services was made by the interdisciplinary team which included herself and the interim director (HD) among others. The DON said she provided P1 a list of other agencies but said she had not provided a seven-day notice prior to discontinuing services and had not notified P1’s provider. Facility policy Discharge of Clients dated July 2021, indicated clients being discharged still needing home care services will be given a proper notice and provided with a list of other agencies in the area and indicated a discharge summary would be completed and forwarded to the physician for signature.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on interview and document review the agency failed to investigate an allegation of abuse for 1 of 1 patient (P1) reviewed who alleged physical abuse by a staff member. The agency failed to develop policies and procedure for reporting and investigation of abuse allegations. Findings include: 1’s Vulnerable Adult Assessment dated 2/8/24, indicated indicators of vulnerability, not applicable (N/A), Abuse/neglect, N/A, Financial abuse/exploitation, N/A, Indicators of indirect vulnerability, N/A, Risk factors, N/A. No apparent risk. P1’s Home Health Care Certification and Plan of Care for certification period 3/18/24 through 5/16/24, identified diagnosis that included heart disease, depression, anxiety and pain. The care plan indicated P1 received skilled nurse visits one time per week and home health aide (HHA) visits twice weekly. The plan of care indicated HHA services included assistance with bathing, dressing, and grooming. P1’s Visit Note, Activity Summary dated 4/23/24, indicated a call was made to the police department related to the report to the state agency involving P1 and home health aide (HHA)-A. Verbal report was given to the police officer. Visit Report dated 4/23/24, indicated the police officer was onsite at the agency related to the incident. A facility document dated 4/18/24, untitled indicated a phone call was made to P1 to discuss interaction reported by HHA-A on 4/15/24. P1 indicated HHA-A was “rude, rough and disrespectful.” During interview on 5/1/24 at 10:00 a.m. the director of nursing (DON) stated she had not interviewed other patients who received cares from HHA-A about the care they received. The DON stated she asked the agency nurses if they had concerns and was told there were none. The DON said she had no documentation the incident had been investigated. During interview on 5/1/24 at 10:24 a.m. HHA-A stated on 4/15/24, she had shown up to P1’s home for a normal visit to help her with her bath. HHA-A stated P1 was already in the tub reading a book. HHA-A said she thought she saw something move on P1’s bed so she called the nurse to find out how to proceed. HHA-A stated the nurse told her to get P1 safely out of the tub and leave the home. HHA-A stated P1 was upset and refused to get out of the tub and was swearing and “swatting” a washcloth toward her. During interview on 5/1/24 at 12:50 p.m., the director of nursing (DON) stated when she spoke with the investigator, he had mentioned P1 had reported bruising on her body. The DON stated when she spoke with P1, P1 had reported to her HHA-A had been rushing her. The DON stated she did not clarify with P1 what rude, rough, and disrespectful meant. During a subsequent interview at approximately 3:00 p.m. the DON stated the facility did not have a policy or procedure related to reporting or investigation of reports to the SA. A policy regarding reporting or investigating allegations was requested and not provided.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and document review the agency failed to provide services as ordered in the Plan of Care (POC) and failed to inform the physician of services that were not provided for 2 of 7 patients (P1, P5) reviewed for receiving services as indicated per the POC. Findings include: P1’s plan of care (POC) for the certification period 1/31/24 to 3/30/24, indicated P1’s start of care (SOC) was 10/3/23, and diagnoses included infective endocarditis (the inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart), cerebral infarction (stroke), and anxiety disorder. POC further indicated P1 received skilled nurse visits (SNV) once per week for various assessments, which included vital signs (blood pressure, pulse, temperature), weight, education and monitoring of blood sugars. Review of P1’s clinical record indicated a SNV was completed on 1/29/24, for recertification and a comprehensive assessment was completed. An order was obtained 1/29/24 for SNV once per weeks for two months. Review of P1’s SNV for the certification period 1/31/24 to 3/30/24 revealed P1 received a SNV on 2/5/24, 2/12/24 and 2/26/24. The record lacked documentation that any SNV were completed the week of 2/19/24. SNV were not performed weekly in February as ordered by the physician. There was no indication the provider was notified when the SNV were not conducted according to the POC. P3’s POC for the certification period 1/20/24 to 3/19/24, indicated P3’s SOC was 8/3/21, and diagnoses included neoplasm of the left lung (lung cancer), essential hypertension (elevated blood pressure), and chronic fatigue. POC further indicated P3 received SNV home health aide (HHA) visits weekly for assistance with activities of daily living (ADL’s) and SNV weekly for various assessments and medication management. Review of P3’s clinical record indicated a SNV was completed on 1/16/24, for recertification and a comprehensive assessment was completed. An order was obtained on 1/18/24 for HHA and SNV once per week for two months. Review of P3’s HHA visits for the certification period of 1/20/24 to 3/19/24 revealed a missed HHA visit on 2/27/24. There was no indication the provider was notified when the HHA visit was not conducted according to the POC. During an interview on 3/12/24 at 2:12 p.m., director of nursing (DON) verified P1 and P3 had not received all the visits per the POC, and the physician had not been notified of the missed visits. DON confirmed there was a potential for a decline in P1’s clinical condition related to the missed SNV visit. DON stated P3 had not received help with ADL’s as ordered. DON stated staff were expected to notify the physician of any missed visits. The agency Patient Visits- Scheduling policy dated 7/21, identified each individual providing care and/ or services to the patient should contact the manager if patient visits are not completed as scheduled. Further identified the physician was to be contacted whenever changes to the type and/or frequency of patient visits are required based on patient needs.”