Every finding on record at Advanced Home Health Care, Inc.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 9/22/25 through 9/24/25 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 9/22/25 through 9/24/25. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 168 patients at the time of the survey, including 93 who received services from the Burlington office and 75 who received services from the Keokuk office.

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 agency policy review and clinical record review, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 10 sampled patients. (Patient #1 and #7) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. 2. Patient #1 had a Start of Care date of 2/20/25. Clinical record review and associated agency staff interviews revealed the following: a. Plan of Care, dated 8/19/15 to 10/17/25, included orders for Skilled Nurse frequency of 1 time per week with orders for medication set up and identified the patient had a diagnosis that included Diabetes Mellitus. b. The POC included medication orders for Loratadine 10 milligrams (mg) daily as needed for allergy symptoms. c. During a home visit observation visit on 9/23/25 at 9:00 AM with Staff C, Registered Nurse, the surveyor identified the RN included Loratadine 10 mg tablet in the medication planner on a daily schedule. During an interview at the same home visit, the RN and patient stated Laratadine had been set up daily The clinical record lacked documentation the physician was notified of the variance in the medication frequency identified on the POC. The above findings were reviewed with the Administrator and Clinical Manager. Findings: According to the agency policy, titled Plan of Care, dated 10/16/24, the plan of care is composed of the types of services, supplies and equipment needed; frequency and duration of visits made; identification of patient needs and problems, disciplines, patient-specific goals and interventions necessary to meet those goals; and medication profile that is updated whenever there are changes in the patient’s prescribed medication regimen and treatments. 1. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and order for skilled nursing to remove left hip dressing on 8/5/25, incision to be left open to air and may be washed with antibacterial soap and water then patted dry. b. Skilled nursing visit, dated 8/8/25, included documentation the patient had a non-removable dressing to the left hip wound and the dressing was dry and intact. The skilled nurse failed to remove the left hip dressing as ordered.

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 on home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and oxygen used by the patient for 2 of 10 sampled patients (Patients #2 and #10). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #10 had a start of care date of 11/16/18 and a discharge date of 10/18/24. Clinical record review revealed the following: a. The POC, dated 8/16/24 to 10/14/24, identified the patient had a diagnosis of hypertensive heart and chronic kidney disease with heart failure. The POC included orders for medications, treatments and the following supplies/equipment used by the patient: wheelchair, tape, bedside commode, catheter insertion kit, gauze pads, grab bars, oxygen, depends, tubigrips, scale, medication planners, pill splitter, compression pumps to lower legs, stand aid, incentive spirometer and ace wraps. b. The recertification visit note, dated 10/10/24, completed by Staff L, RN, identified the patient uses oxygen at 2 liters per nasal cannula. c. Review of the clinical record lacked orders for patient's use of oxygen. The agency failed to include all orders on the patient's POC, including oxygen orders required by the patient. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Plan of Care (POC), revised 10/16/24, the POC is composed of several documents which include: the types of services, supplies, and epuipment required and a medication profile that is updated whenever there are changes in the client's prescribed medication regimen (including dosage, frequency or route of administration) and treatments. 1.Patient #4 had a start of care date of 8/30/25. Clinical record review revealed the following: a. The Plans of Care (POC), dated 6/26/25 to 8/24/25 and 8/25/25 to 10/23/25, identified the patinet had diagnosis that included decubitis ulcer and included the following supplies and epuipment used by the patient: Sterile gloves, tape, dressing supplies, grab bars, exam gloves, tub bench, drainage bag, leg bag, ABDs, Chux, alcohol pads, hospital bed, thermometer, power scooter, removable shower head, slide board, reacher, bedside table, life alert, egg crate cushion, emergency alert button, colostomy supplies, prisma, suprapubic catheter, catheter supplies, gloves, incontinent briefs, colostomy supplies, suprapubic catheter and supplies. b. During a home visit observation on 9/23/25 at 10:00 AM, with Staff H, Registered Nurse (RN), the surveyor identified the following supplies and equipment utilized by the patient: bed rails, wheelchair cushion, lift chair and wheelchair ramp. During an interview at the same home visit, the patient stated the equipment utilized including the lift chair. The POC failed to include the suipplies and equipment including bed rails, wheelchair cushion, lift chair and wheelchair ramp.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency staff interview, clinical record review and agency policy review, the agency failed to only provide services ordered by the physician for 1 of 4 sampled patients with wounds (Patient #9). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Verbal Orders, revised 10/25/19, verbal orders will be accepted only by personnel authorized to do so by applicable state and federal laws and regulations as well as by the home health agency's policy. During an interview on 10/1/24 at 1:39 PM, Clinical Manager reported communication with physician's documented in the communication notes and the expectation for verbal orders and communication notes to be completed (documented) in 7 days. Patient #9 had a start of care date of 8/22/24 and discharge date of 10/16/24. The clinical record review revealed: a. Plan of Care, dated 8/22/24 to 10/20/24, identified the patient had a diagnosis of urinary tract infection and included orders for skilled nursing visits one time a week. b. The skilled nurse visit note at start of care, dated 8/22/24, Staff L, Registered Nurse (RN), included documentation the patient had a large hematoma on the right leg that measured 20 centimeters (cm) length by 14 cm width by 0 cm depth. The note identified the patient used treatment that included elevating the leg and applied ice to reduce inflammation. c. The skilled nurse visit note, dated 9/2/24, Staff M, RN, documented she changed the patient's right leg dressing due to an increase in drainage. The dressing applied included Vaseline gauze, ABD dressing, kerlix and coban to secure the dressing. d. The skilled nurse visit note, dated 9/3/24, Staff L, RN, documented the patient complained of left sided pain and rated the pain an 8 on a scale from 0 (no pain) to 10 (worse pain imaginable). The patient treated the pain with Tylenol and applied heat with some relief noted. e. Review of the clinical record failed to include physician orders for treatment to the right leg hematoma including application of ice and dressing change and application of heat for complaints of left sided pain. Agency staff failed to include physician verbal orders for treatments administered including ice, heat and dressing change. The above findings were reviewed with the Administrator and Clinical Manager.

HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This ELEMENT is not met as evidenced by: Based on agency staff interview, clinical record review, personnel file review and agency policy review, the agency failed to ensure 3 of 3 sampled home health aides (Staff I, Staff J and Staff K) assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 7 sampled patients (Patients #9) with home health aide services, had documented evidence of competency by a registered nurse in the assigned task area prior to independently performing the task with a patient. The agency provided home health aide services to 59 patients at the time of the survey and employed 21 home health aides. Failure to ensure home health aides successfully complete a competency evaluation in any assigned extra skills which exceed the level of basic home health aide skills placed the patients at risk to receive inadequate or unsafe home health aide services. Findings include: The Medicare Conditions of Participation require home health agencies to determine competence of home health aides in those skills which exceed the general basic home health aide skills areas prior to assigning the home health aide to a patient who would require the task to be performed. According to the agency policy titled Home Care Aide Competency and Supervision, revised 1/2024, the agency ensures that home care aides are competent and proficient to perform the assigned duties. The agency trains and tests aides to ensure the aide is competent to perform skills which exceed the basic skills. During an interview on 9/24/25 at 9:22 AM, Staff B, Clinical Manager, stated the Clinical Manager and/or a Registered Nurse is responsible for training the aide in the skill that exceeds the general basic skills once the extra skill is assigned for a patient. Patient #9 had a start of care date of 10/5/24 and a discharge date of 1/20/25. Clinical record review revealed: a. The aide care plan included Registered Nurse (RN) instructions to the aide to complete home exercise program with the patient. b. Review of the clinical record showed Staff I, Staff J and Staff K, Home Health Aides, provided services independently for Patient #9. c. Staff I, Home Health Aide, had a hire date of 9/12/23. Staff I's personnel file lacked documentation a RN had observed Staff I competently perform the task of complete home exercise program. d. Staff J, Home Health Aide, had a hire date of 6/5/23. Staff J's personnel file lacked documentation a RN had observed Staff J competently perform the task of complete home exercise program. e. Staff K, Home Health Aide, had a hire date of 4/26/23. Staff K's personnel file lacked documentation a RN had observed Staff K competently perform the task of complete home exercise program. The agency failed to ensure home health aides successfully completed a competency evaluation in assigned extra skills prior to performing the extra skills. The above findings were reviewed with the Administrator and Clinical Manager.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on staff interview, policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 7 sampled patients receiving home health aide services (Patients #4 and #7). Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. 2. Patient #4 had a start of care date of 8/30/24. The plans of care (POCs), dated 6/26/25 to 8/24/25 and 8/25/25 to 10/23/25, included physician orders for skilled nursing services 5 days a week and home health aide services 3 times per week to assist with personal care. The POC identified the patient had a diagnosis that included decubitis ulcer. Clinical record review revealed: a. The Aide Care Plan, dated 8/30/24 and last reviewed on 8/21/25, included direction to the aide to perform the following: shower, sponge bath, perineal care, bed bath, shampoo, comb hair, skin care lotion to extremities and back, oral care, assist dress, bed linen change, personal laundry empty trash, wash dishes. b. Home health aide visit notes, dated 9/2, 9/3, 9/5, 9/8, and 9/10/24, failed to include documentation the aide performed a shower and sponge bath or why the task not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the Administrator and Clinical Manager. Findings include: According to the policy, titled Home Care Aide Competency and Supervision, dated January 2024, the home care aides deliver services according to the plan of care. During an interview on 9/23/25 at 10:19 AM the Director of Nursing reported home care aides should document the reason a task on the aide care plan is not completed. 1. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and orders for skilled nursing and home health aide services. b. Home health aide care plan, dated 8/1/25, included the tasks shower and sponge bath – patient only able to sponge bathe until 8/5/25. c. Home health aide visit notes, dated 8/9/25, 8/12/25, 8/22/25 and 9/6/25, identified the tasks shower and sponge bath as completed. Home health aide failed to identify which bath type was actually completed and which bath type was not completed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record reviews and agency policy review, the home health agency failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards of practice for 4 of 7 sampled patients receiving home health aide services (Patients #3, #4, #7 and #9). Failure to ensure all documentation was completed and appropriately authenticated decreased the ability of the home health staff to communicate and coordinate patient care effectively and to provide safe, effective home health services to its patients. Findings include: 2. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 8/5/25 and 9/19/25, included aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 8/14/25, 8/22/25, 8/26/25, 9/9/25 and 9/16/25, included aide initials, date and time but failed to include aide signature and credentials. d. Home health aide visit notes, dated 8/9/25, 8/12/25 and 9/6/25, included aide initials, credentials, date and time but failed to include aide signature. Home health aide staff failed to accurately authenticate visit note documentation. 3. Patient #4 had a start of care date of 8/30/25. Clinical record review revealed the following: a. Plan of Care, dated 8/25/25 to 10/23/25, included a diagnosis of decubitis ulcer and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 9/2/25, included Staff D, Home Care Aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 9/3, 9/5, and 9/8/25, included Staff E, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. 4. Patient #9 had a start of care date of 8/30/25 and discharge date of 10/16/24. Clinical record review revealed the following: a. Plan of Care, dated 8/22/2 to 10/23/25, included a diagnosis of urinary tract infection and orders for skilled nursing and home health aide services. b. Home health aide visit notes, dated 8/24/24 and 10/5/24 included Staff I, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. Tghe above findings reviewed with the Administrator and Clinical Manager. According to the agency policy titled Clinical Records, revised 1/2024, documentation includes the date, time and place or circumstance of the entry and the documentation is signed with first name, last name, title, date and time. 1.Patient #3 had a start of care date of 9/11/25. Clinical record review revealed: a. The Plan of Care (POC), dated 9/11/25 to 11/9/25, included a diagnosis of Acute myeloblastic leukemia and included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Home health aide visit notes, dated 9/15/25 and 9/22/25, completed by Staff D, Home Health Aide, included signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. According to the agency policy titled Clinical Records, revised 1/2024, documentation includes the date, time and place or circumstance of the entry and the documentation is signed with first name, last name, title, date and time. 1.Patient #3 had a start of care date of 9/11/25. Clinical record review revealed: a. The Plan of Care (POC), dated 9/11/25 to 11/9/25, included a diagnosis of Acute myeloblastic leukemia and included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Home health aide visit notes, dated 9/15/25 and 9/22/25, completed by Staff D, Home Health Aide, included signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. 2. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 8/5/25 and 9/19/25, included aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 8/14/25, 8/22/25, 8/26/25, 9/9/25 and 9/16/25, included aide initials, date and time but failed to include aide signature and credentials. d. Home health aide visit notes, dated 8/9/25, 8/12/25 and 9/6/25, included aide initials, credentials, date and time but failed to include aide signature. Home health aide staff failed to accurately authenticate visit note documentation. 3. Patient #4 had a start of care date of 8/30/25. Clinical record review revealed the following: a. Plan of Care, dated 8/25/25 to 10/23/25, included a diagnosis of decubitus ulcer and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 9/2/25, included Staff D, Home Care Aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 9/3, 9/5, and 9/8/25, included Staff E, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. 4. Patient #9 had a start of care date of 8/30/25 and discharge date of 10/16/24. Clinical record review revealed the following: a. Plan of Care, dated 8/22/2 to 10/23/25, included a diagnosis of urinary tract infection and orders for skilled nursing and home health aide services. b. Home health aide visit notes, dated 8/24/24 and 10/5/24 included Staff I, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. The above findings were reviewed with the Administrator and Clinical Manager.

The recertification survey, conducted from 10/11/22 through 10/13/22, identified the agency in substantial compliance related to emergency preparedness regulations.

The recertification survey for 42CFR 484 Home Health Conditions of Participation, conducted 10/11/22 through 10/13/22, found the agency operating out of compliance with the following standard level deficient practices. The agency reported a census of 193 patients at the time of the survey, including 105 patients served by the parent office in Burlington and 88 patients served by the branch office in Keokuk.

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 agency policy review, clinical record review, home visit observation, agency staff interview, patient and family interview, the agency failed to complete a drug regimen review within the required timeframes at the time of start of care, recertification, and discharge for 3 of 11 patients requiring comprehensive assessments (Patients #1, #4, and #10). Failure to ensure medications were reviewed to be current and accurate at the time of each drug regimen review, placed the patient at risk for potential unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings include: 3. Patient #1 had a start of care date of 9/20/22. Review of the clinical record revealed the following: The Plan of Care (POC), dated 9/20/22 to 11/18/22, included physician orders for medications and a completed (Drug Regimen Review) DRR as part of the comprehensive assessment completed at the start of care. On 10/11/22, in an interview, during a home visit observation with Staff D, Certified Occupational Therapist Assistant, the patient reported a family member assisted the patient with medication set up; otherwise, the patient independently took medications. In addition to the medications identified on the POC, the patient reported taking Advil 200 milligrams (mg) one tablet as needed daily at times when the patient did not feel well. The patient identified taking this medication since prior to the start of agency services. The patient also reported occasionally using a topical analgesic, for left-side shoulder pain. The patient reported the family member who set up the patient's medications had this medication with them and applied it for the patient when needed. The patient thought the medication was Biofreeze. On 10/13/22 at 9:10 AM, during an interview, the patient's family member identified as the Medical Power of Attorney (POA) confirmed the patient had been using both Advil and Biofreeze prior to the start of agency services. The POC and DRR failed to include Advil and Biofreeze in the review. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. According to agency policy, titled Drug Regimen Review, dated 10/2019, the comprehensive assessment (Start of Care, Recertification, and Discharge) must include 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 non compliance with drug therapy....Drug Regimen Review is also documented on the OASIS D documentation and will be transferred to the 485 Care Plan.... 1. Patient #4 had a start of care date of 3/19/19. Clinical record review and home visit observation revealed the following: During home visit observation with Staff C, Registered Nurse, RN, the surveyor observed the RN performing medication set up. After the medication set up was complete, the surveyor reviewed the patient's use of Polyethylene Glycol 17 grams daily mixed with 8 ounces of liquid daily for a laxative as indicated on the patient's medication list. The patient revealed not using the Polyethylene Glycol daily and brought a bottle of Docusate Sodium 100 mg tablets and stated had been taking on tablet daily for a long time . When asked how long the patient thought "a long time" was, the patient stated "probably a year". a. The updates to the comprehensive assessments at the time of recertification, dated 4/28/22 and 6/30/22, documented a completed drug regimen review including all required components, however, identified duplicate therapies as antidepressants (Mirtazapine and Effexor) and Antihistamines (Claritin and Hydroxyzine). The review lacked identification of duplicate drug therapies, Busipirone and Hydroxyzine, both listed on the medication profile as antianxiety medications, Ropinirole and Carbidopa/Levodopa, both listed on the patient's medication profile as medications to treat Parkinson's disease and the Polyethylene Glycol and Docusate Sodium as bowel medications being used by the patient. b. The update to the comprehensive assessments at the time of recertification, dated 8/25/22, documented a completed drug regimen review including all required components, however, identified duplicate therapies as antidepressants (Mirtazapine and Effexor), Antihistamines (Claritin and Hydroxyzine),, supplements-Vitamin D3 and Vitamin B1, and analgesics (Tylenol, Tramadol, and Voltaren Gel). The review lacked identification of duplicate drug therapies, Buspirone and Hydroxyzine, both listed on the medication profile as antianxiety medications, Ropinirole and Carbidopa/Levodopa, both listed on the patient's medication profile as medications to treat Parkinson's disease, and the Polyethylene Glycol and Docusate Sodium as bowel medications used by the patient. The clinical record lacked documentation of accurate drug regimen reviews. 2. Patient #10 had a start of care date of 11/29/21. Clinical record review revealed the following: a. The initial comprehensive assessment at start of care dated 11/29/22, documented a completed drug regimen review including all required components, however, identified duplicate therapies as analgesics and laxatives. The review lacked identification of duplicate drug therapies, for duplicate antihypertensive medications, Amlodipine and Metoprolol Succinate, both listed on the medication profile as hypertensive medications. b. The updates to the comprehensive assessments at the time of recertification, dated 1/24/22 and 6/30/22, documented a completed drug regimen review including all required components, however, identified duplicate therapies as analgesics and laxatives. The review lacked identification of duplicate drug therapies, for duplicate antihypertensive medications, Amlodipine and Metoprolol Succinate, both listed on the medication profile as hypertensive medications. c. The update to the comprehensive assessment completed at discharge, dated 5/17/22 documented a completed drug regimen review including all required components, however, identified duplicate therapies as analgesics and laxatives The review lacked identification of duplicate drug therapies, for duplicate antihypertensive medications, Amlodipine and Metoprolol Succinate, both listed on the medication profile as hypertensive medications. The clinical record lacked documentation of accurate drug regimen reviews.

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 on clinical record review, agency policy review, home visit observation, patient, family and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 5 of 10 sampled patients (Patients #1, #2, #3, #5 and #6). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: Review of the agency's policy, titled Plan of Care (POC), dated 3/31/22, revealed the POC includes the frequency and duration of services and the patient's medications and treatments. Agency staff establish the POC in collaboration with the physician and patient/family and update the POC as often as the patient's condition changes, but review the POC at least every 60 days. 1. Patient #1 had a start of care date of 9/20/22. Review of the clinical record revealed the following: The Plan of Care (POC), dated 9/20/22 to 11/18/22, included physician orders for Preservision 2 capsules by mouth two times per day. On 10/11/22, in an interview, during a home visit observation with Staff D, Certified Occupational Therapist Assistant, the patient reported a family member assisted the patient with medication set up; otherwise, the patient independently took medications. The patient reported taking Preservision 1 capsule twice per day since prior to starting agency services. On 10/13/22 at 9:10 AM, during an interview, the patient's family member identified as the Medical Power of Attorney (POA) confirmed the patient had been taking Perservision 1 capsule twice per day, not 2 capsules twice per day. The POC included inaccurate information on how the patient took the Preservision. 2. Patient #2 had a start of care date of 12/17/14. Review of the clinical record revealed the following: The POC, dated 9/6/22 to 11/4/22, included orders for Tramadol (a narcotic pain medication) 50 milligrams (mg) 1 tab every 6 hours as needed with a start date of 5/6/2019, Hydrocodone-Acetaminophen (a narcotic pain medication) 5 mg- 325 mg 1 tab every 6 hours for pain with a start date of 9/8/21 and Tylenol 325 mg 2 tabs three times per day as needed. On 10/12/22 at 12:40 PM, during a home visit observation with Staff F, Registered Nurse (RN), the surveyor observed a bottle of Acetaminophen Extra Strength (Tylenol) 500 mg tablets. The bottle of 200 tablets was almost empty. In an interview, during the same home visit observation, the patient reported taking Acetaminophen 500 mg as needed for pain for a long time and had another bottle to replace the current almost empty one. The patient reported not having Tramadol for some time and had been taking Hydrocodone-Acetaminophen instead. Staff F, RN, confirmed the patient has not had Tramadol in the home for a while and the medication was not in the patient's home. The POC failed to include a current list of the patient's medications. 3. Patient #3 had a start of care date of 10/5/22. Review of the clinical record revealed the following: The POC, dated 10/5/22 to 12/3/22, included orders for the following medications: Prednisone 2.5 mg one tablet by mouth every day; Tacromilus 1 mg two capsules (2 mg total) by mouth twice per day; Rapamune 0.5 mg 1 tablet by mouth daily; Acetaminophen 325 mg 2 tabs every 6 hours; and, Ketoconazole external cream 2 percent apply topically to face twice per day. On 10/12/22 at 1:55 PM, during a home visit observation with Staff E, Physical Therapy Assistant, the surveyor observed a bottle of Acetaminophen Extra Strength 500 mg tablets. In an interview during the same home visit observation, the patient reported not taking Prednisone for 4 months. The patient reported taking Tacromilus 2 mg in the morning and 1.5 mg in the evening for a long time and since prior to agency services. The patient reported taking Rapamune 1.5 mg daily since prior to starting agency services. The patient explained the hospital had the patient's medications messed up from how the patient's heart physician wanted the patient to take them. The patient discharged from the hospital on 9/30/22, and went back to taking the medications correctly. The patient reported not using Ketaconazole external cream since this summer. The patient reported using the medication seasonally. The patient reported taking Acetaminophen Extra Strength 500 mg one-half tab (250 mg) as needed since prior to starting agency services. The POC contained inaccurate medication information. 4. Patient #5, a pediatric patient, had a start of care date of 6/1/2020. Review of the clinical record revealed the following: a. The POCs, dated 7/21/22 to 9/18/22 and 9/19/22 to 11/17/22, included a physician order for the skilled nursing services 6 to 8 hours per day, 7 days per week. The POC included an order for the skilled nurse to take the patient's vital signs, including pulse, respirations, blood pressure and temperature, every 4 hours and report abnormal readings to the physician. b. The skilled nursing visit notes, dated 9/1 to 9/30/22, lacked documentation of a blood pressure. On 10/13/22 at 11:22 AM, during an interview, the Clinical Manager reported the POC incorrectly included an order for the nurse to obtain blood pressure readings for the pediatric patient. 5. Patient #6 had a start of care date of 2/15/21. Review of the clinical record revealed the following: The POCs, dated 6/10/22 to 8/8/22, 8/9/22 to 10/7/22 and 10/8/22 to 12/6/22, included an order for home health aide services as requested by the the patient and the availability of staff excluding holidays. The POC failed to specify a frequency for the delivery of home health aide services. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and agency staff interview, the agency staff failed to provide medications and treatments only as ordered by the physician for 3 of 10 sampled patients (Patients #2, #5 and #8). Failure to ensure staff obtain/follow physician orders for administration of medications and treatments placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency policy, titled Plan of Care (POC), dated 3/31/22, identified agency staff provided services based physician orders and the POC. Staff will not make changes to the POC without an order from the physician. 1. Patient #2 had a start of care date of 12/17/14. Review of the clinical record revealed the following: The POC, dated 9/6/22 to 11/4/22, included orders for the skilled nurse to set up the patient's medications weekly and an order for Calcium 500 milligrams (mg) one tablet by mouth twice per day. On 10/12/22 at 12:40 PM, during a home visit observation with Staff F, Registered Nurse (RN), the surveyor observed Staff F set up Calcium 600 mg one tablet twice per day. The bottle was more than half gone and originally contained 60 tablets. In an interview, during the same home visit observation, Staff F, RN, was unaware of the different dose of Calcium she had set up. She explained the pharmacy must have sent a different dose. 2. Patient #5, a pediatric patient, had a start of care date of 6/1/2020. Review of the clinical record revealed the following: a. The POCs, dated 7/21/22 to 9/18/22 and 9/19/22 to 11/17/22, identified a diagnosis of obstructive sleep apnea and included a physician order for the skilled nursing services 6 to 8 hours per day, 7 days per week. The POC included an order for the skilled nurse to obtain the patient's blood oxygen saturation levels every hour. b. The skilled nursing visit notes, dated 9/1, 9/2, 9/3, 9/6, 9/7, 9/9, 9/10 to 9/17 to 9/30/22, included documentation the agency provided 8 hours of continuous nursing services, but only documented the patient's blood oxygen saturation 2 times during the 8 hour shifts. c. The skilled nursing visit note, dated 9/4/22, included documentation of 7 hours of continuous nursing services, but only documented the patient's blood oxygen saturation level one time during the 7 hour shift. d. The skilled nursing visit note, dated 9/8/22, included documentation of 8 hours of continuous nursing services, but only documented the patient's blood oxygen saturation level three times during the 8 hour shift. The skilled nurses failed to follow the POC orders for frequency of obtaining blood oxygen saturation levels. 3. Patient #8 had a start of care date of 3/3/22 and discharged from agency services on 3/21/22. Review of the clinical record revealed the following: a. The POC, dated 3/3/22 to 5/1/22, identified a diagnosis of an encounter for surgical aftercare for surgery on the digestive system. The POC included orders for skilled nursing 1 time the first week and 2 times the next week. The POC included orders for the skilled nurse to do wound (cleanse wound with wound cleanser, pat dry, apply Aquacel in wound bed and cover with Mepilex) and ostomy care (remove old ostomy appliance, cleanse with wound wash, pat dry, apply Eakins seal to skin around stoma, cut and fit appliance to size) on Mondays and Thursdays. The week of 3/6/22, lacked documentation of a skilled nursing visit on Monday, 3/7/22. The clinical record included documentation of a skilled nursing visit with wound and ostomy care, dated 3/8/22 (a Tuesday). The clinical record lacked documentation of physician contact or a reason why a nurse failed to perform the wound and ostomy cares on Monday 3/7/22. On 10/13/22 at 11:49 AM, during an interview, the Clinical Manager confirmed the POC included an order for ostomy and wound cares to be done by agency nursing staff on Mondays and Thursdays, and wound and ostomy cares were not done until Tuesday 3/8/22 the week of 3/6/22. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.