Allina Health Home Health

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency (HHA) failed to meet the CFR 484.50 Condition of Participation: Patient Rights. The agency failed to protect a patient (P1) from abuse when registered nurse (RN)-A sexually abused P1 over approximately ten months while assigned as P1’s primary caregiver. The agency failed to thoroughly investigate a sexual abuse allegation when a family friend reported to the agency on 7/31/23 allegations of a romantic relationship regarding P1 and his primary caregiver registered nurse RN-A. The agency failed to immediately report the allegations to the state agency (SA) and the agency failed to protect 171 other patients RN-A was providing cares for from 8/1/23 until her termination on 3/29/24. The survey resulted in an Immediate Jeopardy (IJ) at CFR 484.50 Condition of Participation: Patient Rights. The IJ began on 3/27/24 at 12:01 p.m., when the agency failed to protect multiple patients from potential abuse when the facility failed to report, thoroughly investigate, or protect other patients when the agency was notified of a romantic relationship between a registered nurse (RN)-A nurse and a patient (P1). RN-A sexually abused P1 over approximately ten months while assigned as P1’s primary caregiver. The Interim Vice President of Operations, the Director of Home Health, The Risk Management Manager, and a Registered Nurse Supervisor were notified of the IJ on 3/27/24 at 12:01 p.m. The immediate jeopardy was removed on 4/4/24 at 10:42 a.m. after it could be verified the agency had implemented an acceptable removal plan. The immediate jeopardy that began on 3/27/24, was removed on 4/4/24 when verified the facility contacted all patients seen by RN-A determining psychosocial needs that may be affected by RN-A’s actions, reviewed its policy and procedures response process to allegations of abuse and/or assault as well as their investigation process then educated staff on the agencies policy, procedures and systems for responding to and investigating allegations of abuse and/or assault, and staff completed Allina’s Home Health Professional Boundaries training. Findings include: Refer to G430: The agency failed to protect patients from abuse when RN-A sexually abused P1 over approximately ten months while assigned as P1’s primary caregiver. The facility received an allegation of a romantic relationship between registered nurse (RN)-A and (P1). When this was initially reported on 7/31/23, the agency failed to investigate or take action to protect other patients from potential abuse. RN-A continued to provide care to numerous other patients before being removed from the schedule. This had the potential to affect 171 patients under RN-A’s care. Refer to G478: The agency failed to investigation an allegation of sexual abuse for 1 of 1 patient (P1) reviewed for abuse. The agency did not have policies, procedures, or a system in place to identify a process to investigate allegations of sexual abuse. Refer to G486: The agency failed to take action to prevent further potential violations to patients following allegations of sexual abuse for 1 of 1 patient (P1). The agency received a complaint allegation of a romantic relationship between (P1) and registered nurse (RN)-A. The agency substantiated that a relationship occurred, however allowed RN-A to see 171 other patients in the time she was removed from caring for P1 and the time RN-A was terminated from the agency. Refer to G488: The agency failed to ensure allegations of sexual abuse were immediately reported the state agency for 1 of 1 patient (P1) reviewed when a family friend called the agency to report a romantic relationship between P1 and his nurse (RN)-A.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure the oasis assessment accurately reflected the health status of 2 of 2 patients assessed (P1 & P2). P1’s Oasis assessment indicated he was on a regular diet, however he was on a feeding tube. P1 was assessed to not be vulnerable, on interviews with P1 and registered nurse (RN-B) both identified reasons he does have vulnerability risks. In addition, documentation on his recertification assessment indicated P1 had vulnerability risk. P2’s oasis assessment indicated P2 was over age 65 and had no central line or tunneled device. P1 was assessed not to be vulnerable even with a current inability to self-manage important medications. P2’s recertification summary dated 3/22/24-5/20/24, indicated P2 received services from the HHA for end stage renal disease, atrial fibrillation (rapid heart rate), and chronic respiratory failure. P2 had morbid obesity and was dependent on renal dialysis. P2’s start of care assessment dated 3/22/24, indicated the following: -in section MAHC-10 yes patient 65 years or older -in section O0110-had no central or tunneled catheter -P2 had 0-NONE checked. P2’s hospital discharge summary paperwork dated 2/8/24, indicated P2 was not 65 years or older. P2 had an invasive central line required for dialysis treatment. P2’s start of care summary dated 3/22/24, indicated P2 had not been taking warfarin as ordered upon hospital discharge and P2 required education about the importance of medications and taking as prescribed. The summary further stated sister was P2’s PCA and would now be reminding P2 about medications. An observation and interview on 3/28/24 at 3:26 p.m., P2 was seated in a recliner chair in the living room. P2 had a tee-shirt that was pulled down some and a dialysis catheter was seen on the right upper chest area. P2 stated the dialysis catheter was placed when in the hospital and was used for dialysis treatments. P2 further stated he did not take warfarin for a few weeks as he thought he was out of the medication. P2 stated the agency staff found a bottle with the hospital discharge information during a visit last week. When interviewed on 3/28/24, registered nurse (RN)-C verified P2 had a dialysis catheter in the right chest and was not aware of a surgical wound or other current skin issues. When interviewed on 4/1/24 at 2:31 p.m., care manager (CM)-A stated not taking medications as directed due to inability to find them or know how to get more would make P2 vulnerable. CM-A further verified P2’s start of care assessment lacked indication of a central dialysis catheter. CM-A expected staff to have a dialysis catheter documented when present on the start of care. P1’s Oasis recertification dated 3/28/24 indicated Under the title Recertification summary: Primary diagnosis for Home Health: S [sic] other diagnoses and recent medical procedures impacting episode: left blank Clinical and functional limitations requiring skilled care: left blank Psychosocial concerns/observations: No barriers/concerns Vulnerability risk: 0 - None P1’s recertification summary dated 4/1/24 – 5/30/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right IT, three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. Safety and nutritional assessment indicated a regular diet. Functional assessment: Paralysis Readmission risks/rehab potential unintentional weight loss of a total of 10 lbs. or more in the past twelve months. Decline in mental, emotional, or behavior status in the past three month Currently taking five or more medications. Upon observation on 3/28/24 at 2:15 p.m. P1 told RN-B of the Botox procedure he had completed on 3/27/24. P1 had called it a surgical procedure as he was placed under general anesthesia and had Botox injection into his bladder. He mentioned had and was continuing to have bladder spasms and increased pain following the procedures. This information was not on the Oasis certification under new procedures. Upon interview on 3/28/24 at 4:15 p.m. P1 stated he considered himself vulnerable because he is a paralyzed. He stated he is “forced” to rely on nursing staff and his family for all cares including his safety. “I also take a lot of meds and some make me loopy.” Upon interview on 4/1/24 at 9:55 a.m. registered nurse, RN-B stated would identify P1 as vulnerable due to his condition of being “bed bound”, having 5 wounds and on being a stage IV, having a catheter and a feeding tube and the “main reason” he is dependent on care givers for what he can’t do. An Oasis assessment policy was requested however none received.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review the agency failed to use standard infection control precautions to prevent the transmission of infections for 1 of 1 patient (P1) observed during five wound care dressing changes. RN-B failed to prepare a clean barrier on a surface to place clean equipment before providing P1’s wound cares and failed to disinfect a spoon used to prepare a medication paste during the treatment process. Findings include: P1’s recertification summary dated 2/1/24 – 3/31/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right ischial tuberosity IT,( sitting bone) three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder and a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. P1 was oriented to person, place, time, environment, and family. Upon observation on 3/28/24 at 2:18 p.m. RN-B began the five dressing changes for P1. RN-B did not set-up a clean barrier space for the supplies. P1 had a hospital wash basin with multiple dressings and other supplies on a table near his bed. RN-B kept her gloves for changing in her pockets. RN-B used hand sanitizer and donned clean gloves as she removed dressing from P1’s ischial wound. She cleansed the wound, packed the dressing with lidocaine saturated gauze and let the wound sit for thirty minutes as ordered. RN-B sanitized her hands and donned clean gloves then removed the three old dressings from P1’s back. RN-B used the same gloves she removed the dressings to look through the basin to find the wash and dressings for cleansing P1’s back wounds. RN-B laid the wash and the dressings on P1’s bed sheet, cleansed her hands, donned clean gloves, and finished the back wounds without concerns. RN-B then went back to complete the ischial wound. She sanitized her hands and gloved. She reached into the bottom of the basin and found a rubber ended spoon laying on the bottom of the basis. She did not disinfect the spoon. She used the spoon to mix Flagyl (a crushed medication that P1’s father had already crushed) and an ointment to make a paste, then used the spoon and her gloves to place the paste directly inside the wound bed. Upon interview on 4/1/24 a 9:55 a.m. RN-B stated she usually will set-up a barrier for wound care, but just “didn’t” on 3/28/24 when her cares were observed. She stated the rubber ended spoon is stored in the basin after use to be there for the next use. She stated the spoon gets “wiped down” after the procedure, but she would not be certain that other contaminants do not come into contact with the spoon between dressing changes since it stored uncovered at the bottom of the basis. Upon interview on 4/4/24 at 4:15 p.m. the Home Care Director stated her expectation of staff is to set-up a clean barrier field before providing any wound care and that an equipment must be sanitized prior to use. An agency pressure ulcer procedure sheet developed in cooperation with Leading Age dated 5/2023 indicated staff were to prepare an area in a clean, convenient location and assemble the necessary supplies. The procedure also indicated for topical agents that a sterile cotton-tipped applicator or sterile tongue blade is to be used.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on interview and record review, the agency failed to protect patients from abuse when RN-A sexually abused P1 over approximately ten months while assigned as P1’s primary caregiver. The facility received an allegation of a romantic relationship between registered nurse (RN)-A and (P1). When this was initially reported on 7/31/23, the agency failed to investigate or take action to protect other patients from potential abuse. RN-A continued to provide care to numerous other patients before being removed from the schedule. This had the potential to affect 171 patients under RN-A’s care. The Immediate Jeopardy (IJ) began on 3/27/24 at 12:01 p.m., when the agency failed to protect multiple patients from potential abuse when the facility failed to report, thoroughly investigate, or protect other patients when the agency was notified of a romantic relationship between a registered nurse (RN)-A nurse and a patient (P1). RN-A sexually abused P1 over approximately ten months while assigned as P1’s primary caregiver. The Interim Vice President of Operations, the Director of Home Health, The Risk Management Manager, and a Registered Nurse Supervisor were notified of the IJ on 3/27/24 at 12:01 p.m. The immediate jeopardy was removed on 4/4/24 at 10:42 a.m. after it could be verified the agency had implemented an acceptable removal plan. Findings Include: The agency investigative summary dated 7/31/23 indicated the agency received a call from a friend of P1’s family on 7/31/23, reporting RN-A, P1’s nurse, stopped dating P1 and he had issues with getting supplies. The friend reported RN-A was involved in a romantic relationship with P1. Interviews revealed that RN-A and P1 did not have a relationship prior to P1’s start of care of 8/10/22. The agency spoke to P1 who said he did have a romantic relationship with RN-A and that he was getting his supplies. P1 told the agency RN-A never told him she could not be his nurse. The agency told P1 he had a new case manager assigned. RN-A was interviewed by the agency on 8/2/23 and denied a relationship with P1 but admitted that she saw P1 outside of working hours to assist him with needs while his personal caregivers were away. A written warning for violating professional boundaries was issued to RN-A and RN-A continued to work with other patients. A letter from the Office of Minnesota Attorney General dated 10/24/23 addressed to the agencies Human Resources Director enclosed a subpoena indicated per the Minnesota Statutes second 214.10 subdivision 3, to produce a copy of the complete employment records, personnel file, and/or supervisors anecdotal file, including, but not limited to application for employment, curriculum vitae, job description, employment contracts, performance evaluations, records of verbal and written complaints, incident reports, internal investigation documents, disciplinary actions/warnings, leave of absence documents, and termination documents in your possession of P1. The records were to be sent to the Investigator of Health and Teacher Licensing Division no later than 11/6/23. The document was issued by the Minnesota Board of Nursing on 10/23/24. The requested employment records were emailed to the Minnesota Attorney General on 10/30/23. P1’s recertification summary dated 2/1/24 - 3/31/24 indicated P1 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right ischial tuberosity IT, sitting bone, three pressure ulcers on his back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. P1 was oriented to person, place, date, time, environment, and family. A letter from the Minnesota Board of nursing (Board) dated 1/29/24 was emailed to RN-A. The letter indicated Minnesota Board of Nursing had received a complaint about her nursing practice involving and allegation which would violate the Minnesota Nurse Practice Act (“NPA”). “The Board received a complaint alleging about being engaged in an inappropriate relationship with a patient while working at the agency: -MN Stat.148.261, subd. 1 (5) Failure to or inability to perform professional or practical nursing as defined in MN Stat. 148.171, subd. 14 or 15, with reasonable skill and safety, including failure of a registered nurse to supervise or a licensed practical nurse to monitor adequately the performance of acts by any person working at the nurse’s direction. -MN Stat.148.261, subd. 1 (6) Engaging in unprofessional conduct, including, but not limited to, a departure from or failure to conform to board rules of professional or practical nursing practice that interpret the statutory definition of professional or practical nursing as well as provide criteria for violations of the statutes, or, if no rule exists, to the minimal standards of acceptable and prevailing professional or practical nursing practice, or any nursing practice that may create unnecessary danger to a patient’s life, health, or safety. Actual injury to a patient need not be established under this clause. MN Stat.148.261, subd. 1 (11) Engaging in any unethical conduct, including, but not limited to, conduct likely to deceive, defraud, or harm the public, or demonstrating a willful or careless disregard for the health, welfare, or safety of a patient. Actual injury need not be established under this clause. -MN Stat.148.261, subd. 1 (12) Engaging in conduct with a patient that is sexual or may reasonably be interpreted by the patient as sexual, or in any verbal behavior that is seductive or sexually demeaning to a patient or engaging in sexual exploitation of a patient or former patient. An investigation is being conducted to determine if the allegations are true or not. The Board specifically reviewing your nursing practice as a result of information the Board has received and has asked the Attorney General to conduct an investigation.” A civil lawsuit summons dated 3/19/24 was received by the agencies Employee Relations (ER) business unit. The lawsuit indicated P1 was the Plaintiff and RN-A, and the agency were the Defendants. The letter indicated RN-A and the agency were being sued and must reply within 20 days to protect their rights. The facts in the summons indicated: -P1 now a paraplegic having sustained catastrophic injuries in a roll-over care accident at the age of 18. -P1 at that time was a teenager with a wide circle of friends and is now isolated and confined to his bed virtually 24-hours a day. -P1 lives with long-term, profound depression, had chronic pain, endures severe bed sores and host of other serious medical conditions. -P1 followed an elaborate regimen of medications to alleviate his pain and depression. RN-A in the summer of 2022 was assigned to P1 as his nurse, making three home visits a week to check vitals, dress wounds, breathing function, took urine samples reordered medical supplies. The visits generally lasted 90 minutes. -RN-A became P1’s case manager after two months. At that time, she sent P1 a text message expressing her romantic interest in him. The day after the first text, RN-A kissed P1 for the first time. The romantic interludes quickly went from kissing to fondling, to dozens of instances of digital penetrations and oral sex. RN-A introduced sex toys into the relationship. Intercourse had been discussed, but not consummated because P1 had chronic and excruciating bladder pain and a urinary tract infection which prevented it. -RN-A took “selfie” photos in various stages of undress and gave to P1. P1 has retained the photographs. -RN-A and P1 exchanged hundreds of romantic text messages. P1 has retained the texts. -RN-A attitude to P1 soured, she began complaining about inconsequential personal matters between the two, questions his ability to ever father a child with her and to live outside of a hospital bed. -On 7/14/23 RN-A ended the relationship. -P1 already isolated, physically, and emotionally vulnerable, was utterly shattered by RN’s betrayal. An agency investigation report dated 3/19/24, indicated the agency’s Employee Relations (ER) received notification of a civil lawsuit involving RN-A. RN-A was alleged to have engaged in inappropriate conduct while conducting care for P1. The compliant was substantiated. Between 3/19/24 and 3/21/24 records were reviewed, and interviews were conducted: 1. On 3/19/24 RN-A was placed on administrative leave pending outcome of the investigation 2. On 3/19/24 RN-A was interviewed by phone 3. On 3/21/24 the investigation record was closed. The summary of the investigation findings indicated RN-A was assigned to care for P1 from 10/12/22 to 8/1/23. During RN-A’s interview she admitted that she had a “personal relationship” with P1, and they exchanged text messages that were “sometimes work related. When asked if any of the text messages were sexual in nature, RN-A stated she did not want to answer that question. When RN-A was asked if she ever kissed P1 RN-A began to cry and said she was already being investigated by the Board of Nursing and did not “want to do this again.” RN-A terminated the interview. A Minnesota Adult Abuse Reporting Center (MAARC) report was filed by the agency on 3/20/24 by the agency. Upon interview on 3/26/24 at 11:26 a.m. the Human Resources Directed stated the agency provided the information requested in the Minnesota Board of Nursing subpoena but took no further action to determine why the information was requested. Upon interview on 3/25/24 at 2:08 p.m. the Home Health Director stated the agency received a call 7/31/23 from a friend of P1 who shared P1 was in a romantic relationship with his nurse and the couple broke up and since the break-up she was concerned he was not getting his wound supplies. She stated RN-A denied a romantic relationship but admitted to seeing P1 outside of work. P1 did admit to romantic involvement with RN-A. The director denied interviewing any other HHA staff or any other HHA clients. The director turned the investigation over to ER on 8/1/24. RN-A was removed from P1’s assignments on 7/31/23. On 2/1/24 RN-A shared that she was investigated by the Board of Nursing and was feeling “so stressed out” that she wanted to take a leave of absence starting 2/2/24. RN-A was granted the leave and she returned to work after 2/9/24. The director stated the agency did not do an investigation of why RN-A was being investigated by the Board of Nursing. She stated then on 3/19/24 the agency received notification of a civil case regarding the HHA, because of RN-A committing sexual abuse. She stated on 3/19/24 she immediately reached out to employee relations and worked with them to interview RN-A. She stated RN-A was terminated “based on some of her answers to the questions,” but she elected to resign. The director stated the agency did not reach out to P1 after these allegations, nor any other staff members or other patients seen by RN-A from 8/1/24 until 3/19/24. Upon interview on 3/25/24 at 3:06 p.m. RN-A stated P1 never made any inappropriate requests during his nursing visits, his visits took a long time for him to get situated because P1 had a lot of wounds. RN-A stated she was not comfortable talking about her relationship with P1 without her attorney present. In addition, she stated she took a leave of absence from work following the e-mail she received from the Minnesota Board of Nursing about being investigated. Upon interview on 3/26/24 at 9:12 a.m. family member (FM)-A stated he did not want to be interviewed or have P1 interviewed without an attorney present because the situation was too emotionally scarring to P1 to be brought up again. FM-A requested all questions go through his attorney and requested a list of questions via email. Upon interview on 3/26/24 at 11:26 a.m. the Human Resources Directed stated the agency provided the information requested in the Minnesota Board of Nursing subpoena but took no further action to determine why the information was requested. Upon interview on 3/27/24 at 9:42 a.m. P1 stated he had suffered mental and emotional stress at the hands of RN-A. He stated he felt coerced and manipulated “that is all I want to say without an attorney present.” Agency policy titled Vulnerable Adult Maltreatment Assessment and Reporting in Minnesota dated 4/2022 indicated reports of suspected or known incidents of maltreatment must be reported as soon as possible, but in no event longer than 24 hours. One definition of abuse was criminal sex conduct. A vulnerable adult was described as a person age 18 or older who regardless of resident or type of service received, possess a physical, mental, or emotional infirmity which impairs the person’s ability to basic cares without assistant and as a result of the infirmity and the dependence, the adult has an impaired ability to protect themselves from maltreatment. The immediate jeopardy that began on 3/27/24, was removed on 4/4/24 when verified the facility contacted all patients seen by RN-A determining psychosocial needs that may be affected by RN-A’s actions, reviewed its policy and procedures response process to allegations of abuse and/or assault as well as their investigation process then educated staff on the agencies policy, procedures and systems for responding to and investigating allegations of abuse and/or assault, and staff completed Allina’s Home Health Professional Boundaries training.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on interview and record review the agency failed to provide proper written notice in advance of specific services being furnished if the agency believes that the serve may non-covered; or in advance of the agency reducing or terminating ongoing care. This deficient practice did not allow Medicare beneficiaries to exercise or dispute their Medicare-covered services for 3 of 17 (P1, P5, P12) patients reviewed. P1’s skilled nursing services were reduced from three times per week to two without providing advance notice. P5’s physical therapy services were terminated due to P5 not reaching her goals without notice given to P5 to dispute. P12’s physical therapy, skilled nursing and occupational services ended due to P12 reaching goals and was not given notice to dispute. P12’s recertification summary dated 2/2/24-4/1/24, indicated P12 received services from the HHA for bladder cancer, artificial opening of urinary tract and heart failure. P12’s summary further indicated P12 had the following services: -skilled nursing 1 visit every 9 days (2/2/24-2/10/24) and then 1 visit weekly for 3 weeks (2/11/24-3/2/24) for respiratory assessment, genitourinary assessment, skin/wound assess, pain and anxiety. -physical therapy 1 visit every 9 days (2/2/24-2/10/24) and then 1 visit every 3 days (2/8/24-2/10/24) then weekly visits for 5 weeks (2/11/24-3/16/24) for gait and transfer training, balance, exercises, and education. -occupational therapy 1 visit every 9 days (2/2/24-2/3/24). Then 2visits for 3 weeks (2/4/24-2/24/24) for activities daily living, safety, and education. P12’s skilled nursing intervention for discharge planning indicated P12 will receive proper notification 48 hours or more of discharge for Medicare patients. P12’s skilled nursing visit note dated 2/29/24, indicated P12 was being discharged from skilled nursing services due to goals met. P12’s physical therapy home care note dated 3/29/24, indicated P12 was discharged from physical therapy as all goals were met. P12’s occupational therapy visit note dated 3/27/24, indicated P12 was discharged from occupational therapy services with all goals met. P12’s ABN notice for discontinuation of Servies was requested however was not received. Medicare Claims Processing Manual Chapter 30 – Financial Liability Protections dated 12/20/23 indicated the Advance Beneficiary Notice of Non-coverage (ABN) is a type of financial liability notice. The ABN musted be provided far enough in advance of delivering potentially non-covered items or services to allow sufficient time for the beneficiary to consider all available options. Reductions involve any decrease in services or supplies, such as frequency, amount, or level of care, provided by the HHA and/or care that is part of the POC. If a reduction occurs for an item or service that will no longer be covered by Medicare, but the beneficiary wants to continue to receive the care and assume the financial charges, the HHA must issue the ABN prior to providing the non-covered items or services. P1’s start of care certification dated 8/10/22 and certifications through dated 8/4/23 indicated skilled nursing frequencies was: 3 visits every week. 8/10/22 to 10/8/22: 1 to 8 (PRN) as needed visits Comments: assess wound/cares, skin/pressure relief, pain, medications, gastrointestinal/gastrourinal GI/GU, safety P1’s certification dated 10/9/2022 to 12/3/2022 indicated skilled nursing visits frequency was: 10/9/22 – 12/7/22: 3 visits every week for 8 weeks. 10/9/22 to 12/7/22: 1-6 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s recertification dated 12/4/2022 to 2/4/23 indicated skilled nursing visit frequency was: 12/4/22 – 12/7/22: 2 visits every 4 days for 4 days. 12/11/22 - 2/4/22: 3 visits every week for 8 weeks. 12/4/22 – 2/4/22: 1-5 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s recertification dated 2/6/23 – 4/6/23 indicated skilled nursing visit frequency was: 2/6/2023 to 2/11/2023: 3 visits every 6 days for 6 days. 2/12/2023 to 3/18/2023: 3 visits every week for 5 weeks. 2/6/2023 to 3/18/2023: 1-4 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s recertification dated 4/7/23 – 6/5/23 indicated skilled nursing visit frequency was: 4/7/23 – 4/8/23: 1 visit every 2 days for 2 days. 4/9/23 to 6/5/23: 3 visits every week for 4 weeks. 4/7/23 to 6/5/23: 1-4 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s recertification dated 6/6/23 – 8/4/23 indicated skilled nursing visit frequency was: 6/6/23 – 6/11/23: 1 visits every 3 days for 4 days. 6/11/2023 to 7/8/2023: 3 visits every week for 7 weeks. 6/6/2023 to 8/4/2023 1-5 PRN visits Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety The agency investigative summary dated 7/31/23 indicated they received a call from a friend of P1’s family on 7/31/23 reporting RN-A, P1’s nurse, stopped dating P1 and he had issues with getting supplies. The friend reported RN-A was in a relationship with P1. RN-A was removed from care with P1 7/31/23. P1’s recertification dated 8/5/23 – 10/3/23 indicated skilled nursing visit frequency was: 8/6/23 – 9/30/23: 2 visits every week for 7 weeks. 8/5/23 – 10/3/23: 1-5 PRN visits. 10/1/23 – 10/3/23: 1 visit every 3 days for 3 days. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s recertification dated 10/4/23 – 12/2/23 indicated skilled nursing visit frequency was: 10/4/23 – 10/7/23: 1 visit every 4 days for 4 days. 10/8/23 – 12/2/23: 2 visits every week for 8 weeks. 10/4/23 – 12/2/23: 1-5 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s recertification dated 12/3/23 – 1/31/24 indicated skilled nursing visit frequency was: 12/3/23 – 1/31/24: 2 visits every week for 8 weeks. 12/3/23 – 1/31/24: 1-3 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s recertification dated 2/1/24 – 3/31/24 indicated skilled nursing visit frequency was: 2/1/24 – 2/10/24: 2 visits every 10 days for 10 days. 2/11/24 – 2/20/24: 2 visits every week for 2 weeks. 2/25/24 – 3/30/24: 1 visit every week for 5 weeks. 2/1/24 – 3/31/24: 1-3 PRN visits Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety P1’s orders from the wound care clinic dated 3/5/24 indicated P1’s plan was to continue with 3 days weekly skilled nursing visits. Upon interview on 3/28/24 at 2:00 p.m. P1’s family member (FM)-A stated P1’s skilled nursing decreased in 8/1/23. He stated P1 had been getting skilled nursing visits consistently three times a week since his start of care on 8/10/22 and the skilled nursing care was decreased to twice a week on 8/1/23. FM-A stated “no two nurses” give him “the same story” as to why visits decreased. FM-A denied signing any Medicare form or educated on how to dispute the decrease in services. Upon interview on 3/24/24 at 4:15 p.m. P1 stated he did not sign any Medicare form approving the decrease in visits. He denied receiving education on how to dispute the decrease in skilled nursing services through Medicare. P1’s recertification summary dated 4/1/24 – 5/30/24 indicated P1 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right IT, three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. Upon interview on 4/1/24 at 10:58 a.m. RN-D P1’s case manager stated she has had discussion with FM-A and P1 about the decrease in skilled nursing services due Medicare may not pay because education needs to remain a component of the visits for Medicare to pay. RN-D denied providing an ADN form to the family. P5’s certification dated 2/1/24 – 3/31/24 indicated P5 pertinent diagnoses were chronic obstructive pulmonary disease with exacerbation and acute respiratory failure with hypoxia (difficulty breathing), congestive heart failure, rheumatoid arthritis, and osteoporosis. P5’s services were physical therapy for strength, gait, activity tolerance and safety. Skilled nursing for oxygenation, safety, medication changes, and lab draws. 2/1/24 – 2/10/24: P5’s physical therapy visits were 1 visit every 10 days for 10 days to evaluate and treat for gait, balance, and exercises. 2/6/24 – 2/17/24: 1 visit every 12 days for 12 days for lower extremity strength, activity tolerance, gait/transfer training, and safety instruction. 2/18/24- 3/24/24: 1 visit every week for 2 weeks. For lower extremity strength, activity tolerance, balance, gait/transfer training and safety. 3/24/24 – 3/30/24 1 visit for 1 week for strength, gait, balance, transfers manual therapy, modalities, and oxygen saturation checks. Upon observation on 3/29/24 at 3:10 p.m. physical therapist (PT)-A explained to P5 that the visit would be P5’s last physical therapy visit because P5 hasn’t functionally improved. She explained to P5 that after six off therapy P5 only increased her ambulation by 20 feet. PT-A told P5 to have her daughter assist with any exercises P5 had learned through therapy. P5 responded that she was just having a bad day and that she was tired because occupational therapy (OT) had just worked with her. P5 stated her daughter works full-time and has family that assisting with exercises would be a burden on her. P5 stated she wanted to continue with physical therapy. PT-A informed P5 that it was Medicare standards that if someone is not improving therapy can not be renewed. An ABN form was not discussed. Upon interview on 4/1/24 at 11:00 a.m. PT-A stated she did not use the ABN form because it wasn’t required because P5 had completed the visits as ordered on the service agreement. Upon interview on 4/1/24 at 11:12 a.m. P5 stated she wanted to continue with therapy. She denied signing any Medicare forms about physical therapy ending or who to report a dispute to. Upon interview on 4/4/14 at 4:15 p.m. The Director of Home stated that an ABN form is required for Medicare patient who wish to continue services under Medicare or have the option to choose another payor source. In addition, an ABN form was to be used for all Medicare reductions in services. A facility policy titled Home Health-Beneficiary Notices effective 11/26/22 indicated an ABN notice is issued to Traditional Medicare beneficiaries when payment is expected to be denied. In addition, the ABN needs to be re-issued at least annually to assure patient rights are maintained.”

“Freedom from discrimination or reprisal CFR(s): 484.50(c)(11) Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity. This Element is not met as evidenced by: Based on interview and record review the agency failed to be free from any discrimination of reprisal for exercising his rights after the family requested a family friend to file a complaint against the home heath agency. P1 and P1’s family stated immediately following the complaint filing his skilled nursing visits decreased. The family felt it retaliation for the complaint filed. Findings Include: P1’s start of care certification dated 8/10/22 to 10/8/22 indicated skilled nursing frequencies was: 2 visits every 4 days for 4 days 8/10/22 – 8/13/22. 8/14/22 to 10/8/22: 3 visits every week for 8 weeks. 8/10/22 to 10/8/22: 1 to 8 (PRN) as needed visits Comments: assess wound/cares, skin/pressure relief, pain, medications, gastrointestinal/gastrourinal GI/GU, safety. P1’s certification dated 10/9/2022 to 12/3/2022 indicated skilled nursing visits frequency was: 10/9/22 – 12/7/22: 3 visits every week for 8 weeks. 10/9/22 to 12/7/22: 1-6 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s recertification dated 12/4/2022 to 2/4/23 indicated skilled nursing visit frequency was: 12/4/22 – 12/7/22: 2 visits every 4 days for 4 days. 12/11/22 - 2/4/22: 3 visits every week for 8 weeks. 12/4/22 – 2/4/22: 1-5 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s recertification dated 2/6/23 – 4/6/23 indicated skilled nursing visit frequency was: 2/6/2023 to 2/11/2023: 3 visits every 6 days for 6 days. 2/12/2023 to 3/18/2023: 3 visits every week for 5 weeks. 2/6/2023 to 3/18/2023: 1-4 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s recertification dated 4/7/23 – 6/5/23 indicated skilled nursing visit frequency was: 4/7/23 – 4/8/23: 1 visit every 2 days for 2 days. 4/9/23 to 6/5/23: 3 visits every week for 4 weeks. 4/7/23 to 6/5/23: 1-4 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s recertification dated 6/6/23 – 8/4/23 indicated skilled nursing visit frequency was: 6/6/23 – 6/11/23: 1 visits every 3 days for 4 days. 6/11/2023 to 7/8/2023: 3 visits every week for 7 weeks. 6/6/2023 to 8/4/2023 1-5 PRN visits Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. The agency investigative summary dated 7/31/23 indicated they received a call from a friend of P1’s family on 7/31/23 reporting RN-A, P1’s nurse, stopped dating P1 and he had issues with getting supplies. The friend reported RN-A was in a relationship with P1. RN-A was removed from care with P1 on 8/1/23. P1’s recertification dated 8/5/23 – 10/3/23 indicated skilled nursing visit frequency was: 8/6/23 – 9/30/23: 2 visits every week for 7 weeks. 8/5/23 – 10/3/23: 1-5 PRN visits. 10/1/23 – 10/3/23: 1 visit every 3 days for 3 days. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s recertification dated 10/4/23 – 12/2/23 indicated skilled nursing visit frequency was: 10/4/23 – 10/7/23: 1 visit every 4 days for 4 days. 10/8/23 – 12/2/23: 2 visits every week for 8 weeks. 10/4/23 – 12/2/23: 1-5 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s recertification dated 12/3/23 – 1/31/24 indicated skilled nursing visit frequency was: 12/3/23 – 1/31/24: 2 visits every week for 8 weeks. 12/3/23 – 1/31/24: 1-3 PRN visits. Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s recertification dated 2/1/24 – 3/31/24 indicated skilled nursing visit frequency was: 2/1/24 – 2/10/24: 2 visits every 10 days for 10 days. 2/11/24 – 2/20/24: 2 visits every week for 2 weeks. 2/25/24 – 3/30/24: 1 visit every week for 5 weeks. 2/1/24 – 3/31/24: 1-3 PRN visits Comments: assess wound/cares, skin/pressure relief, pain, medications, GI/GU, safety. P1’s orders from the wound care clinic dated 3/5/24 indicated P1’s plan was to continue with 3 days weekly skilled nursing visits. Upon interview on 3/28/24 at 2:00 p.m. P1’s family member (FM)-A was question why P1’s skilled nursing decreased “immediately” after a family friend filed a complaint to the agency. He stated P1 had been getting skilled nursing visits consistently three times a week since his start of care on 8/10/22 and the skilled nursing care was decreased to twice a week on 8/1/23. FM-A stated “no two nurses” give him “the same story” as to why visits decreased. Upon observation on 3/28/24 at 3:45 p.m. RN-B was asked why the skilled nursing had been decreased. RN-B replied that she did not know why. FM-A showed RN-B the orders in which RN-D was using for the dressing changes she had just completed where the form indicated 3/5/24 “continue 3 days weekly skilled nursing visits.” RN-B told FM-A that she would change the visits back to 3 times weekly and speak with her supervisor about the change. Upon interview on 3/28/24 at 4:15 p.m. P1 stated he was unaware why his skilled nursing visits had been decreased form 3 times a week to 2 times a week and then to 1 time a week. He stated he was “certain” it was from the complaint and the fear of losing his visits was adding to his anxiety. He stated staff had told him because he has not improved in over a year, other staff had told him it was because they were “running out of education material.” Upon interview on 4/1/24 at 10:58 a.m. RN-D stated the reason the P1’s visits were being decreased was because per Medicare guidelines the agency is required to be teaching P1 or his caregiving. She stated P1 and his family have been educated on everything and “recently” FM-A leaves the room when she is providing cares to P1. RN-D could not identify any specific education completed with the family. She stated the education is general wound care. She stated she had never provided educational handout materials and did not document any specific education give to the family or P1. She stated she did not have any documentation of education and return demonstration from, P1, FM-A, or FM-B. An agency policy titled Vulnerable Adult Maltreatment: Assessment and Reporting in Minnesota effective date 4/2022 indicated the agency will not retaliate any against any employee, practitioner, contractor, volunteer, or other person who, in good faith reports suspected maltreatment of a vulnerable adult, nor against any person with respect to whom a vulnerable adult maltreatment report is made.”

“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 record the agency failed to investigation allegations of sexual abuse. The agency did not have policies or procedures in place to identify a process to investigate allegations of sexual abuse. See G430 Based on interview and record the agency failed to investigation an allegation of sexual abuse for 1 of 1 patient (P1) reviewed for abuse. The agency did not have policies, procedures, or a system in place to identify a process to investigate allegations of sexual abuse. Finding include: P1’s recertification summary dated 2/1/24 – 3/31/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right ischial tuberosity IT (sitting bone), three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. P1 was oriented to person, place, time, environment, and family. The agency investigative summary dated 7/31/23 indicated they received a call from a friend of P1’s family on 7/31/23 reporting RN-A, P1’s nurse, stopped dating P1 and he had issues with getting supplies. The friend reported RN-A was in a relationship with P1. Interviews revealed that RN-A and P1 did not have a relationship prior to initiation of care. The agency spoke to P1 who said he did have a romantic relationship with RN-A and that he was getting supplies. P1 told the agency RN-A never told him she could not be his nurse. The agency told P1 he has a new case manager assigned. RN-A was interviewed by the agency on 8/2/23 and denied a relationship with P1 but admitted that she saw P1 outside of working hours to assist him with needs while his personal caregivers were away. A written warning for violating professional boundaries was issued to RN-A and RN-A continued to work. On 1/29/24 a letter from the Minnesota Board of Nursing was emailed to RN-A. The letter indicated the RN-A was involved in an allegation that she engaged in an inappropriate relationship with a patient while working at the HHA. On 2/1/24 RN-A contacted the agency requesting a leave of absence because she received a letter from the Minnesota Board of Nursing that they are looking into her and she needed time off. Employee Relations received notification of a civil lawsuit against RN-A and Allina Home Health on 3/19/24. RN-A was alleged to have sexually assaulted P1 during the time she was P1’s primary nurse in the summer of 2022 until July 2023. An agency investigation report dated 3/19/24 indicated the agency’s Employee Relations (ER) received notification of a civil lawsuit involving RN-A. RN-A was alleged to have engaged in inappropriate conduct while conducting care for P1. The compliant was substantiated. Between 3/19/14 and 3/21/24 records were reviewed, and interviews were conducted: 1. On 3/19/24 RN-A was placed on administrative leave pending outcome of the investigation 2. On 3-19-24 RN-A was interviewed by phone 3. On 3/21/24 the investigation record was closed. The summary of the investigation findings indicated RN-A was assigned to care for P1 from 10/12/22 to 8/1/23. During RN-A’s interview she admitted that she had a “personal relationship” with P1, and they exchanged text messages that were “sometimes work related. When asked if any of the text messages were sexual in nature, RN-A stated she did not want to answer that question. When RN-A was asked if she ever kissed P1 stated began to cry and said she was already being investigated by the Board of Nursing and not “want to do this again.” RN-A terminated the interview. Upon interview on 3/25/24 at 2:08 p.m. the Home Health Director stated the agency received a call 7/31/23 from a friend of P1 and shared P1 was in a romantic relationship with his nurse and the couple broke up and since the break-up she was concerned about he was not getting his wound supplies. The director stated RN-A denied a romantic relationship but admitted to seeing P1 outside of work. P1 did admit to romantic involvement with RN-A. The director denied interviewing any other agency staff or any other HHA clients. The director turned the investigation over to employee relations on 8/1/24. RN-A was removed from P1’s assignments on 7/31/24. On 2/1/24 RN-A shared that she was investigated by the Board of Nursing and was feeling “so stressed out” that she wanted to take a leave of absence from starting 2/2/4. RN-A was granted the leave and she returned to work after 2/9/24. The director did not identify any other investigation activity. Upon interview on 3/27/24 at 9:42 a.m. P1 stated he had suffered mental and emotional stress at the hands of P1. He stated he did feel coerced and manipulated “that is all I want to say without an attorney present.” Upon interview on 3/27/24 at 2:40 p.m. the Risk Management Manager stated the risk management team, did not assist in any investigation when the agency filed the MAARC report on 3/20/24 because the agency closed the case in August of 2022 because the agency had completed their investigation then. In addition, she stated If the agency would have filed a MAARC report on 7/31/24 risk management would have assisted in that investigation. Upon interview on 3/27/24 at 9:38 a.m. RN-E stated she supervised RN-A and when the initial allegations came in on 7/31/24 she was emailed the information from the staff member who took the call. She stated she called the complainant who told her she was concerned of a romantic relationship between RN-A and P1. She stated she reached out to the human resources department to meet and talk about the situation. RN-E called P1, and he admitted to having a romantic relationship with RN-A. No further questions were asked of P1. She stated she did not reach out to any other staff members of patients as part of an investigation. In addition, she did not let the complainant know the results of any investigation. RN-E stated when the agency became aware on 2/1/24 that RN-A was being investigated by the Minnesota Board of Nursing the agency gave RN-A some requested time off. The agency did not investigate the allegations again RN-A because they were unaware of who the patient was. On 3/19/24 when the agency receive notification that there was a civil lawsuit involving RN-A the agency brought her in for questioning and during the meeting the agency as going to terminate RN-A but RN-A resigned. No other investigation activity was identified. P1 was not interviewed. Upon interview on 3/27/24 at 12:09 p.m. the human resource consultant stated she became involved in the investigation on 3/19/24 when the agency received information of the civil suit. She stated the civil lawsuit were very detailed between P1 and RN-A. She stated they did not investigate because in August of 2023 the agency was unable to substantiate any findings, but on a violation of policy. She stated RN-A was interviewed to the sexual nature of the allegations and began to cry and ended the interview. RN-A then resigned. A facility policy titled Vulnerable Adult Maltreatment Assessment and Reporting in Minnesota effective 4/2022 indicated the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors. The policy did not indicate any investigative activities.”

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This Element is not met as evidenced by: Based on interview and record review the agency failed to take action to prevent further potential violations to patients following allegations of sexual abuse for 1 of 1 patient (P1). The agency received a complaint allegation of a romantic relationship between (P1) and registered nurse (RN)-A. The agency substantiated that a relationship occurred, however allowed RN-A to see 171 other patients in the time she was removed from caring for P1 and the time RN-A was terminated from the agency. Findings include: P1’s recertification summary dated 2/1/24 – 3/31/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right ischial tuberosity IT (sitting bone), three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a prepubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. P1 was oriented to person, place, time, environment, and family. The agency investigative summary dated 7/31/23 indicated they received a call from a friend of P1’s family on 7/31/23 reporting RN-A, P1’s nurse, stopped dating P1 and he had issues with getting supplies. The friend reported RN-A was in a relationship with P1. Interviews revealed that RN-A and P1 did not have a relationship prior to initiation of care. The agency spoke to P1 who said he did have a romantic relationship with RN-A and that he was getting supplies. The agency told P1 he had a new case manager assigned. RN-A was interviewed by the agency on 8/2/23 and denied a relationship with P1 but admitted that she saw P1 outside of working hours to assist him with needs while his personal caregivers were away. A written warning for violating professional boundaries was issued to RN-A and RN-A continued to work. Upon interview on 3/25/24 at 2:08 p.m. the Home Health Director stated the agency received a call 7/31/23 from a friend of P1 and shared P1 was in a romantic relationship with his nurse and the couple broke up and since the break-up she was concerned about he was not getting his wound supplies. PT-A stated RN-A denied a romantic relationship but admitted to seeing P1 outside of work. P1 did admit to romantic involvement with RN-A. The director denied interviewing any other residents at the time of the allegations and RN-A was allowed to work with any other agency patients. The director did not indicate how the residents who RN-A care for were kept safe during the investigation. She stated none of patients complained to the agency. The director provided a list of the patient’s RN-A saw from the time of the allegations of 7/31/23 until her termination date of 3/20/24. On 3/25/24 at 3:06 p.m. RN-A stated she was removed from caring for P1 on 8/1/23 for a relationship. She stated her duties at the agency remained the same except for the inability to see P1. On 3/26/24 at 10:09 a.m. Excel spread sheet was provided listing all patients RN-A provided care for between 8/1/24 and 3/19/29. The list consisted of 686 nursing visits completed on a total of 171 patients. An agency policy titled Vulnerable Adult Maltreatment: Assessment and reporting in Minnesota dated 4/2022 did provide any documentation about preventing further potential abuse. No other abuse policies were provided.”

“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 facility failed to ensure allegations of potential sexual abuse were immediately reported the state agency for 1 of 1 patient (P1) when a family friend called the agency to report a romantic relationship between P1 and his nurse (RN)-A. Findings include: P1’s recertification summary dated 2/1/24 – 3/31/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right ischial tuberosity IT (sitting bone), three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. P1 was oriented to person, place, time, environment, and family. The agency investigative summary dated 7/31/23 indicated the agency received a call from a friend of P1’s family reporting RN-A, P1’s nurse, stopped dating P1 and he had issues with getting supplies. The friend reported RN-A was in a relationship with P1. The agency spoke to P1 who said he did have a romantic relationship with RN-A. On 1/29/24 a letter from the Minnesota Board of Nursing was emailed to RN-A. The letter indicated RN-A was involved in an allegation that she engaged in an inappropriate relationship with a patient while working at the HHA. On 2/1/24 RN-A contacted the agency requesting a leave of absence because she received a letter from the Minnesota Board of Nursing that they are looking into her and needed time off. The agency’s Employee Relations department received notification of a civil lawsuit against RN-A and Allina Home Health on 3/19/24. RN-A was alleged to have sexually assaulted P1 during the time she was P1’s primary nurse in the summer of 2022 until July 2023. A Minnesota Adult Abuse Reporting Center (MAARC) report was filed by the agency on 3/20/24 by the agency. Upon interview on 3/25/24 at 2:08 p.m. the Home Health Director stated the agency received a call 7/31/23 from a friend of P1 who shared P1 was in a romantic relationship with his nurse and the couple broke up and since the break-up she was concerned about P1 was not getting his wound supplies. P1 did admit to romantic involvement with RN-A. On 2/1/24 RN-A shared that she was investigated by the Board of Nursing for inappropriate relationship with a patient. The director stated on 3/19/24 the agency received notification of a civil lawsuit regarding the agency due to RN-A. The director denied reporting the allegations to the SA when the initial allegations came in 7/31/24 or on 2/1/24 when RN-A shared that she was being investigated for an inappropriately relationship with a patient. Agency policy titled Vulnerable Adult Maltreatment Assessment and Reporting in Minnesota dated 4/2022 indicated reports of suspected or known incidents of maltreatment must be reported as soon as possible, but in no event longer than 24 hours. An updated policy titled Vulnerable Adult Maltreatment Assessment and Reporting in Minnesota dated 4/3/24 indicate reports of suspected or know incidents of maltreatment must be reported as soon as possible.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review the facility failed to ensure the start of care assessment was completed within 48 hours of the patient’s return home for 1 of 7 patients (P2) observed during home care visit. P2 discharged from the hospital on 2/10/24 however the agency closed the referral due to a request for a new home care order when P2’s hospital discharge was delayed from 2/8/24 to 2/10/24. Findings include: P2’s recertification summary dated 12/6/23-2/6/24, indicated P2 received services from the HHA for atrial fibrillation (rapid heart rate), chronic respiratory failure and obesity. P2’s hospital discharge summary dated 2/8/24, indicated P2 was in the hospital from 12/26/23-2/10/24. P2’s hospital provider order dated 2/8/24 and expiring 2/8/25, requested home care services of skilled nursing, physical therapy, occupational therapy, home health aide, and social work for P2 upon discharge from the hospital. P2’s recertification summary dated 3/22/24-5/20/24, indicated P2 received services from the HHA for end stage renal disease, atrial fibrillation (rapid heart rate), and chronic respiratory failure. P2 had morbid obesity and was dependent on renal dialysis. P2’s agency referral note dated 2/8/24, indicated Allina intake received the referral on 2/8/24 with a planned discharge of 2/8/24. P2’s agency intake communication notes dated 2/8/24, indicated agency was at capacity, however “NW RN (northwest registered nurse) accepted in over cert”. P2’s hospital care coordination note dated 2/8/24, indicated P2 was placed with Allina Home care upon discharge. P2’s hospital discharge summary dated 2/10/24, indicated P2 was discharging home after dialysis with home care services. P2’s intake communication note dated 2/10/24, indicated a voicemail was left with the hospital requesting new orders as the 2/8/24 orders were expired as of 2/10/24 and P2 had not discharged. P2’s referral was then closed. P2’s provider order dated 3/19/24, indicated physician assistant (PA)-A ordered physical therapy for in home services. P2’s agency referral dated 3/19/24, indicated in coordination with P2 and P2’s sister, a start of care visit with physical therapy was scheduled for 3/22/24. P2’s start of care assessment dated 3/22/24, indicated P2 was had discharged from the hospital on 2/10/24. P2 was discharged with home care services but had not been seen through Allina Home Health. A request for documentation indicating P2 was no longer accepted into services from the 2/8/24 hospital order was requested however was not received. When interviewed on 3/28/24 at 3:05 p.m., P2 stated he discharged from the hospital in February. P2 stated home care just started coming again last week. P2 was not sure why it was not started sooner. When interviewed on 4/1/24 at 2:31 p.m., care manager (CM)-A reviewed intake notes and stated a request for a new order was needed as P2 did not discharge on 2/8/24 like anticipated. CM-A stated since P2 was not at an Allina facility, communication was a little harder. CM-A verified there was no documentation or follow up after 2/10/24 until PA-A placed an order for physical therapy. A follow up interview on 4/4/24 at 9:57 a.m., CM-A explained when a patient referral was accepted there was a 48-hour window to start care. If there was a delay in the ability to start care such as a delay in hospital discharge or patient’s preference, the intake department requested a new order. CM-A verified the initial orders did not expire after 48 hours, but this helped the agency to start care within 48 hours of the order. When interviewed on 4/4/24 at 1:30 p.m., PA-A stated she was aware P2 was in the hospital for kidney failure but had not been aware home care was not following until P2’s sister called the clinic to request therapy orders. PA-A then placed orders for in home physical therapy on 3/19/24. PA-A usually stated home care orders come from the hospital at the time of discharge. PA-A stated she had not seen Pt for a post hospital visit but believed one was now scheduled. When interviewed on 4/4/24 at 3:15 p.m., the Director of Home Care Services stated P2’s initial hospital referral showed an opportunity for improved documentation on what the situation was and if there was any further follow up with P2 or the hospital. There was a lack of documentation to show why the referral was closed if there was any communication follow up with the hospital or with the supervisors on duty. Sometimes when a patient did not discharge from the hospital when planned, it was not known why and if we would be able to safely admit them. The decision is then placed back on the provider and a new order is requested. Furthermore, the director stated they would trust the supervisors to look into the situation but cannot provide any information as to why P2’s referral was closed and if discussion with the supervisors or the hospital had taken place. A facility policy on start of care was requested however was not provided.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview, and record review the agency failed to ensure a comprehensive assessment accurately reflected the patient’s status for 2 of 17 patients (P1 and P2) who received home health services. P1’s comprehensive assessment failed address his psychosocial status including screening of P1’s relationships, living environment, and impact on delivery of services. P2’s comprehensive assessment failed to include an assessment of P2’s dialysis treatment and dialysis catheter. P2’s recertification summary dated 3/22/24-5/20/24, indicated P2 received services from the HHA for end stage renal disease, atrial fibrillation (rapid heart rate), and chronic respiratory failure. P2 had morbid obesity and was dependent on renal dialysis. P2’s start of care assessment dated 3/22/24, failed to include assessment of P2’s dialysis treatment including where services obtained, any needed coordination of care needed with dialysis facility, patient concerns with treatment, concerns with treatment, or any potential monitoring, education, or assessment of the central dialysis catheter. P2’s skilled nurse evaluation summary dated 3/22/24, lacked indication any assessment, monitoring or education of P2’s dialysis treatment or dialysis catheter occurred. An observation on 3/28/24 at 3:26 p.m., P2 was seated in a recliner chair in the living room. P2 had a tee-shirt that was pulled down some and a dialysis catheter was seen on the right upper chest area. P2 stated the dialysis catheter was placed when in the hospital and was used for dialysis treatments. Upon interview on 3/28/24, registered nurse (RN)-C verified P2 had a dialysis catheter in the right chest and was not aware of any required monitoring, care, or restrictions. Furthermore, RN-C was not aware of where P2 received dialysis treatment. Upon interview on 4/1/24 at 2:31 p.m., care manager (CM)-A verified P2’s start of care assessment lacked indication of a central dialysis catheter, or any interventions needed to support P2’s dialysis treatment. P1’s recertification summary dated 2/1/24 – 3/31/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right IT, three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. Upon observation and interview on 3/28/24 at 2:15 p.m. P1 was confined to a hospital bed in his parents home. P1 would shout out to his parents for any needs he required assistance with. P1 stated he had financial concerns, P1 had concerns about his insurance coverage and his ability to continue living at home and his parents aging and unable to care for him in the near future. P1 stated loneliness and how getting into the community, even the rehabilitation center would be beneficial for him. P1’s nursing note dated 3/14/24 indicated P1’s parent provide care 24 hours a day for P1. The note also indicated P1 was very anxious because FM-B did not pick-up any medications at the pharmacy. P1 was calling the pharmacy which did have complete doses yet. P1’s nursing note dated 3/18/24 indicated P1 had anxiety during visit when it relates to medications or supply issues. P1 was non-ambulatory and had phone next to his bed. P1’s nursing note dated 3/25/24 indicated when P1 leaves home he experiences unsteady gait, weakness, poor endurance, and debilitating pain. P1’s compressive assessment dated 3/28/24 indicated psychosocial concerns observations: No barriers/concerns. Decline in mental, emotional, or behavior status in the past three months. The assessment did not indicate any further details regarding the decline. Upon interview on 4/1/24 at 9:55 a.m. RN-B stated for the psychosocial assessment she looks at cognition, anxiety and depression. She stated she asked patients mood and watches for for signs of nonverbal ques for anxiety and depression including crying, anger, and being withdrawn. RN-B denied assessment for relationships, financial concerns or community involvement. Upon interview on 4/4/24 at 4:15 p.m. the Director of Home Care stated she believed the staff were assessing for for psychosocial needs. An email correspondence on 4/5/24 at 4:04 p.m. showed a snapshot of the criteria staff are to be basing their psychosocial assessments on: Relationship concerns, transportation concerns, housing concerns, food insecurity, lack of family/caregiver support and unable to afford medications.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review the agency failed to ensure medication reconciliation was completed for 3 of 3 patients (P1, P2 and P7) observed in home visits. P1 had a recertification visit and the nurse failed to reconcile his medications. P2’s medications were not reconciled and had medication questions that were not addressed by the nurse during the home visit. P7’s medications also were not reconciled at the onsite visit. Findings include: P1’s recertification summary dated 4/1/24 – 5/30/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right ischial tuberosity IT (sitting bone), three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. P1 was oriented to person, place, time, environment, and family. P1’s care plan dated 3/28/24 indicated skilled nursing was to assess for new, high risk or changed or discontinued medications. The care plan did not identify when a medication reconciliation was to be completed. During an observation of a home visit on 3/28/24 at 2:15 p.m. registered nurse, (RN)-B was completing P1’s sixty-day recertification assessment. P1 had a tray table over his bed with multiple bottles of liquid medications and a plastic container with three drawers filled with medications. RN-B asked P1 if he had any medications changes or any new allergies. RN-B failed to look at each of P1’s medications bottes and care them to the medication list the agency had on file. Upon interview on 3/28/24 p.m. at 4:15 p.m. P1 stated he did not recall the nursing staff ever going through all his medication bottles and comparing them to a medication sheet. He also stated he did not have a sheet of what the “agency thinks I am taking.” Upon interview on 4/1/24 at 9:55 a.m. RN-B stated during a recertification assessment the staff is to do a medication reconciliation. She stated that process was to find out if the patient had any new medications or any new allergies. When asked if she compares the bottles to the agency medication sheet she stated, “I guess I should be doing that.” Upon interview on 4/4/24 at 4:15 p.m. the Director of Home Care stated medication review is done at each visit where the nurse inquiries about new medications or new allergies. At the certification assessment the nurse is to complete a full reconciliation consisting of looking at all of the medications the patient has and comparing them to the agency medication list and notification the provider of any discrepancies. P2’s recertification summary dated 3/22/24-5/20/24, indicated P2 received services from the HHA for end stage renal disease, atrial fibrillation (rapid heart rate), and chronic respiratory failure. P2 had morbid obesity and was dependent on renal dialysis. P2 had skilled nurse interventions of medication review at each visit and update medication list as needed, update provider of medication discrepancies or problems and instruct on medication purpose, dose, schedule, and side effects. P2’s start of care assessment dated 3/22/24, indicated P2 was had discharged from the hospital on 2/10/24 and had not been taking warfarin (blood thinning medication) for the last month due to being out of the medication. A skilled nurse visit was requested asap to clarify medication questions and medication discrepancies forwarded to P2’s provider for clarification. P2’s skilled nurse visit note dated 3/22/24, indicated a focus on medication compliance. P2’s medications were reconciled and was noted P2 had not taken warfarin in 2-3 weeks and required refills of triphrocaps capsules (supplement medication) and midodrine (medication to support blood pressure). P2’s skilled nurse visit note dated 3/28/24, indicated P2 had change in medications since last visit however medications were not reconciled. P2’s skilled nurse visit note dated 3/29/24, indicated P2 had no change in medications since last visit and medications were not reviewed. During an observation of a home visit on 3/28/24 at 3:26 p.m., registered nurse (RN)-C began the home visit. P2 stated had questions about medications that pharmacy had filled this week. RN-C stated was not able to look at the medications as RN-C could not get into the system but would “look into it later.” RN-C continued the visit and completed the visit without coming back to address P2’s medication concerns. RN-C further stated a nurse was coming on 3/29/24 and could help with the medication questions at that time. When interviewed on 3/28/24 at 3:05 p.m., P2 stated the pharmacy filled medications that he had not taken since returning home from the hospital. P2 stated last week the nurse was supposed to clarify my medications with primary provider, but P2 had not heard back. P2 stated the medications filled from the pharmacy were listed as discontinued on the hospital discharge instructions. P2 stated “I am not sure what I am supposed to be taking” and wanted clarification in the visit today. When interviewed on 3/28/24 at 4:10 p.m. RN-C stated typically medications were reviewed and any questions answered, but just could not connect to internet to review his chart. RN-C was aware P2 had stopped taking warfarin, but P2 stated they were taking it now. RN-C was going to communicate to the next nurse about medication questions needing to be addressed. Upon interview on 4/1/24 at 2:31 p.m., care manager (CM)-A expected staff to complete a medication review if indicated in the plan of care. Furthermore, staff were expected to address medication questions or concerns the patient may have. P7’s Home Health Plan of care effective 3/2/24-4/30/24 dated 3/22/24-5/20/24, indicated P7 received services from the HHA for spondylosis with myelopathy ( a neurologic condition that develops gradually over time as degenerative changes of the spine results in compression in compression of the spinal cord and nearby structures), spinal stenosis (the space inside the backbone is too small) of the thoracic region (the area between the abdomen/stomach and the base of the neck), encounter for orthopedic aftercare, and paroxysmal (resolving within seven days) atrial fibrillation (rapid heart rate). A review of the POC directed the staff to assess for new, high risk, changed or discontinued medications. Additionally, the plan of care directed the nurse review medications each visit and update the patient’s copy of the medication list. The POC directed the nurse to, if applicable, notify the prescribing physician of any medication discrepancies or problems and with the client is not achieving the desired effects of medications. P7’s start of care assessment dated 3/2/24, indicated P7 was had discharged from the hospital on 2/29/24. P7 was admitted to home care services on 3/2/24 to coordinate visit with family member presence. During an observation of a home visit on 4/1/24, at 1:15 p.m. a review of the medications was completed with P7. During this visit, RN-E reviewed R7’s medications as completed, and the following medications were listed on medication profile: -Acetaminophen (Tylenol Extra Strength) 500 mg, take every 6 hours for 1 week, then every 6 hours as needed for pain. P7 stated he is using three times daily with the gabapentin with good effect. Bisacodyl (DULCOLAX) 10 mg suppository, insert one suppository rectally once daily if needed for constipation. -Epinephrine (EPIPEN) 0.3 mg/0.3 ml, inject 0.3 mg intramuscularly (in the muscle) if needed for an allergic reaction. (P7 stated his current supply was expired.) -Gabapentin (NEURONTIN) 200 mg three times daily. P7 reports this had improved his pain management. P7 stated he used the gabapentin, Robaxin, and acetaminophen together for effective pain relief. -Guar Gum (NUTRISOURCE FIBER) packet, mix one packet in liquid then take by mouth two times daily. Mix one packet in four ounces of beverage or soft food. -Melatonin 3 mg tablet, take two tablets at bedtime. P7 stated he has been using 10 mg tablet as other supply was unavailable. -Methocarbamol (Robaxin) 500 mg, take two tables by mouth four time a day as needed. P7 stated he is currently using three times daily, with gabapentin and Tylenol. -Metoprolol succinate (Toprol XL) 25 mg Sustained Release Tablet, one half tablet (12.5 mg) by mouth once daily. -Oxycodone (Roxicodone) 5 mg immediate release tablet, take one to two tablets by mouth (five to ten milligrams) every four hours as needed for pain. The medication profile identified this was to be used as first choice for severe pain. P7 reported he has no supply present and has not used since right after he returned from the hospital. -Sennosides (SENNA) 8.6 mg, one tablet by mouth at bedtime. P7 reported that he does not use this medication. -Warfarin (COUMADIN) 5 mg, two- and one-half tablets, to total 12.5 mg daily. P7 reported to nurse he also had Furosemide 20 mg which he uses as needed. Upon review of the label, it was noted that it was ordered on 3/14/24 with the directions to take daily. After all meds had been reviewed/reconciled between P7 and nurse, additional medications were noted in the client’s medication bin to include the following: Amoxicillin (antibiotic), cyclobenzaprine (muscle relaxant), Tums, and Nystatin Powder. RN-E stated she was unaware of these medications in the home. P7 stated the cyclobenzaprine was a medication prescribed prior to his surgery. P7 stated the Amoxicillin was also a medication which had been prescribed prior to the hospitalization, and stated they were meds he had not completed. P7 stated he has not used the Nystatin Powder since he returned. P7 stated the medications were always kept in his basket. On 4/1/24, at 3:00 p.m. following home visit, RN-E stated medication reconciliation should be done upon admission, and with every visit thereafter RN-E stated she had not seen the medications in the basket prior to this visit and was unaware P7 had them. RN-E stated it was important to review medications with every visit to assure medications were taken as ordered. RN-E stated as P7 was already receiving a muscle relaxer (Robaxin), the use of a second muscle relaxer could have negative effects for P7. A facility policy titled Home Health Plan of Care revised 6/15/22, indicated a plan of care was based off the comprehensive assessment and included patient specific services, treatment, and teaching ordered and provided for a patient.”

“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 observation, interview, and record review the agency failed to provide all pertinent information required on the individual plan of care for 6 of 17 clients reviewed. (P1, P2, P4, P5, P9 and P10). P1’s plan of care failed to provide his psychosocial status, identify all his supplies under durable medical equipment (DME) and provide patient specific interventions and education including measurable outcomes and goals identified by the HHA and P1. P2’s plan of care failed to identify hemodialysis treatment and schedule, a right tunneled dialysis catheter, and any cares or safety measures to prevent injury or infection of the dialysis catheter. P4’s plan of care lacked indication of any secondary diagnoses even though P4 received skilled service related to intravenous therapy (IV) and wound care following hospitalization. P4’s plan of care also lacked indication of DME supplies needed for provision of care which included IV therapy supplies, wound care supplies, and a cam (type of equipment) walker boot. P5’s plan of care failed to identify all her DME supplies. P9’s plan of care identified multiple diagnosis which included pressure ulcers (pressure injuries, also termed bedsores), encounters for fitting/adjusting/attention to urinary catheter (a tube which goes into the bladder to drain urine) and colostomy (a surgical process which creates a stomach opening to the colon). P9’s POC medication listing also identified use of a nebulizer for respiratory (breathing) treatments and a Roho cushion (a specialized cushion to be placed in chair to decrease pressure). A review of the P9’s POC lacked information for any DME related to pressure relief, dressing supplies, nebulizer machine, catheter, and ostomy supplies. P10’s POC included diagnoses listing of osteomyelitis (a bone infection), and aftercare for surgical amputation. The POC medication listing indicated P10 received IV antibiotic therapy. Although the diagnoses listing and medication profile indicated the need for wound care, IV therapy, and potential for mobility aides, the POC lacked indication of supplies for these services under the DME listing. Findings Include: A website https://www.medicare.gov/coverage/durable-medical-equipment-dme-coverage viewed 3/27/24 indicated DME supplies included blood sugar meters, lancets and test strips, canes, commode chairs, continuous passive motion machines devices and accessories, continuous Positive Airway Pressure (CPAP) machines, crutches, home infusion supplies, hospital beds, infusion pumps and supplies, nebulizers and nebulizer medications, patient lifts, pressure-reducing support surfaces, suction pumps, traction equipment, walkers, wheelchairs and scooters. P1’s recertification summary dated 4/1/24 – 5/30/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right IT, three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder, suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. Under safety and nutrition P1 was identified as having a regular diet. Under the title medications P1 had a nebulizer, with a disposable kit, reusable kit, a mask, and tubing, he was on albuterol (Proventil) 0.083 nebulizer solution given via nebulizer twice daily. P1 will be receiving a WellSense Map system (pressure sensing map). P1’s durable medical equipment included: -a colostomy bag -a hospital bed -electric wheelchair -manual wheelchair Under other mental, psychosocial, and cognitive the plan of care indicated to “see summary documentation”. The summary indicated psychosocial concerns/observations: no barriers or concerns. There was no indication of his psychosocial status as indicated through interpersonal relationships, financial status, homemaker/household needs, vocational needs, family social problems or transportation needs. P1’s pressure ulcer prevention goals: P1 will remain free from skin breakdown. Patient/caregiver will demonstrate teach-back of pressure education to reduce the risk of pressure ulcers by 10/3/23. There was no documentation of the teaching implemented or measurable outcomes on 10/3/23 through current plan of care. P1’s care planning goals indicated; all goals will be met by end of episode. Patient/caregiver will be independent with emergency response plan. Patient will remain safe in their home as determined by home safety assessment. Patient/caregiver will verbalize understanding of fall risk reduction techniques. Patient/caregiver will understand what next visit expectations are at end of each visit. Patient/caregiver will verbalize understanding of safe discharge plan. Oximetry levels will be maintained at a safe level at rest and during activity. Patient will understand prevention strategies for COVID-19. There is no documentation of the teaching implemented or how the goals were being measured for P1. P1’s medication goals: Patient/caregiver will teach back self-management of prescribed medication therapy by the following date of 10/3/23. The documentation did not indicate if patient did teach-back medication self-management since 10/3/23. P1’s pain goals: To report understanding of pain management of regimen. Patient/caregiver will verbalize understanding of pain management regimen including pharmacological and non-pharmacological techniques through homecare episode. The documentation does not indicate a measurable outcome for pain management. P1’s gastrointestinal ostomy goals: Patient/caregiver will teach back self-management of ostomy care. Pt is independent with ostomy. Patient is independent with his ostomy cares. P1’s supra-pubic catheter goal: Patient/caregiver will teach back self-management of catheter care. P1 was independent with catheter cares. P1’s psychosocial health goal: Patient/caregiver will teach back self-management of anxiety by the following date of 10/3/23. There was no documentation of the education given to P1 for the self-management of his anxiety of measurable goals of his status from 10/3/23 through current plan of care. P1’s thoracic wound goal: Wound care will show 25% improvement by 10/3/23. There was no documentation of measurement, color, turgor, texture, moisture, or epithelization to measure improvement or decline from 10/3/23 and going forward. P1’s gluteal wound goal: 15% improvement by 10/3/23. There was no documentation of measurement, color, turgor, texture, moisture, or epithelization to measure improvement or decline from 10/3/23 and going forward. P1’s focus of care goals for the next 60 days: Wound care and healing. There was no patient identified goals. Upon observation on 3/28/24 2:00 p.m. P1 was observed to have a suprapubic catheter and supplies, a pressure relieving mattress, a nebulizer with medication and supplies, and a gastrostomy tube (G-tube) and supplies. These items were not listed under DME on P1’s plan of care. Upon interview on 3/28/24 at 4:13 p.m. P1 stated he is not aware of what his goals are through the agency. He stated the agency made-up all the goals. “I have never been asked about my goals. Would like to be able to get in the swimming pool again.” P1 stated he has not been asked about psychosocial concerns. P1 stated another goal for him would be going to appointments in a wheelchair again and not a stretcher. His appointments are difficult because currently he needs to go via ambulance because his height is 6 feet, 3 inches and due to his wounds and lack of mobility, he requires a stretcher, He stated he is concerned that his family will be unable to care for him soon because of their age. He stated that both his mother and Father struggle to complete the wound care “like the nurses do” and they “can’t reposition him like they used to.” P1 was state he has increased “different” pain during his assessment. On 3/28/24 P1 was placed under general anesthesia and had Botox injections in his kidneys. This surgical procedure was not documented on the plan of care. P5’s certification dated 2/1/24 – 3/31/24 indicated P5 pertinent diagnoses were chronic obstructive pulmonary disease with exacerbation and acute respiratory failure with hypoxia (difficulty breathing), congestive heart failure, rheumatoid arthritis, and osteoporosis. P5’s services were physical therapy for strength, gait, activity tolerance and safety. Skilled nursing for oxygenation, safety, medication changes, and lab draws. Durable medical equipment identified was a seated walker, oxygen concentrator, oxygen tubing connections. Upon observation on 3/29/24 at 3:00 p.m. during a home visit P5 was observed having a portable oxygen tank with supplies, a shower chair, and a standard walker over her toilet as a device assist her to stand from the toilet. Upon interview on 3/29/24 at 3:21 p.m. R5 stated her goal was to be able to walk up the stairs. This goal was not documented on the plan of care. P5 stated the therapist tells her what her goals should be “all the time.” Upon interview on 3/29/24 at 4:15 p.m. the home care director stated that nebulizers and supplies, shower chairs, portable oxygen concentrator and supplies, g-tube and supplies, catheters, and pressure relieving mattresses should be documented under DME on the plan of care. She stated goals should include the patient, should be measurable and reassessed at the recertification time and with any changes. In addition, she stated that psychosocial should be assessed, but could not provide an assessment tool. She stated it would financial, living situation, food, and housing. Following the survey an email dated 4/5/24 at 3:53 indicated for psychosocial assessments the staff had the options of no barrier/concerns, relationship concerns, transportation concerns, housing concerns, food insecurity, lack of family/caregiver support and unable to afford medications. P2’s recertification summary dated 3/22/24-5/20/24, indicated P2 received services from the HHA for end stage renal disease, atrial fibrillation (rapid heart rate), and chronic respiratory failure. P2 had morbid obesity and was dependent on renal dialysis. P2’s plan of care lacked indication type and frequency of dialysis services were needed. P2’s plan of care lacked had a tunneled dialysis catheter, when it was placed, or any interventions or safety measures required to maintain the catheter and prevent infection. An observation on 3/28/24 at 3:26 p.m., P2 was seated in a recliner chair in the living room. P2 had a tee-shirt that was pulled down and a dialysis catheter was seen on the right upper chest area. P2 stated the dialysis catheter was placed when in the hospital and was used for dialysis treatments 3 times a week. P2 stated he was not sure about any monitoring needed at home. Upon interview on 3/28/24, registered nurse (RN)-C stated she was unsure of where P2 received dialysis treatments or how often. RN-C verified P2 had a dialysis catheter in the right chest and P2’s plan of care did not indicate a dialysis catheter was in place. RN-C was not sure of why it was not documented in the plan of care or if any monitoring or cares were needed. Upon interview on 4/1/24 at 2:31 p.m., care manager (CM)-A verified P2’s plan of care contained no information about dialysis or a dialysis catheter in place. CM-A expected P2’s plan of care to include P2’s dialysis treatments and dialysis catheter. P4’s Home Health Plan of Care (POC) effective 3/28/24-5/26/24, indicated P4 received services from the HHA for the primary diagnosis of essential (primary) hypertension (high blood pressure). The POC lacked identification of any secondary diagnoses. P4 was, however, identified as receiving skilled nurse visits for assessment and management of IV (intravenous-a process to give medications through the vein) management/cares, IV med delivery, IV dressing change, and dressing change to the right foot. In addition, P4 was to receive nursing assessment and education on disease process’ which included diabetes (a disease which affects how the body uses blood sugar (glucose), hypoglycemia (low blood sugar), hyperglycemia (high blood sugar), hypertension, signs and symptoms of infection (in surgical site) and exacerbation (return/flare up) of infection. Although P4’s POC indicated P4 was to use a cam walker boot (a boot placed to prevent pressure on healing surgical site), and had orders for IV dressing change, and dressing changes to the surgical site, the POC lacked DME listing for any of these supplies. P9’s Home Health Plan of Care (POC) effective 2/10/24-4/9/24, indicated P9 received services from the HHA for the primary diagnosis of other specified diagnosis of the peritoneum. P9’s secondary diagnosis included a pressure ulcer (pressure injuries, also termed bedsores) of the right buttocks, stage 4 (are deep wounds that may impact muscle, tendons, ligaments, and bone), pressure ulcer of right lower back unstageable (Ulcers covered with slough or eschar- a collection of dry, dead tissue within a wound). P9’s POC also identified the diagnoses of depression and anxiety, encounter for fitting and adjustment of a urinary device, neuromuscular dysfunction of the bladder(a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves), encounter for attention to colostomy (a colostomy is surgery to create an opening for the colon (large intestine) through the belly (abdomen), and neurogenic bowel (disruption of signals between the brain and the bowel which may be caused by spinal cord injuries or nerve disease). P9’s additional diagnoses included quadriplegia (paralysis of all four limbs and the torso), injury at C5 level of cervical spinal cord, dependence on wheelchair, and dependence on supplemental oxygen. Although many of the diagnosis listed required use of durable medical equipment (DME), the only items listed as DME were an electric wheelchair and Hoyer (trade name for a mechanical lift) lift. The DME listing lacked indwelling urinary catheters, insertion trays, drainage systems, ostomy supplies, oxygen equipment including oxygen concentrator, portable devices, and oxygen tubing, and supplies for treatment of the pressure ulcers as identified. Although P9’s medication listing identified orders for routine nebulization of a medication the DME listing lacked identification of a nebulizer. P9 also has a Roho cushion (cushion is designed specifically for individual needs) listed under the medications, however, this was not listed under DME. P10’s Home Health Plan of Care (POC) effective 3/3/24 to 5/1/23/24, indicated P10’s principal diagnosis was Type 2 diabetes mellitus. Other pertinent diagnosis listed included subacute osteomyelitis (bone infection) of the left tibia and fibula (bones of the lower leg), with various identified infections. P10’s diagnoses included encounter for orthopedic aftercare following surgical amputation. The POC identified P10 had acquired absence of both the left and right legs below the knees (amputation). The POC identified P10 had orders for IV antibiotics ordered. Although the POC identified a walker, wheelchair, crutches, bath chair and commode (portable toilet) were indicated for P10’s care, it lacked identification of supplies for IV therapy, including tubing and dressing changes for IV site, wound vac (a machine to manage the wound site), or dressing supplies. P10 also had recommendations for use of rigid immobilizers bilaterally, however they were not identified within the POC. A facility policy titled Home Health Plan of Care dated 6/15/22 indicated the patient shall activity participate in the plan of care development, the policy indicated all medical supplies and required equipment are required on the plan of care but did not identify specially DME supplies. The plan indicated any recent surgical procedures are to be documented on the plan of care.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and review of documents, the facility failed to complete the process of obtaining a verbal order, documentation of said order, and routing to the provider for review and signature, for one of one patient (P7), seen on a home visit for medication set up. P7 was receiving anticoagulant (blood thinners) therapy following discharge from the hospital, which required routine lab monitoring with medication adjustment based on results. Findings Include: P7’s Home Health Plan of care effective 3/2/24-4/30/24 dated 3/22/24-5/20/24, indicated P7 received services from the agency for spondylosis with myelopathy (a neurologic condition which developed gradually over time with degenerative changes of the spine which result in compression in compression of the spinal cord and nearby structures), spinal stenosis (a disease in which the space inside the backbone is too small) of the thoracic region (the area between the abdomen/stomach and the base of the neck), follow up encounter for orthopedic aftercare, and paroxysmal (resolving within seven days) atrial fibrillation (rapid heart rate). A review of the plan of care (POC) directed the staff to assess for new, high risk, changed or discontinued medications. Additionally, the plan of care directed the nurse review medications each visit and update the patient’s copy of the medication list. The POC directed the nurse to, if applicable, notify the prescribing physician of any medication discrepancies or problems and with the client is not achieving the desired effects of medications. A review of P7’s discharge summary from the hospital, dated 2/29/24, indicated P7 was to be on warfarin 5 mg tablets, two tablets to total 10 mg, one daily. The discharge summary identified P7’s INR (a test to see how the blood clotted when on an anticoagulant therapy) was to be checked on 3/2/24, with further dosing to be reviewed with primary care provider. P7’s start of care assessment dated 3/2/24, indicated P7 had discharged from the hospital on 2/29/24. P7 was admitted to home care services on 3/2/24, which allowed P7 and agency to coordinate the initial visit with a family member present. A review of the initial visit notes on 3/2/24, indicated P7’s INR was checked during the visit and was noted to be less than therapeutic. During the visit, the results of the INR was relayed to the INR clinic. At that time, new orders were received for an increase in warfarin to 17.5 mg on that date (3/2/24), then decrease to 12.5 mg daily until next INR check on 3/8/24. Although P7’s warfarin was adjusted on the date of admission based on the results of the INR check completed, with the dosage of warfarin increased, the POC identified the order for warfarin under medications to be warfarin five mg, two tablets (to total 10 mg) daily, and lacked indication of the new orders of 3/2/24. A request was made for orders to reflect orders for INR review, and subsequent med adjustments based on 3/8/24. The order dated 3/8/24, indicated P7’s INR was checked on 3/8/24, and was noted to be subtherapeutic. Orders were received on 3/8/24, for warfarin 17.5 mg on that date (3/8/24), then decrease to 12.5 mg daily. P7 was to have next INR checked on 3/15/24. A review of the narrative notes from 3/15/24, indicated P7’s INR was at 2.7 and directions were received to continue on 12.5 mg of warfarin daily and to recheck INR on 3/22/24. A request was made for the documentation of orders received and processed for 3/15/24, although was not received. A review of the narrative notes of 3/22/24 was completed. P7’s INR was checked at that time with results at 2.3. A call was placed to the INR clinic and orders were received to continue the dosing of warfarin at 12.5 mg daily. P7 was to have a recheck of his INR on 4/1/24. Although the narrative note reflected this information, the medical record lacked orders to reflect this was processed after receipt of verbal directions. Upon request from the agency for the order to reflect the orders of 3/22/24 an order dated 3/22/24, at 12:27 p.m. was provided. Although dated 3/22/24, the content of this order was reflective of the order initially obtained on 3/8/24, with the directions for recheck on 3/15/24. The orders received on 3/22/24, for continuation of warfarin at 12.5 mg daily with a recheck of INR on 4/1/24, as indicated in the documentation of 3/22/24, were not found in the medical record. On 4/2/24, at 1:15 p.m., a review of the documentation and information was completed with registered nurse (RN) RN-F. RN-F identified, upon review of records, although there is documentation to reflect outreach on INR, there is no order on file to correspond with this. Upon interview on 4/4/14 at 4:15 p.m. The Director of Home stated that when there was outreach to a provider, it was the expectation that the process to complete the order was to create an order and route for signature and documentation of implementation. A policy titled Medication Management Policy for Home Health, approved on 12/14/23, identified if the physician changed the medication order, staff must document the reasons for changes, and record the new or changed medications as orders. The order was then to be sent to the prescriber physician for signature.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review the facility failed to assure there was communication with all physicians or allowed practitioners involved in the plan for 2 of 15 patients (P1 and P2) reviewed for provider communication. P2 was able to identify three provider types who the agency was not communicating with, Registered nurse (RN)-C and care manager (CM)-A were not aware of P2’s dialysis facility or the nephrologist coordinating dialysis treatments. P1 had multiple providers such as a urologist, nutritionist, and psychiatrist. P1’s recertification summary dated 2/1/24 – 3/31/24 received services from the home health agency (HHA) for a Stage 4 pressure ulcer of his right IT, three pressure ulcers on the back and two pressure ulcers on his thigh. P1 had a spinal cord injury T1-T16 in 1999. P1 had a neurogenic bladder with a suprapubic catheter, neurogenic bowel ileostomy, and required a jejunostomy tube for nutritional supplementation. P1 was bedbound. P1 was diagnosed with spastic hemiplegia affecting unspecified side, dysphagia, depression, and anxiety. P1’s patient care team received from agency on 4/1/24 at 10:37 a.m. indicated P1’s Patient Care Team consisted of a Primary Care Physician (PCP), Physician Assistant (PA), two Physical Medicine and Rehabilitation, M.D and a D.O, and a Pharmacist (PharmD). Upon interview on 3/8/24 at 4:15 p.m. P1 stated he has multiple providers. He stated he can’t name them all. “It would be nice to have a list of all of them.” He stated providers who were not on the agency list were a Urologist, who cares for all his catheter cares, a Nutritionist who cares for all his feeding tube supplies, a psychiatrist, “three or four” Physiatrists, and a Physical Therapist not through the agency. Upon interview on 4/1/24 at 10:58 a.m. RN-D stated she was aware that P1 had a psychiatrist because a “few months ago” she had taken “some lab orders” from a psychiatrist. She stated she recently took an antibiotic order from a urologist but could not recall the name. She denied adding the urologist to the P1’s provider list. RN-D said it made sense that due to the feeding tube P1 would have a nutritionist and she was aware that he did physical therapy through another provider. RN-D was certain if those professionals were on P1’s provider list or not. Upon interview on 4/4/24 at 4:15 p.m. the Director of Home Care stated that all providers should be on the patient’s provider list to assure all involved receive information on the patient. A provider notification policy was requested however none was provided. P2’s recertification summary dated 3/22/24-5/20/24, indicated P2 received services from the HHA for end stage renal disease, atrial fibrillation (rapid heart rate), and chronic respiratory failure. P2 had morbid obesity and was dependent on renal dialysis. P2’s recertification summary lacked indication of where P2 was receiving dialysis and the nephrologist providing care. Upon interview on 3/28/24 at 4:10 p.m., RN-C stated she was unsure of where P2 received dialysis care or who the nephrologist was. RN-C stated the provider may be listed in P2’s hospital discharge in February but didn’t see a nephrologist listed in P2’s EMR. Upon interview on 4/1/24 at 2:31 p.m.CM-A verified P2’s medical record had not indicated a nephrologist or location of dialysis. CM-A stated it was harder to determine with outside providers. CM-A then was able to search outside networks within the electronic medical record system to determine P2’s dialysis was at Fresenius Dialysis Center and was followed by Acumen Nephrology.”

“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 record review the agency failed to ensure home health aide (HHA) supervisory visits were completed every 14 days for 1 of 3 patients (P11) currently receiving HHA services from the agency. Findings include: P11’s recertification summary dated 1/20/24-3/19/24, indicated P11 had diagnoses of lumbar and cervical fractures (bone fracture of neck and spine) and subdural hemorrhage (brain bleed). P11 had orders for HHA to provide cares for 1 visit every 8 days from 1/20/24-1/27/24 and weekly visits from 1/28/24-2/17/24. Furthermore, P11’s HHA interventions directed professional staff (skilled nursing/therapy) to perform supervision of HHA at least every 14 days. P11’s change order dated 2/15/24, indicated P11 required HHA visits to continue for weekly visits from 2/18/24-3/9/24. P11’s change order dated 3/3/24, indicated P11 required HHA visits to continue for weekly visits from 3/3/24-3/16/24. A review of P11’s HHA visit notes for recertification period 1/20/24-3/19/24, indicated P11 was seen by HHA as ordered. P11’s skilled nursing and skilled therapy notes for recertification period 1/20/24-3/19/24, indicated HHA supervisory visits occurred on 2/15/24 and 3/15/24, and did not occur at least every 14 days. When interviewed on 4/4/24 at 3:10 p.m., care manager (CM)-A stated skilled visits such as nursing or physical therapy should be completing supervisory visits at least every 14 days. Furthermore, CM-A verified P11 did not have supervisory visits every 14 days for the certification period of 1/20/24-3/19/24. When interviewed on 4/4/24 at 3:35 p.m. the director of home health expected staff skilled staff to perform supervisory visits at least every 14 days. Furthermore, the director of home health stated this was important to ensure patients received cares as ordered from HHA staff without concerns. A facility policy titled Home Health Aide Training, Competency Testing and Supervision reviewed 3/15/24, directed all HHA staff to be supervise care as outlined by federal and state regulations, standards of practice and as often as needed to assure safe care delivery. Furthermore, when skilled nursing or therapy services were being provided the RN/therapist must make a supervisory visit in the patient’s home at least every 2 weeks to assess the relationship and determine whether goals are being met.”

“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 ensure provider notification was made for 2 of 4 patients (P10, P6) reviewed for missed visits. Furthermore, the agency failed to ensure home health aide (HHA) visits were reduced due to agency scheduling for 1 of 4 patients (P12) reviewed for missed visits. The agency also failed to document reasoning for missed visit for 1 of 4 patients (P2) reviewed for missed visits. Findings include: P10’s plan of care (POC) for certification period of 1/14/24-3/13/24, indicated had diagnoses of urinary tract infection and pressure ulcer of left heel. Furthermore, P10’s POC indicated P10 received home care from the agency since 9/23/2023. P10’s SN visit strings dated 12/17/23-1/13/24, indicated P10 required 3 SN visits every week. P10’s electronic medical record lacked indication P10’s provider was notified of a missed SN visit for the week of 12/18-12/23/23. P12’s POC for certification period 12/5/23-2/2/24, indicated P12 had diagnoses of chronic kidney disease and congestive heart failure. Furthermore P12’s POC indicated P12 had orders for HHA to assist with bathing and dressing once a week for 3 weeks from 12/12/23-12/30/23. P12’s HHA visit note dated 12/23/23, indicated a missed visit due to full schedule. P12’s HHA visit note dated 12/28/23, indicated a missed visit due to scheduling. P12’s medical record lacked indication P12 was offered alternative times. P2’s POC for certification period 1/25/24- 3/24/24, indicated P2 had diagnoses of tibia fracture and required HHA visits once a week for bathing between 1/28/24-2/24/24. P2’s HHA visit note dated 2/5/24, indicated P2 missed a HHA visit on 2/2/24. P2’s note lacked indication why the visit was missed or that an alternative date was offered. When interviewed on 2/13/24 at 2:15 p.m., registered nurse (RN)-A verified the missed nurse visit for P10 and missed HHA visits for P12 and P2. RN-A verified any missed visits had to be documented as to why the visit was missed and to ensure the provider and nurse were aware. Furthermore, RN-A stated visits should not be missed due to schedules being full. When interviewed on 12/14/24 at 2:15 p.m., the Administrator expected all missed visits to be documented and providers to be notified. Furthermore, visits should not be missed due to full schedules and expected staff to follow the process of letting the scheduler know so the visit can be routed to a team member who may have more openings in their schedules stating it was a team approach. An agency policy titled Missed Visit revised 4/5/23, directed staff to notify staffing of a need to amend the visit schedule to complete the visit at an alternate time within the same week to prevent a missed visit. Furthermore, the policy directed staff to ensure documentation of a missed visit note included the reason for the missed visit and provider/case manager notification. P6’s plan of care with certification period dated 1/14/24-3/13/24, indicated P6 had diagnoses of iron deficiency anemia, encounter for fitting and adjustment of urinary device (catheter) and malignant neoplasm of the bladder. It further indicated P6 received home health aide services twice a week for six weeks for personal cares and urinary catheter care. P6’s missed visit note dated 1/17/24, indicated a home health aide (HHA) visit had been missed due to R6 being admitted to the hospital. It lacked documentation P6’s primary physician was notified. P6’s missed visit note dated 1/25/24, indicated a HHA visit was missed due to P6 not wanting HHA visit today because of other appointments. It lacked documentation P6’s primary physician was notified. During interview on 2/14/24, at 2:08 p.m. the clinical manager (CM)-A verified the primary physician had not been notified of the missed HHA visits on 1/17/24 and 1/25/24 stating their policy was to notify the primary physician and that’s what staff are expected to do. During interview on 2/14/24 at 2:55 p.m., the administrator stated they have a clear process in regard to missed visits and the provider should be notified. It was important to notify the provider because the care plan was in agreement with the physician’s orders and if the agency was not meeting the contract for care, we need to let them know so they can say what needs to happen, “it’s important to follow.””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure a resumption of care was completed within 48 hours after return from a hospital stay for 1 of 5 patients (P13) who had been discharged from the agency. Findings include: P13’s Plan of Care (POC) for certification period 12/6/23-2/3/24, indicated P13 had diagnoses of paraplegia, bladder dysfunction, and diabetes. Furthermore, P13’s POC indicated P13 required skilled nursing services from the agency. P13’s hospital discharge summary dated 2/5/24, indicated P13 was admitted to the hospital on 2/2/24- 2/5/24 for infection. Furthermore, P13’s hospital discharge summary indicated P13 required skilled home nursing and occupational therapy. P3’s medical record lacked information the agency had resumed services as ordered. When interviewed on 12/14/24 at 1:15 p.m., registered nurse (RN)-A verified R13’s hospital discharge orders were scanned into the medical record on 2/5/24. The hospital R13 was admitted to was outside the Allina family and stated at times the communication was not as good with outside hospitals. RN-A further stated there was a breakdown somewhere between intake and the charge nurse team. RN-A stated this was complicated as P13 had been discharged the same day as their certification period was ending and they had not returned home yet. Communication between the intake team and nurses were important to ensure the patient was seen upon return from home. When interviewed on 12/14/24 at 2:15 p.m., the administrator stated there was a breakdown in the process. When intake received the orders, the nurses should have been notified. The Administrator further stated R13 had not discharged from the hospital by the end of their certification period and technically was discharged from the agency. The administrator further stated she was unsure if the resumption of care order would have been adequate, but if the right communication had occurred between intake and the nursing team, the correct orders would have likely been obtained and P13 would have been seen upon discharge. The administrator stated P13 was contacted and verified home care services had not started. The agency had obtained new orders so care could start. An agency policy titled Admission to Home Care dated 6/14/23, directed staff to schedule the admission visit within 48 hours of a referral or facility discharge.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure a comprehensive assessment accurately reflected the current health status upon return from hospitalization and transitional care stay for 1 of 7 (P9) patients observed on a home care visit. Findings include: P9’s Plan of Care (POC) for certification period 12/26/23- 2/23/24, indicated P9 was disoriented and had diagnoses of dementia, diabetes and anxiety. Furthermore, P9’s POC indicated P9 was incontinent and dependent on activities of daily living (ADL). P9’s start of care comprehensive assessment dated 12/26/23, indicated P9 was incontinent of bowl and bladder. P9’s hospital discharge summary was requested however was not provided. P9’s resumption of care (ROC)comprehensive assessment dated 1/20/24, indicated P9 was recently hospitalized. P9’s ROC assessment further indicated P9 had no incontinence or catheter and had no UTI within the past 14 days, however indicated a recent diagnosis of UTI on 1/15/24. Furthermore, P9’s ROC lacked interventions related to monitoring or minimizing risk of UTI. When interviewed on 2/13/24 at 11:10 a.m., at registered nurse (RN)-A verified P9’s ROC assessment did not include P9’s recent UTI infection and continence was different than what was indicated on the start of care assessment. Furthermore, RN-A stated it was important to include this information to ensure P9’s POC would include appropriate interventions to minimize risk of further UTI infections. When interviewed on 2/14/24 at 2:03 p.m., the administrator expected staff to have an accurate ROC assessment that reflected any health changes or diagnoses from their hospitalization. Furthermore, this was important to ensure cares and goals included recent changes to the patient’s health. A facility policy titled Nursing Services dated 4/25/23, directed nurses to complete the initial comprehensive assessment and re-evaluate and revise the POC to address changes in patient’s clinical condition.”