Town and Country Home Health Care

“Basis and Scope CFR(s): §484.1 Basis and Scope (a) Basis. This part is based on: (1) Sections 1861(o) and 1891 of the Act, which establish the conditions that an HHA must meet in order to participate in the Medicare program and which, along with the additional requirements set forth in this part, are considered necessary to ensure the health and safety of patients; and (2) Section 1861(z) of the Act, which specifies the institutional planning standards that HHAs must meet. (b) Scope. The provisions of this part serve as the basis for survey activities for the purpose of determining whether an agency meets the requirements for participation in the Medicare program. This Condition is not met as evidenced by: Based on the number and/or severity of deficiencies cited, the home health agency failed to meet the Condition of Participation: G325 at 42 CFR 484.1. The agency failed to establish the conditions that a home health agency (HHA) must meet to participate in the Medicare program which includes being primarily engaged in providing skilled nursing or therapeutic services and establishing a quality assessment performance improvement program (QAPI). This had the opportunity to affect all patients who received or will receive home health services. Findings include: Refer to G640: Based on the number and/or severity of deficiencies cited, the home health agency failed to meet the Condition of Participation: G640 at 42 CFR 484.65. The agency failed to establish a quality assessment performance improvement program (QAPI); to measure, analyze and track quality indicators; to establish a system to collect and evaluate program data; establish performance improvement activities; establish a system to track adverse patient events, analyze their causes and implement preventive actions; perform actions aimed at performance improvement and tracking performance; and ensure the agency had and operating QAPI program. This had the opportunity to affect all patients who received home health services. Refer to G892: Based on interview and document review the facility failed to maintain a current contract for therapy provision, therefore lacking a second therapeutic service available for potential patients. Additionally, the present staff available lack ability to implement care based on the limitations and lack of home health aides. When interviewed on 7/14/26 at 11:06 a.m., registered nurse (RN)-A stated the agency census was zero and the agency had no patients since their prior patient passed away on 7/8/25. RN-A stated there had been no admissions since then. The Administrator and DON were out of the office for vacation and medical leave. RN-A stated currently there were two RNs employed at the agency. RN-A explained staffing for home care was difficult as the nurses also serviced the attached assisted living. Physical therapy was contracted through a therapy provider, however, have not had any physical therapy clients in over 2 years. RN-A further stated there had been no referrals or new admissions to home care since 10/2022. When interviewed on 7/15/2026, at 4:13 p.m., the Chief Executive Officer (CEO) acknowledged admissions to the agency had not happened for a while. The CEO did not have an understanding of the referral process or if referrals were coming in to be reviewed. The agency was a key component of the community and there was discussion with different stakeholders and researching different ways for payment. Staff recruitment continued as well. CEO further stated the agency was in a period of transitioning and refiguring. No additional information was received.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on the number and/or severity of deficiencies cited, the home health agency failed to meet the Condition of Participation: G640 at 42 CFR 484.65. The agency failed to establish a quality assessment performance improvement program(QAPI); to measure, analyze and track quality indicators; to establish a system to collect and evaluate program data; establish performance improvement activities; establish a system to track adverse patient events, analyze their causes and implement preventive actions; perform actions aimed at performance improvement and tracking performance; and ensure the agency had and operating QAPI program. This had the opportunity to affect all patients who received home health services. Findings include: Refer to G642: Based on interview and document review, the agency failed to establish a process to measure, analyze and track quality indicators. This had the potential to affect all patients who received home care services. Refer to G644: Based on interview and document review, the agency failed to utilize quality data to identify opportunities for improvement. This had the potential to affect all patients who received home care services. Refer to G646: Based on interview and document review, the agency failed to identify performance improvement activities. This had the potential to affect all patients who received home care services. Refer to G660: Based on interview and document review the agency failed to ensure an ongoing quality assurance performance improvement (QAPI) program was implemented and maintained. This had the potential to affect all patients who received home care services.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to maintain ongoing collaboration and failed to review and update contact information for local, tribal, regional and state agencies for use in the event of emergency situations. Although expressed awareness of the Southwest Healthcare Preparedness Coalition, there is no documentation to reflect ongoing involvement and participation since 7/22/24. Findings include: A review of the agency Emergency Preparedness plan was reviewed on 7/15/26. Upon review of the policy titled “Coordination and Cooperation with Emergency Preparedness Officials”, effective/revised 4/1/24, it was identified that although there was contact information listed, this had not been identified as having been reviewed and revised since 4/1/24. Additionally, upon review of the documents, there was no further information provided as to interacting collaboratively with any meetings, phone calls, joint exercises, or outreach with the collaborative partners since 7/22/24. The documentation on 7/22/24 was from the Southwest Healthcare Preparedness Coalition exercise for Emergency Evacuation/Mass Transfer and included a reference document. There has been no additional information regarding collaboration on the local, tribal, regional, or state level referenced in the Emergency Preparedness binder. On 7/15/26 at 3:50 p.m., the office manager (OM)-A stated although the agency was aware of the Southwest Healthcare Preparedness Coalition, to her knowledge the agency was not aware of agency collaboration with the Coalition partners. OM-A stated she was unaware of current efforts of collaboration with partners. The administrator was unavailable for interview during survey.”

“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 interview and document review the facility failed to assure availability of emergency packets to be used in the event of an emergency evacuation of the patient from their residence. Findings include: Upon review of the facility policy Evacuations, effective/revised date 4/1/24, the document identified the potential for relocation of patients to an alternate location. A review of the the policy identified “Resident emergency packets”. The policy identified the “Emergency Packet” being sent with the patients. The policy identified the Emergency Packet was to include the following: Identification triage tag; Face sheet containing the following: contact information of responsible party/family: Insurance provider numbers: Elderly Waiver case manager information, if applicable: Date of birth: Allergies: Diagnoses/medical conditions: current medications: diet and special provisions: mode of transfer: POLST or advance directive/resuscitation instructions with copy of DNR documentation if applicable; and Power of Attorney. On 7/16/26 at 4:04 p.m., the office manager (OM)-A stated she was unable to locate the Emergency Packet information as outlined. The administrator and director of nursing were unavailable for interview during the course of the survey.”

“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 establish a process to measure, analyze and track quality indicators. This had the potential to affect all patients who received home care services. Findings include: The agency’s quality assessment process improvement (QAPI) program, including data and performance improvement projects, were requested. A document was provided, labeled Minnesota Assisted Living & Home Health Care License Resource Manual, with the title of policy identified as Quality Management Project, effective/revised date 2/26. Although titled Quality Management Project, within the body titled “Policy”, there were definitions as follows: “Quality management activity” means evaluating the quality of care by periodically reviewing resident services, complaints made, and other issues that have occurred and determining whether changes in services, staffing or other procedures need to be made in order to ensure safe and competent services to residents. The document lacks identification of concerns, prioritization of activities, collaboration with team, development of plans, or implementation of program. On 7/15/26 at 4:13 p.m., spoke with the chief operating officer (CEO) as administrator was absent from the agency during survey. CEO stated she was unaware of what the current project is in place for the agency and deferred this question to the office staff. On 7/16/26 at 4:04 p.m., the office manager (OM)-A stated although she was able to locate the policy as described above, she was unaware of any specific programs in place for quality assurance and performance improvements (QAPI). OM-A stated she was unable to locate any specific documentation to reflect current programs/projects/ status/ or routine meetings. No further information was received.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to utilize quality data to identify opportunities for improvement. This had the potential to affect all patients who received home care services. Findings include: The agency’s quality assessment process improvement (QAPI) program, including data and performance improvement projects, were requested. A document was provided, labeled Minnesota Assisted Living & Home Health Care License Resource Manual, with the title of policy identified as Quality Management Project, effective/revised date 2/26. Although titled Quality Management Project, within the body titled “Policy”, there were definitions as follows: “Quality management activity” means evaluating the quality of care by periodically reviewing resident services, complaints made, and other issues that have occurred and determining whether changes in services, staffing or other procedures need to be made in order to ensure safe and competent services to residents. Although identifying opportunities for potential areas for performance improvement and quality assurance were defined in the description of the process under the section titled policy, there were no identified processes, surveys, reviews, or data included within the document titled “Quality Management Project”. On 7/15/26 at 4:13 p.m., the chief operating officer (CEO) stated she was unaware of what the current project is in place for the agency for the quality assurance and performance improvement (QAPI) program and deferred this question to the office staff. On 7/16/26 at 4:04 p.m., the office manager (OM)-A stated she although she was able to locate the policy as described above, she was unaware of any specific programs in place for quality assurance and performance improvements (QAPI). The document provided as the facility policy, labeled Minnesota Assisted Living & Home Health Care License Resource Manual, with the title of policy identified as Quality Management Project, effective/revised date 2/26, lacked further direction as to how to formally gather, review, and identify priority areas for QAPI projects. No further information was received.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to identify performance improvement activities. This had the potential to affect all patients who received home care services. Findings include: The agency’s quality assessment performance improvement plan was requested, however, was not received. A request was made for any supporting documentation and was not received. On 7/15/26 at 4:13 p.m., the chief operating officer (CEO) stated she was unaware of what the current project is in place for the agency and deferred this question to the office staff. On 7/16/26 at 4:04 p.m., the office manager (OM)-A stated she although she was able to locate the policy as described above, she was unaware of any specific programs in place for quality assurance and performance improvements (QAPI). OM-A stated she was unable to locate any specific documentation to reflect current programs/projects/ status/ or routine meetings. The document provided as the facility policy, labeled Minnesota Assisted Living & Home Health Care License Resource Manual, with the title of policy identified as Quality Management Project, effective/revised date 2/26, lacked further direction as to how to formally gather, review, and identify priority areas for QAPI projects.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and document review the agency failed to ensure an ongoing quality assurance performance improvement (QAPI) program was implemented and maintained. This had the potential to affect all patients who received home care services. Findings include: The agency’s QAPI program, including data and the performance improvement plan was requested and was not received. On 7/15/26 at 4:13 p.m., the chief operating officer (CEO) stated she was unaware of what the current project is in place for the agency and deferred this question to the office staff. The agency administrator was unavailable to survey staff for interview. On 7/16/26 at 4:04 p.m., the office manager (OM)-A stated she although she was able to locate the policy as described above, she was unaware of any specific programs in place for quality assurance and performance improvements (QAPI). OM-A stated she was unable to locate any specific documentation to reflect current programs/projects/ status/ or routine meetings. The document provided as the facility policy, labeled Minnesota Assisted Living & Home Health Care License Resource Manual, with the title of policy identified as Quality Management Project, effective/revised date 2/26, indicated “Minnesota Assisted Living & Home Health Care will have at least one documented quality management project in place at all time, and retain records of such projects for at least two years.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on interview and document review the facility failed to maintain a current contract for therapy provision, therefore lacking a second therapeutic service available for potential patients. Additionally, the present staff available lack ability to implement care based on the limitations and lack of home health aides. Findings include: On 7/14/26 at 2:00 p.m., registered nurse (RN)-A, reviewed services available through the home health agency. RN-A stated they currently were able to provide skilled nurse services and physical therapy. RN-A stated home health aide services were a possibility; however, they lacked staff to do so. RN-A stated HHA services were last provided to R2, who had discharged 1/5/24. RN-A stated she, herself, had provided these services at that time as there was not a home health aide to do so. RN-A stated the last admission to the agency was on 10/24/22. RN-A stated the end of services date for most recent patient was 7/8/25. RN-A stated the last admission for physical therapy through home care services was in 2022, however stated the contract remains in place for the agency. A document, dated 7/7/20, titled Statement of Home Care Services: Comprehensive Home Care Provider identified the following services may be provided with a comprehensive home care license. The document identified the following services were a service the agency was able to provide: Registered Nurse Service; Licensed practical nurse services; Physical therapy services; Medication management services; Delegated tasks to unlicensed personnel; Treatment and therapies; Assistance with dressing, self-feeding, oral hygiene, hair care, grooming, toileting, and bathing; Verbal or visual reminders to take regularly scheduled mediation (includes bringing clients previously set-up medication in original containers, or liquid or food to accompany the medication; Verbal or visual reminders to the client to perform regularly scheduled treatments and exercises; and Laundry. On 7/15/26, at 10:00 a.m. a copy of the Home Health Therapy Services Agreement, completed on 2/1/08 with contracted therapy provider, was provided. The contract identified the services to be performed for home health agency, included services provided by the Physical Therapist, Physical Therapist Assistant, Occupational Therapist, Occupational Therapist Assistant, or Speech Therapist. A call was placed to the contracted therapy provider on 7/15/26 at 11:05 a.m. with a message which requested a return call back to surveyor. On 7/15/26, at 4:13 p.m. a call was placed to the chief executive officer (CEO) as the administrator and director of nursing were not available for interview. CEO stated the agency continued to attempt to recruit staff through agency websites and online recruitments. On 7/16/26 at 2:24 p.m. a call was returned from the therapy site manager at the local therapy site. The therapist identified at that time that the contract was no longer valid, and had not been since 1/1/24, to his knowledge. On 7/16/26, at 3:52 p.m. a call was placed to CEO regarding status of contracted therapy. A message was left for return call to discuss this. On 7/17/26 at 8:17 a.m., a discussion was held with CEO in follow-up. CEO stated she was unaware the contract for contracted services was no longer valid. CEO stated she would follow up on this accordingly. A request was made for information in follow up if there were further discoveries. No additional information was received.”