Everytime Home Care

“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 facility failed to develop and maintain a collaborative partnership with community partners and local members of emergency response system to facilitate prompt response and assistance in the event of any emergency event. This had the potential to affect all patients who were provided service by the agency. The undated agency policy, titled Emergency Disaster Plan Orientation and Training, identified the Emergency Preparedness Policies and Procedures must minimally contain the procedures to inform State and local emergency preparedness officials about agency clients in need of evacuation from their residence at any time due to an emergency situation. During interview on 2/7/24 at 3:00 p.m., the director of nursing stated they have not participated in any local health coalition building and outreach. The DON stated they do not have an outreach plan to work with partners in collaboration in the event of an emergency and have not participated in any events to establish plans mutually in the event of an emergency.”

“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 observation and interview, the facility failed to maintain and keep current and up to date the contact information for both agency staff and local emergency contact information to be used in the event of emergency. This had the potential to impact all patients served by the agency. The undated agency policy, titled Emergency Disaster Plan Orientation and Training, identified the Emergency Preparedness Policies and Procedures must minimally contain the procedures to follow up with on-duty staff and clients to determine services that are needed, in the event there is an interruption in services during or due to an emergency. During interview on 2/7/24 at 3:00 p.m., the director of nursing (DON) stated they do not have an outreach plan to work with partners in collaboration in the event of an emergency. Additionally, upon review of the Phone List for Emergency Needs document, undated, the DON stated the listing did not contain updated staff information. The document lacked identification of the current DON and lacked any information for the assistant director of nursing (ADON) who had been with the agency since June of 2023.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on observation and interview, the facility failed to develop and maintain current contact information for the local emergency officials and health partners within the facility plans for emergency preparedness plans. This had the potential to impact all patients served by the agency. The undated agency policy, titled Emergency Disaster Plan Orientation and Training, identified the Emergency Preparedness Policies and Procedures must minimally contain the procedures to inform State and local emergency preparedness officials about agency clients in need of evacuation from their residence at any time due to an emergency situation. During interview on 2/7/24 at 3:00 p.m., the director of nursing (DON) stated they have not participated in any local health coalition building and outreach. The DON stated they do not have an outreach plan to work with partners in collaboration in the event of an emergency. Upon review of the current Phone List for Emergency Needs document, undated, the DON stated the listing did not provide information for any collaborative partners.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to conduct a full scaled exercise or utilize a real time response with follow up to meet the requirements of training in Emergency Preparedness. This had the potential to affect all patients who were provided service by the agency. The undated agency policy, titled Emergency Disaster Plan Orientation and Training, identified the agency must conduct exercises to test the emergency plan at least annually with a full-scale exercise (an exercise which includes actually trialing policies and procedures developed for emergency use) that is community based, or activate a real time response related to events occurring (weather related, disease outbreak). In addition to a full-scale exercise, the agency must also complete a functional exercise with review of policies and procedures in a workshop setting. The policy identified the agency may also participate in a second full scale exercise to meet the second requirement. During interview on 2/7/24 at 3:00 p.m., the director of nursing (DON) stated they had completed a tabletop discussion on 6/21/22 based on isolation and quarantine screening and use of personal protective equipment. The DON stated aside from this tabletop, the last exercise, classified as full-scale was completed on 7/9/2020. DON stated they had not completed any after action reports, development of improvement plan, or testing of changes based on real time events.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview, and document review, the agency failed to assure ongoing orders for home health aide (HHA) services were carried forward for 1 of 1 client (C7) who was observed for personal cares in the home setting. C7’s Home Health Certification and Non-Medicare Plan of Care (POC) for certification period of 12/16/23 to 2/13/24, identified C7’s medical diagnoses included chronic obstructive pulmonary disease (a long-standing respiratory problem which causes difficulty with breathing), essential (primary) hypertension (high blood pressure), nicotine dependence, and alcohol dependence with alcohol-induced sleep disorder. The POC identified C7 was to receive skilled nurse visits two to three times month. The skilled nurse visit was for medication management with medication set up, and nurse to monitor and assess general health and safety in the home. During home visit on 2/6/24 at 12:15 p.m., observation was completed of HHA-A as she provided personal assistance to C7. HHA-A stated she had worked with C7 for many years. C7 affirmed ongoing, long-standing services and stated his cares were provided as he wished. Following observation of personal cares, with initiation of document review, it was noted the current POC lacked orders in place for HHA services. A review of the following POCs was completed: 10/17/23 to 12/15/23 and 8/18/23 to 10/16/23, also lacked orders for HHA services. A review of the POC from 6/19/23 to 8/17/23 identified orders in place for 16 to 20 hours of HHA services monthly. On 2/7/24, at 2:15 p.m. the POC’s were reviewed with director of nursing (DON). DON reviewed services provided and billing processes in place. DON stated the orders were absent from the above-mentioned certification periods and appeared to have been missed inadvertently with the recertification process. DON stated typically this would have been caught with scheduling process, however, stated this was not captured with the new system. DON stated all orders are to be carried forward with recertification unless otherwise ordered.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to contact the provider for a change in dosage/usage pattern in medication for 1 of 1 client (C4) observed with medication set up in the home. C4’s Home Health Certification and Plan of Care (POC) for certification period from 1/20/24 to 3/19/24, identified C4’s medical diagnoses to include presence of aortocoronary bypass graft (a surgery on the heart to improve function) and essential (primary) hypertension (high blood pressure). The POC indicated C4 was to receive skilled nurse services weekly to assess and monitor general health and safety in the home. In addition to assessment and monitoring of general health and well-being, the nurse visit was also to include medication set up. This was to include ordering of medication, assessment for compliance in taking medication, and observation for the therapeutic effect. During home visit observation on 2/5/24 at 1:30 p.m., C4’s medication set up was observed as completed by licensed practical nurse (LPN)-A. During observation of the med set up, it was identified C4 had orders in place for acetaminophen 325 mg, two tablets every four hours as needed. C4’s medication supply included a bottle of acetaminophen 500 mg. C4 requested of LPN-A to use this dosage with medication set up. This was set up by LPN-A as requested. Following set up of the routine medications, LPN-A stated she was going to follow up with the provider regarding the pain medication used for pain management, as well as seek clarification on the dose of acetaminophen to be given. Upon review of the documentation completed for the med set up, the acetaminophen was documented as having set up two tablets of 325 mg. The documentation lacked outreach to the provider regarding dosage, and amendment of the orders in place. On 2/7/24 at 2:30 p.m., a review of the medication setup documentation was reviewed with the director of nursing (DON). DON stated the order for the medication acetaminophen should have been amended to reflect the actual dose of medication set up. In addition, outreach to the provider should have been completed, with order change acknowledgement. DON stated the medication profile, and subsequent documentation should include the medication set up, including the dose and frequency. Upon review of the undated facility policy, Medication Management, the purpose of the policy was to reduce errors and improve quality of care and promote safety throughout the home care program. It also outlined the process being established to standardize processes y to improve medication/treatment systems. The policy directed staff to document the dates medication were set up, quantity of dose and times to be administered. Additionally, the policy identified the medication management record must be current and updated when there are any changes.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure documentation of medication set up included the required content for 1 of 1 client (C4) visited for medication set up. with home visits and record review. C4’s Home Health Certification and Plan of Care (POC) for certification period from 1/20/24 to 3/19/24, identified C4’s medical diagnoses to include presence of aortocoronary bypass graft (a surgery on the heart to improve function) and essential (primary) hypertension (high blood pressure). The POC indicated C4 was to receive skilled nurse services weekly to assess and monitor general health and safety in the home. In addition to assessment and monitoring of general health and well-being, the nurse visit was also to include medication set up. This was to include ordering of medication, assessment for compliance in taking medication, and observation for the therapeutic effect. During home visit observation on 2/5/24 at 1:30 p.m., C4’s medication set up was observed. LPN-A stated she had last set up C4’s medications a week ago on 1/31/24. LPN-A commented the medications were set up for twice a day administration. Upon checking the meds sets, LPN-A stated C4 had taken only two doses of the morning medications set up, missing three days of morning medications, and had taken the evening medications on only one occasion since meds were set up. During observation of the med set up, the following discrepancies were identified: The medication pramipexole dihydrochloride 1 mg was ordered to take one to three tablets at bedtime. C4 requested LPN-A to set up 2 tablets routinely in the med set. This was completed by LPN-A as requested. Additionally, C4 had orders in place for acetaminophen 325 mg, two tablets every four hours as needed. C4’s medication supply included a bottle of acetaminophen 500 mg. C4 requested of LPN-A to use this dosage with medication set up. This was set up by LPN-A as requested. Following set up of the routine medications, LPN-A proceeded to review other medications identified on the profile with C4. C4 stated he managed the following medications independently: Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 microgram (a unit of measurement-mcg)/activation one puff by inhalation twice a day, Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 mcg/activation two puffs by inhalation as needed every four hours, and polyethylene glycol powder 17 grams daily. At this time, the use of oxycodone HCl (a prescription pain medication) was also reviewed. C4 stated he no longer used this medication. C4 stated he had a supply of morphine and Dilaudid from previous orders. C4 stated he has a long-standing history of chronic pain and had worked with multiple providers historically. LPN-A stated she was going to follow up with the provider regarding the pain medication used for pain management. In addition, she was going to follow up regarding the dosage of acetaminophen. LPN-A completed documentation of the medication set up in the electronic medical record as it was set up. LPN-A showed how within the program, the medication set up is hyperlinked to the Medication Profile, which included dosage and frequency. A review of the documentation indicated the following: Medication Setup Medication: ASPIRIN 81 Start Date: 2024/02/05, End Date: 2024/02/12, Dose: 2 tablets Route: ORAL, Setup By: Nurse Medication: FERROUS GLUCONATE, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: 1 tablet, Route: ORAL, Setup By: Nurse Medication: ACETOMINOPHEN, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: 2 tablets Route: ORAL, Setup By: Nurse Medication: ATORVASTATIN CALCIUM, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: 1 tablet, Route: ORAL, Setup By: Nurse Medication: DULOXETINE HCL, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: 1 tablet, Route: ORAL, Setup By: Nurse Medication: FAMOTIDINE, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: 1 tablet, Route: ORAL, Setup By: Nurse Medication: GABAPENTIN, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: 2 capsules, Route: ORAL, Setup By: Nurse Medication: PRAMIPEXOLE DIHYDROCHLORIDE, Start Date: 2024/02/12, End Date: 2024/02/05, Dose: 1-3 capsules, Route: ORAL, Setup By: Nurse Medication: LISINOPRIL, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: take 1 tablet by mouth, Route: ORAL, Setup By: Nurse Medication: EZETIMIBE, Start Date: 2024/02/05, End Date: 2024/02/12, Dose: take 1 tablet (10 mg) by mouth daily, Route: ORAL, Setup By: Nurse Upon review of the documentation, the documentation lacked the frequency of the medication orders in the med set up notes. The following medications are ordered at a frequency outside of daily setup: duloxetine HCl (twice daily), ferrous gluconate (every other day), and gabapentin (three times daily). Additionally, the number of capsules set up for pramipexole dihydrochloride was not identified in the documentation, with the orders being one to three capsules, and two capsules set up. The documentation also lacked indication of the frequency the acetaminophen was set up, and the orders on file indicated it was to use “as needed”. The dose of acetaminophen on the orders was 325 mg and the dose set up was 500 mg tablets. This was not identified in the documentation. The documentation of medication set up lacked indication that only 1/5 of the medications set up the previous week. On 2/7/24, at 2:30 p.m. a review of the medication setup documentation was reviewed with the director of nursing (DON). DON reviewed the example of the hyperlink with the med set up to the Medication Profile, which identified the dose of the medication ordered. DON stated this was not reflected with the range of medications set up (for example the two capsules of pramipexole dihydrochloride set up when the range was one to three). The documentation lacked indication of the altered dose of acetaminophen from 325 mg to 500 mg, as well as the frequency set up. Additionally, although the gabapentin was ordered three times a day, during observation, it was set up twice daily as requested by C4, however, that also was not identified. DON stated they had recently switched their electronic medical records and was unaware of the information not being reflected in the way they system was set. Upon review of the undated facility policy, Medication Management, the purpose of the policy was to reduce errors and improve quality of care and promote safety throughout the home care program. It also outlined the process being established to standardize processes y to improve medication/treatment systems. The policy directs staff to document the dates medication were set up, quantity of dose and times to be administered.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and document review, the agency’s staff failed to report immediately to the State Agency (SA), allegations of misappropriation of patient property for 1 of 1 patient (P1) reviewed, who reported suspicion of theft of narcotic medications. In addition, the agency did not report the suspicion of narcotic theft to law enforcement. P1’s Home Health Certification and Plan of Care dated 11/21/23 – 1/10/24 indicated P1 was admitted on 11/21/23. P1’s diagnoses included anxiety disorder. P1 received weekly skilled nursing visits to assess and monitor health status, to set up medications and assist with refills and assess for medication and compliance side-effects and therapeutic response. P1 was taking Lorazepam 2 milligrams (mg) 1 tablet daily (a controlled anti-anxiety medication) and Hydrocodone 10-325 mg. 1 tablet orally three times a day (a controlled pain medication). Agency Client Grievance/Complaint form dated 1/15/24 indicated P1 stated “that her med cups were coming out empty at noon.” Attached to the complaint form was a typed document dated 1/15/23 of the investigation completed by the clinical manager (CM). The investigation indicated P1 had contacted her case manager (unknown date) and stated that on two occasions after nursing visits some controlled substances were missing. P1 stated around Christmas time she had about a six-month supply of Lorazepam in her home, and she went to get a prn (as needed) dose P1 noticed there were only about 30 medications left in her bottle. P1 also stated she had a visit from a different nurse and noticed her hydrocodone was not set-up in the noon slot of her electronic medication dispenser, she had requested it to be set-up in the a.m., noon, and p.m. Upon interview on 1/18/24 at 2:08 p.m. a non-agency case manager (CM) stated she had received a text from P1 on 1/5/24 indicating that P1 had been missing some medications. The CM told P1 to call the agency and speak with them directly. P1 reached out to the CM again via text on 1/11/24 this time indicating more medications were missing and this time stated they were narcotics. The CM was out on vacation when the text arrived, she returned on 1/15/24 and emailed the agency immediately with missing narcotic allegations. She stated the agency returned the email the following day indicating they were investigating the concerns. Upon interview on 1/18/24 at 2:24 p.m. licensed practical nurse (LPN)-A stated that she saw P1 for the second time on 1/11/24. During the visit P1 mentioned to her that “the last nurse stole my Vicodin” (a narcotic medication brand name for hydrocodone) when P1 was questioning her medications. LPN-A told P1 that nurse would not be visiting her anymore. LPN-A denied reporting the narcotic diversion allegations to the agency. Upon interview on 1/18/24 at 3:08 p.m. registered nurse (RN)-A stated she completed the start of care for P1 on 11/21/23 and “around Christmas time” P1 stated to RN-A that she thought some of her Lorazepam were missing when she went to look for an extra dose to take. RN-A stated she explained to P1 that she did have multiple bottles of Lorazepam, but there was no more than “30-40 pills total.” RN-A denied reporting P1’s missing medication concerns to the agency. Upon interview on 1/19/24 at 10:08 a.m. P1 stated that she has had two nurses from the agency. She stated the first nurse who came out around Christmas time acted “sort of funny” and was always “sorting” her Lorazepam. P1 stated she had about a five-month supply Lorazepam in multiple totaling about 150 pills in her home. She stated she noticed around Christmas time when she went to get a prn pill that she only had about 30 pills and one bottle. She stated she reported this to her case manager after the new year, uncertain of the exact date. In addition, P1 stated a new nurse visited her the first and second weeks of January and she only put her Vicodin in her electronic medication dispenser twice a day, a.m., and p.m. instead of three times a day, a.m., noon, and p.m. P1 stated she asked LPN-A at her next weekly visit why she only set-up the Vicodin for twice a day. Lpn-A told her that she only had enough pills left to set it up twice a day. P1 stated she told LPN-A that the former nurse must have stolen them then. P1 stated a nurse from the agency came out to visit her and told her she “could” report the allegations to law enforcement if she wanted to. Upon interview on 1/19/24 at 12:33 p.m. the clinical nurse manager stated she became aware of the narcotic diversion allegations on 1/15/24 via email from an outside case manager who worked with P1. She stated this was the first she had heard of any complaints with P1. She stated the nurses should have reported the allegations to the agency. She denied reporting the allegations to the SA or law enforcement. A facility policy titled Identifying and Reporting Abuse/Neglect or Exploitation of Clients undated indicated a vulnerable adult is anyone over the age of 18 who receives services such as home care, day services, personal care assistance or other licensed services. Maltreatment including theft, or without of money or property and/or not for the vulnerable adults benefit must reported to the Minnesota Adult Abuse Reporting Center (MAARC).”