Provident Home Healthcare

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and document review, the agency failed to inform the patient’s representative of changes in care for 1 of 3 patients (P1) when the patient was sent to the hospital. P1’s plan of care (485) dated 3/7/25, for certification period 3/10/25 to 5/8/25 indicated P1 had diagnoses of acute and chronic respiratory failure, chronic kidney disease, tracheostomy, gastronomy tube, and epilepsy. P1’s 485 indicated P1 was non-ambulatory, non-verbal, and dependent on caregiver for all activities of daily living (ADLs). P1’s clinical note, dated 3/11/25 at 12:54 a.m. indicated P1’s physician wanted P1 to go to the hospital due to abnormal lab values. P1 left home at 4:41 p.m. (on 3/10/25) to go to the hospital. P1’s signed Combined Federal and State Home Care Bill of Rights, signed 10/25/24 by P1’s guardian, indicated the right to be told in advance, before receiving services, of the right to participate in, be informed about and consent to or refuse care in advance of and during treatment, with respect to (i) any changes in the care to be furnished. On 3/13/25, at 1:28 p.m., licensed practical nurse (LPN)-A stated he was working with P1 on 3/10/25 when he was sent to the hospital. LPN-A accompanied P1 to the hospital and stayed with him in the emergency room until he was admitted. LPN-A stated he did not notify P1’s guardian of P1’s transfer to the hospital. LPN-A stated the case manager (CM) is responsible to notify the responsible party. On 3/13/25, at 2:24 p.m., registered nurse (RN)-A, the CM, stated he did not notify P1’s guardian when he was transferred to the hospital. RN-A stated he expected LPN-A to notify the responsible party. On 3/13/25, at 3:37 p.m., P1’s guardian stated she was not notified by the home health agency (HHA) when P1 was transferred to the hospital. She stated the hospital notified her of the transfer. On 3/14/25, at 10:10 a.m., the director of nursing (DON) stated the responsible party should be notified when the patient is transferred to the hospital. She stated either the bedside nurse or the CM can notify the resident representative. On 3/14/25, at 10:21 a.m., the assistant director of nursing (ADON) stated either the bedside nurse or the CM were expected to notify the patient’s responsible party when they are transferred to the hospital. A facility document, Emergency Procedure Plan, undated, directed staff to call emergency contact after calling 911. A facility document, Protocol for Client Hospitalization, undated, directed staff notify the family and/or emergency contacts. This communication should come from (the agency), not the hospital. A facility document, Coordination of Client Services, dated 4/21/21, directed (3) the client, representative, and caregivers will participate by identifying what they want to achieve and what they feel comfortable doing. This will be built into the plan. Information provided to clients must be verbally and in writing and the agency documentation will also clarify what the plan is and who was informed. (6) Clients, their representatives, and other caregivers will be included in the coordination activities and will receive direct communication related to planning and change in the plan. (8) When there are significant changes made to the client’s plan of care, the agency must inform the client and their representative and the physician directing the care.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and document review, the agency failed to report injuries of unknown origin to the State Agency (SA) immediately for 2 of 3 (P1 and P2) were reviewed for abuse. Findings include: P1’s plan of care (485), dated 1/14/25, for certification period 1/15/25 to 3/15/25, indicated P1 had diagnoses of acute and chronic respiratory failure and transient cerebral attack (TIA). P1’s 485 indicated she had residual weakness, was completely dependent on assistance from staff for all cares and was ventilator dependent and in a persistent vegetative state. P1’s 485 indicated she had a history of a brain aneurysm in 2002 resulting in her immobility and comatose status. P1’s clinical note, dated 2/3/25 at 2:27 p.m., indicated P1 had bruising under her left arm, and it was reported to the registered nurse case manager (RN-B). P1’s clinical note, dated 2/3/25 at 3:46 p.m., indicated left arm edema (swelling) and bruising noted under the arm. RN-B notified. P1’s clinical note, dated 2/4/25 at 12:46 a.m., indicated left upper extremity was grossly swollen with area of darkness measuring two inches and P1 was sent to the hospital. P2’s 485, dated 1/3/25, for certification period 1/9/25 to 3/9/25, indicated P2 had diagnoses of acute on chronic respiratory failure and tracheostomy (a surgical procedure that provides an opening in the trachea to provide an airway when the natural airway is blocked or compromised) status. P2’s 485 indicated P2 was unable to speak, had paralysis and contractures and required total assistance with all activities of daily living (ADLs). P2’s 485 indicated he had swelling in right hand around middle finger on 12/13/24, with heavy bruising noted on 12/16/24. An x-ray was ordered and found to have a broken finger. Case manager assessed the injury as coming from the client getting hand caught in the side rails and tensing up per usual when getting touched. P2’s clinical note, dated 12/13/24 at 5:52 a.m., indicated right middle finger was swollen. RN-C notified. P2’s clinical note, dated 12/14/24 at 11:28 p.m., indicated his right middle finger was bruised and swollen. P2’s clinical note, dated 12/16/24 at 3:37 p.m., indicated his right middle finger had significant bruising throughout the finger. An x-ray report, dated 12/18/24, indicated an x-ray of P2’s right hand was completed on 12/16/24. Results of the x-ray showed a possible fracture of the base of the proximal phalanx (first bone) of the fourth finger. On 2/7/25 at 10:03 a.m., RN-A stated P1 had new bruising this past week. RN-A stated she thought it might be health related because of edema that was present. RN-A stated she thought a blood clot could cause bruising. RN-A stated she reported the bruise to RN-B as soon as she noticed it. On 2/7/25 at 10:33 a.m., the hospital medical doctor (MD) stated P1 was still at the hospital. He stated P1 had left arm edema. He stated the swelling was not likely to be related to bruise. On 2/7/25 at 11:24 a.m., the assistant director of nursing (ADON) stated P2 recently had a broken finger. She stated P2 has spastic movements when he is repositioned, and his finger likely got caught or jammed in the bed rail. The ADON stated she was not involved with the situation as there was no indication of foul play. The ADON stated she was not sure if a full investigation took place. The ADON stated P1 had bruising to her left arm, and she was unsure how it got there. The ADON stated the on-call nurse took care of the scenario. On 2/7/25 at 11:30 a.m., the interim director of nursing (DON) stated when injuries are noted, they try to find the likely cause. She stated the investigations was not sufficient for P1’s left arm bruise or P2’s fractured finger. The interim DON stated bruises of unknown origin should be reported to the SA immediately, but P1 and P2’s were not. On 2/7/25 at 3:07 p.m., RN-B stated she informed the ADON of the bruise on P1’s left arm. RN-B stated she thought the bruise may be due to a blood-pressure cuff, but stated she was not sure how that happened as she did not conduct an investigation. On 2/7/25 at 3:32 p.m., RN-C stated he was called regarding P2’s swollen finger on 12/13/24. He stated the swelling changed from swelling to significant bruising on 12/16/24 and an x-ray was performed. RN-C stated the x-ray indicated P2 had a fracture, and it was thought to have come from P2’s clenching his hand very stiff and getting his hand caught on the side rail of the bed. RN-C stated there was not a specific time and date this occurred, it “seemed to be the mechanism of injury.” RN-C stated he talked to the staff about the injury, but did not document the conversations. RN-C stated he did not assess the other patients the staff cared for. RN-C stated he informed the ADON and DON of the bruise. A facility document, Identifying and Reporting Abuse Neglect and Exploitation of Clients policy, dated 3/1/22, directed: The employee shall immediately make an oral report by phone or otherwise to the Director of Clinical Services or Administrator. The employee shall be instructed to complete a written report of the suspected abuse and/or neglect. (See state-specific requirements for reporting time frames and types of report required.) The Director of Clinical Services/designee will review the information presented and investigate to determine if this is a reportable incident. If so, the information will then be reported to the appropriate county social service Agency or Adult/Child Protection Agency by the Administrator or an appropriate designee.”

“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 observation, interview, and record review the facility failed to identify patient-specific measurable outcomes and goals for a pulse oximeter and ensure the agency house camera was operable for 1 of 3 patients reviewed. Findings include: P1’s Home Health Certification and Plan of Care (485) for period 11/18/24 – 1/16/24 indicated P1’s pertinent diagnoses were chronic respiratory failure, amyotrophic lateral sclerosis (ALS, nerve cell breaks down which reduces functionality of muscles). P1 was paralyzed and P1 was ventilator dependent. P1 received registered nurse (RN) / licensed practical nurse (LPN) complex care up to 24 hours per day. Patient care assistant (PCA) up to 4 hours a day and respiratory therapy twice daily for 60 days. P1’s 485 indicated he had a pulse oximeter, continuous readings while at home, agency was to “spot check” on outings or appointments. The 485 did not indicate the setting or parameters of the oximeter. P1’s 485 indicated a safety measure of cameras installed in the home in public areas to monitor activity on demand. P1’s narrative nursing, end of shift note dated 11/13/24 at 7:55 a.m. indicated at the start of RN-A’s shift she found P1 in bed in respiratory distress with an oxygen saturation reading of 89% (normal 90%-100%) and a heartrate of 160 (normal 60-100). P1 required suctioning immediately as his thumb was out of range of his call bell and was unable to call for help. P1 was suctioned multiple times, however his oxygen levels continued to fluctuate from 94% down to 88% and his heart rate continued to average between 150-165. P1 had a temperature of 101.4 degrees Fahrenheit (F) (normal 98.6 degrees F). Paramedics were called and P1 was taken to the hospital and was admitted. Upon interview on 11/20/24 at 1:46 p.m. RN-B, P1’s nurse case manager, stated on 11/13/24 he received a call from RN-A. RN-A was reporting to RN-B how she found P1 in respiratory distress when she began her shift on 11/13/24 at 12:10 p.m. She reported P1’s call light was out of reach and the outgoing nurse, RN-C had not reported any concerns to her upon shift change. At the hospital P1 stated through blinking contact using yes and no questions that he had not been checked on since 10:00 p.m. on 11/12/24 to RN-A. He also stated he was in respiratory distress for between 30 and 60 minutes prior to RN-A finding him. RN-B stated the agency initiated an investigation and filed a Minnesota Adult Abuse Reporting Center (MAARC) report after the discussion with RN-A. RN-B stated during the agencies investigation there were questions if the evening nurse, RN-C, was sleeping and not checking on P1 appropriately. It was at that time the agency attempted to watch the house camera footage and the camera had not been working. The agency did not attempt to fix the camera at that point. Upon interview on 11/21/24 at 9:06 a.m. RN-A stated she found P1 in respiratory distress on 11/13/24 at 12:10 a.m. unable to reach his call button and no alarms were sounding. She stated the outgoing nurse RN-C did not mention any concerns with P1. RN-A stated she went to the hospital and stayed with P1 for the remainder of her shift. RN-A asked P1 in the hospital the last time he had been checked on and his response was 10:00 p.m. RN-A asked P1 how long he was in respiratory distress, and he relayed it was over 30 minutes, but under 60 minutes. Upon interview on 11/21/24 at 3:20 p.m. RN-C answered her phone and stated, “I am not talking to you.” She then hung up the phone. Upon observation and interview on 11/22/24 at 9:00 a.m. respiratory therapist, (RT)-A was checking P1’s oximeter and ventilator to capture recording data from the evening of 11/12/24. P1’s ventilator only showed a recording for 11/20/24 -11/21/4. P1’s oximetry setting showed that the alarm was set to 160 beats per minute (bpm). RT-A stated he had never ordered the machine to be set at 160 bpm with and the default setting was 60 – 100 bpms. RT-A stated any staff member can change settings on an oximeter machine, but they should have a provider or an order from respiratory therapy to do so because having the alarm set to 160 bpm is dangerous when the normal respirations are to be between 60-100 bmps. RT-A changed the reading on the machine to 130 bmp during the observation. Upon interview on 11/22/24 at 10:00 a.m. P1 stated through yes and no questions by blinking his eyes that he was struggling to breath on 11/12/24 for about 30-60 minutes before RN-A found him. He stated through blinking the last time he was RN-C was about 10:00 p.m. and that time RN-C had repositioned him in bed. P1 was not aware of any staff members changing the settings on his oximeter. Upon interview on 11/22/24 at 3:10 p.m. RN-F the assistant director of nursing stated she could not provide the state surveyor with any camera footage because the camera was not working. She was not aware who was in charge of the cameras for the home. She attempted to reach out to the camera vendor on 11/22/24 during the survey and received a message that the vendor does not take phone calls due to too many spam calls. The ADON stated she would find out who was to be responsible for the camera and how to get a hold of the vendor soon. She stated she was not aware that P1’s oximeter had been changed to alarm at 160 bmp and would follow-up with RN-B, P1’s case manager. The ADON was aware that P1 notified the provider to receive an order for oximeter parameters during the survey. Upon interview on 11/25/24 at 1:46 p.m. the Administrator stated she was not aware that the security cameras were part of the client’s care plan and since they were on the care plan, she expected them to be in working order. In addition, her expectation was that staff notify the provider before making any change to the patient’s machines and to have a person-centered care plan in place for all patients. An agency policy titled Equipment and Supplies Management revision date of 11/20/24 indicated medically necessary supply usage will be documented on the 485 (plan of care). An agency policy titled Safe Medical Devices Act – Medical Device Tracing revision date of 11/2024 indicated the purpose was to identify and report events in which a medical device may been involved in an adverse event that may have caused of contributed to a client’s health, serious illness, or significant harm. One person will be designated by the agency to oversee device-related incident reporting. Medical attention will be provided immediately, and the equipment will be impounded. In the event of a suspected medical device incident, an investigation will be conducted to determine necessity of reporting. A policy regarding care plans was not obtained.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on interview and document review the agency failed to investigate an allegation of staff to patient verbal abuse and a patient grievance of care for 2 of 4 patients (P3 and P4)) reviewed for patient rights. Findings include: P3’s Home Health Certification and Plan of Care for certification period 9/7/24 through 11/5/24, identified diagnosis that included acute and chronic respiratory failure, muscular dystrophy, and dependence on a respirator. The Plan of Care indicated registered nurse (RN)/Licensed practical nurse (LPN) up to 24 hours per day, seven days per week. A Client Grievance form dated 10/2/24, indicated on 10/1/24 through 10/2/24, P3 sent a text message to the recruitment manager (RM), “Long story short, after yelling into the phone for 15 minutes she [RN-B] is now my nurse. I do not feel safe with her, she has scared me twice now with my tubes. I don’t feel safe sleeping under her care.” The resolution section of the complaint form was blank. During interview on 10/31/24 at 12:50 p.m. the RM stated P3 had sent her a text message around 2:00 a.m. and said he did not feel safe with RN-B because of something she had done with his tubes. The RM stated it sounded like it had happened before and said he reported not feeling safe sleeping under her care. The RM stated RN-B had been assigned to care for another patient but had not felt comfortable and did not want to work with him. During interview on 10/31/24 at 12:54 p.m. RN-B stated the day of the care concern, she had gone to the house and did not feel she had been properly trained to work with the client she had been assigned to. RN-B stated she called the on-call staffer (RM) and asked to switch for another client. RN-B stated she went to P3’s room and said P3’s ventilator had a drainage system, and she notice the humidifier cup was full, so she emptied it. RN-B stated immediately after she left the room P3 called and said he could not breathe and asked what she had done to his ventilator. RN-B stated P3’s vital were assessed and stable but said she got a call that P3 was not comfortable working with her. RN-B stated the facility had not reached out to her however, she had reached out to them and told them she had worked with P3 many times and told them she did not touch his ventilator. RN-B said she did not know why P3 had acted that way because she felt there had not been an issue. During interview on 10/31/24 at 1:21 p.m., the staffing coordinator (SC) stated RN-B had sent her a text message but said she had not understood the context. the SC stated she had received a report from the RM that P3 did not feel safe with RN-B. The SC stated she talked to the staffing manager (SM) who said, “let’s get her in here.” The SC stated RN-B acted like she could not come into the agency and then “I am not sure how long after, but at a staff meeting we called her, and the SM said she needed to come in.” The SC said the concern was that P3 felt unsafe and said we needed to bring her in and get her side of the story and investigate it more. The SC stated the SM did the follow up with RN-B. Regarding follow up with P3, the SC stated, “probably the case manager.” During interview on 101/31/24 at 1:27 p.m. the director of nursing (DON) stated the facility had been trying to get hold of RN-B to talked about P3’s concerns. The DON stated she had not spoken to P3 about his concerns. During interview on 10/31/24 at 1:32 p.m. RN-A stated she knew the RM and SM had called RN-B. RN-A stated she had not followed up with P3 about his concerns and said she thought they were trying to get RN-B to come in. RN-A stated, I know it is on the to do list to give her and ultimatum that if she did not come in that she could not work. RN-A stated, “We need to hear from her about the whole incident.” During interview on 10/31/24 at 2:11 p.m. the SM stated the agencies leverage for getting staff to come to the office for discipline was to take them off the schedule. The SM stated, “We can’t devote time to talk to her if she is not on the schedule for say 12 days.” The SM stated he believed the nurse manager had gone out and spoken with P3. The SM then got up and left the room. He returned a few minutes later and said RN-A reported she did not think anyone in the clinical department had talked to P3 to find out what his concerns were. During interview on 10/31/24 at 2:32 p.m. the administrator stated she did not know if anyone had spoken to P3 about his concerns. Agency Client/Family Grievance Policy dated 5/18/23, indicated grievances would be addressed by the department director or designee and response made to the complainant within seven days of receipt. If the grievance will take longer than seven days to complete the director will contact the complainant within the initial seven days to let them know the grievance has been received and is being investigated. Grievances are considered completed when an approved response has been mailed to the client complainant. P4’s Home Health Certification and Plan of Care for certification period 10/1/24 through 11/29/24, identified diagnosis that included respiratory failure, muscular dystrophy, and a tracheostomy. The Plan of Care indicated he was unable to report abuse/neglect independently and identified him as high risk for abuse. The plan indicated on call was available 24 hours per day to report actual or suspected abuse. Facility Client Grievance form dated 5/28/24, indicated on 5/25/24, LPN-A reported LPN-B had gotten into a yelling/swearing match with P4. The form indicated the staffing manager called and spoke to LPN-B about the incident. The form identified a grievance resolution date of 6/26/24, however, lacked evidence of an investigation or follow up with the staff member, client, or complainant. An e-mail to LPN-B, written by RN-A dated 5/25/24, indicated RN-A followed up on how things were going at the home P4 resided in and indicated “I have also been following up with P4” and his behavior about how he sometimes treated his nurses. RN-A wrote she knew it was a challenge. RN-A wrote P4 had told her he wanted his nurses to be attentive to his needs and offer care and indicated P4 made comments about LPN-B being focused too much on his phones/computers. RN-A wrote, “I just want to make sure we all mindful of putting the client’s needs first.” RN-A further wrote P4 was very young and not mature yet and could be crabby and wrote, remaining calm when he acted up tended to help P4 act with better behavior. The e-mail ended with RN-A thanking LPN-B for working weekends at the home. An untitled document dated 5/28/24, identified the following summary written by LPN-A. P4 had an ongoing problem with LPN-B, had brought up the subject to the staffing coordinator (SC) more than once and indicated P4 stated he felt “very intimidated” by LPN-B. The document indicated P4’s family members had been visiting when LPN-B arrived for his shift. The form indicated when the family members left, LPN-B went into P4’s room and LPN-B and P4 were heard swearing at each other. During interview on 10/31/24 at 1:35 p.m. RN-A stated she was aware there had been a yelling match between P4 and LPN-B and said LPN-B had called for help from other staff because P4’s behaviors had been escalating. RN-A stated P4 was verbally derogatory and stated he was challenging. RN-A stated she had spoken to P4 but was not sure if she had written it down. RN-A stated she had a general conversation with P4 about “his ability to shape people verses put them into fear.” Regarding LPN-B, RN-A stated the staffing manager (SM) had an extensive conversation with him. During interview on 10/31/24 at 2:03 p.m., the SM stated P4 had a history of provoking people and said he felt LPN-B reacted poorly after being provoked. The SM stated he thought LPN-B had lost his composure and said P4 felt it was inappropriate, “which I believe it was.” The SM stated the clinical department had reached out to LPN-B and stated nothing had been done other than what had been documented in the e-mail. The SM stated he had spoken to LPN-B but had not documented anything. The SM stated the agency did not discipline staff over the phone and said they tried to coax them to come into the agency and were “gentle” with them. The SM stated, “they know what they did wrong.” The SM further stated the agency did not tolerate staff to resident verbal abuse. During interview on 10/31/24 at 2:32 p.m. the administrator stated when a complaint came in the complaint went to the SM, the administrator, and the director of nursing. The administrator stated they should have talked to the client, staff involved and if needed, a staff retraining was completed. The administrator stated the facility complaint process had been a little fragmented over the past year due to staff turnover. During a subsequent interview on 11/1/24 at 8:34 a.m., the administrator stated there was no documented interview with wither P4 or LPN-B and stated it was a disservice to both to have not done proper diligence. During interview on 11/1/24 at 10:37 a.m., LPN-B stated on the day of the incident he had approached P4 about using the urinal and said P4 “just went off, I don’t know why.” LPN-B stated P4 had been yelling at him, swearing, and told him to get out of his room while making derogatory comments. LPN-B stated he asked another staff member to come into the room and said he had been repeating to the other staff member what P4 had been saying to him. Agency Policy Client Care, Vulnerable Adults Protection identified abuse as the intentional and non-therapeutic infliction of pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. This included verbal abuse intended to upset or disturb a person. Agency policy related to investigation of allegations of abuse was requested. The Agency was unable to locate a policy.”

“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 document review the agency failed to have systems in place to ensure patient protections for 2 of 4 patients (P3 and P4) reviewed following an allegation of verbal abuse. Findings include: P3’s Home Health Certification and Plan of Care for certification period 9/7/24 through 11/5/24, identified diagnosis that included acute and chronic respiratory failure, muscular dystrophy, and dependence on a respirator. The Plan of Care indicated registered nurse (RN)/Licensed practical nurse (LPN) up to 24 hours per day, seven days per week. A Client Grievance form dated 10/2/24, indicated on 10/1/24 through 10/2/24, P3 sent a text message to the recruitment manager (RM), “Long story short, after yelling into the phone for 15 minutes she [RN-B] is now my nurse. I do not feel safe with her, she has scared me twice now with my tubes. I don’t feel safe sleeping under her care.” The resolution section of the complaint form was blank. During interview on 10/31/24 at 12:50 p.m. the RM stated P3 had sent her a text message around 2:00 a.m. and said he did not feel safe with RN-B because of something she had done with his tubes. The RM stated it sounded like it had happened before and said he reported not feeling safe sleeping under her care. The RM stated RN-B had been assigned to care for another patient but had not felt comfortable and did not want to work with him. During interview on 101/31/24 at 1:27 p.m. the director of nursing (DON) stated the facility had been trying to get hold of RN-B to talked about P3’s concerns. The DON stated she had not spoken to P3 about his concerns. During interview on 10/31/24 at 1:32 p.m. RN-A stated she knew the RM and SM had called RN-B. RN-A stated she had not followed up with P3 about his concerns and said she thought they were trying to get RN-B to come in. RN-A stated, I know it is on the to do list to give her and ultimatum that if she did not come in that she could not work. RN-A stated, “We need to hear from her about the whole incident.” During interview on 10/31/24 at 2:11 p.m. the SM stated he spoke with RN-A who reported she did not think anyone in the clinical department had talked to P3 to find out what his concerns were. During interview on 10/31/24 at 2:32 p.m. the administrator stated she did not know if anyone had spoken to P3 about his concerns. P4’s Home Health Certification and Plan of Care for certification period 10/1/24 through 11/29/24, identified diagnosis that included respiratory failure, muscular dystrophy, and a tracheostomy. The Plan of Care indicated he was unable to report abuse/neglect independently and identified him as high risk for abuse. The plan indicated on call was available 24 hours per day to report actual or suspected abuse. Facility Client Grievance form dated 5/28/24, indicated on 5/25/24, LPN-A reported LPN-B had gotten into a yelling/swearing match with P4. The form indicated the staffing manager called and spoke to LPN-B about the incident. The form identified a grievance resolution date of 6/26/24, however, lacked evidence of an investigation or follow up with the staff member, client, or complainant. An untitled document dated 5/28/24, identified the following summary written by LPN-A: P4 had an ongoing problem with LPN-B, had brought up the subject to the staffing coordinator (SC) more than once and indicated P4 stated he felt “very intimidated” by LPN-B. The document indicated P4’s family members had been visiting when LPN-B arrived for his shift. The form indicated when the family members left, LPN-B went into P4’s room and LPN-B and P4 were heard swearing at each other. During interview on 10/31/24 at 1:35 p.m. RN-A stated she was aware there had been a yelling match between P4 and LPN-B and said LPN-B had called for help from other staff because P4’s behaviors had been escalating. RN-A stated P4 was verbally derogatory and stated he was challenging. RN-A stated she had spoken to P4 but was not sure if she had written it down. RN-A stated she had a general conversation with P4 about “his ability to shape people verses put them into fear.” Regarding LPN-B, RN-A stated the staffing manager (SM) had an extensive conversation with him. During interview on 10/31/24 at 2:03 p.m., the SM stated P4 had a history of provoking people and said he felt LPN-B reacted poorly after being provoked. The SM stated he thought LPN-B had lost his composure and said P4 felt it was inappropriate, “which I believe it was.” The SM stated the clinical department had reached out to LPN-B and stated nothing had been done other than what had been documented in the e-mail. During interview on 10/31/24 at 2:32 p.m. the administrator stated when a complaint came in the complaint went to the SM, the administrator, and the director of nursing. The administrator stated they should have talked to the client, staff involved and if needed, a staff retraining was completed. The administrator stated the facility complaint process had been a little fragmented over the past year due to staff turnover. Agency Client/Family Grievance Policy dated 5/18/23, indicated grievances would be addressed by the department director or designee and response made to the complainant within seven days of receipt. If the grievance will take longer than seven days to complete the director will contact the complainant within the initial seven days to let them know the grievance has been received and is being investigated. Grievances are considered completed when an approved response has been mailed to the client complainant. Agency Policy Client Care, Vulnerable Adults Protection identified abuse as the intentional and non-therapeutic infliction of pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. This included verbal abuse intended to upset or disturb a person.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and document review the agency failed to report an allegation of staff to client verbal abuse to the state agency (SA) for 1 of 4 patients reviewed for patient rights. Findings include: P4’s Home Health Certification and Plan of Care for certification period 10/1/24 through 11/29/24, identified diagnosis that included respiratory failure, muscular dystrophy, and a tracheostomy. The Plan of Care indicated he was unable to report abuse/neglect independently and identified him as high risk for abuse. The plan indicated on call staff was available 24 hours per day to report actual or suspected abuse. Facility Client Grievance form dated 5/28/24, indicated on 5/25/24, Licensed Practical Nurse (LPN)-A reported LPN-B had gotten into a yelling/swearing match with P4. The form indicated the staffing manager called and spoke to LPN-B about the incident. An untitled document dated 5/28/24, identified the following summary written by LPN-A. P4 had an ongoing problem with LPN-B and had brought up the subject to the staffing coordinator (SC) more than once and indicated P4 stated he felt “very intimidated” by LPN-B. The document indicated P4’s family members had been visiting when LPN-B arrived for his shift. The form indicated when the family members left, LPN-B went into P4’s room and LPN-B and P4 were heard swearing at each other. During interview on 11/5/24 at 3:25 p.m., the administrator stated the complaint should have been reported to herself, the director of nursing (DON) and the assistant DON’s and a report should have been made to the SA. The administrator stated none of them had been made aware of the complaint. Agency policy Identifying, and Reporting Abuse/Neglect/Exploitation of Clients date 3/1/22 indicated clients had the right to be free from mental, physical, and verbal abuse. Purpose: To protect persons who are either by physical or mental disability or dependence on institutional services, particularly vulnerable to abuse or neglect. The policy indicated when abuse was suspected, the employee shall immediately make an oral report by phone or otherwise to the DON or administrator. The DON or designee will review the information presented and investigate to determine it the incident was reportable and if so, report to the appropriate agency.”