Tlc Home Care of the Twin Cities

The home health agency failed to meet the Condition of Participation: E-0001 at 484.102. The agency failed to maintain an emergency preparedness (EP) plan, determine patient population needs, establish a system to coordinate care, provide training and testing, review and update the EP policy…

The agency failed to meet the Condition of Participation: G560 at 42 CFR 484.58. The agency failed to develop and implement effective discharge planning processes and failed to send all necessary medication information pertaining to the patient's current course of illness and treatment…

The home health agency (HHA) failed to meet the Condition of Participation at G570 42 CFR 484.60. The agency failed to create and follow individual plans of care, received care consistent with provider orders, ensure all regulatory requirement were in the plan of care, coordinate patient care plans…

The home health agency failed to meet the Condition of Participation: G640 at 42 CFR 484.65. The agency failed to establish a quality assessment performance improvement program(QAPI); to measure, analyze and track quality indicators; to establish a system to collect and evaluate program data…

The home health agency failed to meet the Condition of Participation: G940 at CFR 484.105. The agency failed to appoint an administrator and a clinical services director, to provide oversight of day-to-day operations, assure patient needs were continually assessed, assure implementation of care and…

The agency failed to maintain an emergency preparedness (EP) plan, to include contingency planning and to update the plan at least every two years.

The agency failed to include their patient population and vulnerabilities in their emergency preparedness (EP) all-hazards risk assessment.

The agency failed to specify the population served by the home health agency and determine the types of services it could manage, with a strategy to address the those it could not in an emergency and review the plan every two years.

The agency failed to have establish a process to cooperate and collaborate with local, state, tribal, regional and federal emergency preparedness (EP) officials.

The agency failed to review and update their emergency preparedness (EP) risk assessment, policies and procedures at least every two years.

The agency failed to establish and maintain a process to inform state and local emergency preparedness (EP) officials about home care patients in need of evacuation from their residences due to an emergency.

The agency failed to establish a system to follow-up with staff and patients to determine necessary services in the event of an emergency and a system to inform state and local officials of on-duty staff and patients they are unable to contact.

The agency failed to include the use of volunteers in the event of an emergency or disaster in their emergency preparedness (EP) policy and planning.

The agency failed to review and update their emergency preparedness (EP) communication plan at least every two years.

The agency failed to establish and maintain a emergency preparedness (EP) communication plan including a list of contacts.

The agency’s emergency preparedness (EP) plan failed to establish a method to provide assistance to the authority having jurisdiction during an emergency or disaster.

The agency failed to conduct emergency preparedness (EP) training and testing.

The agency failed to maintain an emergency preparedness (EP) training and testing program.

The agency failed to conduct emergency preparedness exercises.

The agency failed to electronically report Outcome and Assessment Information Set (OASIS) to the state agency during the 60-days recertification period for the home health agency (HHA) for 4 of 7 patients (P1, P2, P7 and P8) reviewed for OASIS assessment.

The home health agency (HHA) failed to develop and implement an effective discharge planning process for 2 of 7 patients (P1 and P3) reviewed for discharge.

The home health agency (HHA) failed to send all the necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care and treatment preferences, to the facility or health care practitioner to ensure the safe and effective transition of…

The home health agency (HHA) failed to ensure 4 of 7 (P1, P2, P3 & P4) patients reviewed received care consistent with the providers orders when reviewed for plan of care.

The facility failed to establish a process to measure, analyze and track quality indicators.

The facility failed to establish a system to collect and evaluate program data.

The facility failed to establish performance improvement activities.

The facility failed to establish a system to track adverse patient events, analyze their causes, and implement preventive actions.

The facility failed to conduct performance improvement projects.

The facility failed to ensure the agency had an operating quality assessment performance improvement (QAPI) program with clear expectation of patient safety and included findings of fraud or waste.

The facility failed to establish and maintain an agency-wide program for surveillance, prevention, control, and investigation of infectious and communicable diseases.

The facility failed to provide infection control education to staff and patients.

The agency failed to hire a clinical manager to provide oversight of patient care and personnel.

The agency failed to provide the current version of the Combined Federal and State Home Care Bill of Rights, dated 2/24/26, for 4 of 4 patients (P3. P4 , P5 & P6) reviewed for patient rights.

The home health agency (HHA) failed to investigate a patient complaint related to care that was not furnished for 1 of 4 patients (P4) reviewed for investigation of complaints made by the patient.

The home health agency (HHA) failed to document a patient complaint related to care that was not furnished for 1 of 4 patients (P2) reviewed for investigation of complaints made by the patient.

The agency failed to ensure all regulatory requirements were included in the plan of care (POC) for 5 of 7 patients (P1, P2, P3, P4, P6 & P7) who received home care services.

The home health agency (HHA) failed to provide drugs and services only as ordered by a physician for 3 of 7 patients (P1, P2, & P6) reviewed for physician orders.

The home health agency (HHA) failed to ensure plans of care (POC) were reviewed and signed by their provider every 60 days for 3 of 7 patients (P1, P2, & P4) reviewed for care and services.

The home health agency (HHA) failed to promptly inform the physician of significant changes for 1 of 7 patients (P1) reviewed for home health services.

The home health agency (HHA) failed to revise the plan of care for patient change of status for 2 of 7 (P1 and P3) patients reviewed for updated comprehensive assessments.

The home health agency (HHA) failed to assure communication with all physicians involved in the plan of care was being conducted for 3 of 7 patients (P2, P7, & P8) reviewed for communication with all physicians who were receiving home health services.

The home health agency (HHA) failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedules for 6 of 7 patients (P1, P2, P3, P4, P7 & P8) reviewed for scheduling.

The facility failed to perform actions aimed at performance improvement and tracking performance following those actions.

The agency failed to provide patient education for 1 of 3 patients (P6) reviewed for patient education.

The agency failed to appoint the administrator for the agency.

The agency failed to ensure the administrator was responsible for the day-to-day operations.

The agency failed to ensure clinical manager was available at all times.

The agency failed to ensure a qualified pre-designated person, authorized in writing by the administrator and governing body, was available to assume the administrator’s responsibilities.

The agency failed to make patient and personnel assignments and provide oversight by the clinical manager.

The agency failed to provide oversight in coordinating patient care.

The agency failed to provide oversight in assuring patient needs are continually assessed.

The agency failed to ensure implementation of the patients’ plans of care (POC).

The home health agency (HHA) failed to accurately document clinical records for 2 of 7 patients (P3 and P7) reviewed for clinical records content.

The home health agency (HHA) failed to document the dates of medication set-up, name of the medication, quantity of dose, time to be administered, route of administration, and the name of the staff completing the medication set-up at the time of the set-up for 3 of 3 patients (P6, P7, & P8)…

The home health agency (HHA) failed to ensure one or more qualified individuals; licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse provided oversight of all patient care services and personnel when the…

The facility failed to appropriately discharge 2 of 3 patients (P1 and P2) reviewed for discharges.

The home health agency (HHA) failed to complete a comprehensive assessment including the Outcome and Assessment Information Set (Oasis) within two days of discharge for 1 of 3 patients (P1) reviewed for discharge.

The home health agency (HHA) failed to meet the Condition of Participation 484.50, Patient Rights.

The home health agency (HHA) failed to ensure abuse did not occur for 1 of 1 patients (P1) who was verbally abused and threatened by Registered Nurse (RN)-A who was providing care for P1. The Immediate Jeopardy (IJ) began on 4/13/22, when P1 called the agency office and reported he had been abused…

The agency failed to develop and implement a process to thoroughly investigate allegations of abuse following and allegation of verbal abuse by a patient (P1) to determine other patients who may have been abused by RN-A.

The agency failed to meet the Conditions of Participation 0001 to develop an emergency preparedness program that met all of the standards specified within the condition, including a comprehensive approach to meet the health, safety and security needs of the staff and client population during an…

The facility failed to review and update the plan annually, and failed to include in their emergency plan, the potential for emerging infectious diseases, natural disasters, man-made disasters, care related emergencies, equipment failure interruptions in communication, loss of al or a portion of…

The facility failed to ensure their emergency preparedness policies and procedures were based on the facility and community-based risk assessment and communication plan utilizing an all hazards approach, and failed to ensure they maintained documentation that their policies and procedures had been…

The agency failed to include in their emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine services that are needed in an emergency situation.

The home health agency failed to provide training upon hire or annually related to the home health agencies emergency preparedness plan (EPP).

The agency failed to ensure the plan of care, physician orders were followed for 2 of 3 patients (P11 and P12) who received a home visit and document review.

The agency failed to investigate complaints made by 1 of 3 patients (P12) who complained of mental abuse by verbal threats and failed to protect that patient from further abuse.

The agency failed to report allegations of verbal abuse made by 1 of 3 patients (P12) who complained of mental abuse by verbal threats.

The agency failed to ensure the plan of care (POC) included all required components for 3 of 3 home visit clients (P11, P12, and P13) whose records were reviewed with the home visit.

The agency failed to update the plan of care to reflect revisions made to medication orders for 2 of 3 patients (P11 and P12) observed for medication set up in the home.