Every finding on record at Avera at Home

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 1/12/26 through 1/15/26 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 1/12/26 through 1/15/26. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations.

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 observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 1 of 3 sampled patients with home observation visits (Patient #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Medication Profile, dated 11/9/23,a drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. During an interview on 1/14/26 at 9420 AM the Clinical Manager stated the Registered Nurse (RN) responsible to complete the Drug Regimen Review (DRR) at admission, recertification and discharge. Patient #1 had a start of care date of 11/11/25. Clinical record review revealed the following: a. The Plans of Care (POC), dated 11/11/25 to 1/9/25 and 1/10/25 to 3/10/25, identified the patient had a diagnosis of Schizophrenia and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at recertification, dated 1/6/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 1/6/26 at 7:30 AM with Staff E, RN, the patient interview revealed the following medication discrepancies orders and patient stated medication schedule: Fenofibrate 48 milligrams oral, 1 tablet daily with a fill date of 12/10/25. The agency medication list failed to include the medication. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator and Clinical Manager.

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, clinical record review and agency staff interview, the agency failed to follow a Plan of Care or notify the physician of missed visits for 1 of 2 sampled patients with missed visits. (Patient #5) 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. Findings include: According to the agency policy, titled Care/Service Coordination, dated 6/7/22, team members will communicate with the attending primary care physician in the case of a missed visit for any ordered discipline. During an interview on 1/14/25 at 10:10 AM, the Director of Patient Care Services reported the nurse notified the physician of home health aide missed visits but not the skilled nurse missed visit. Patient #5 had a start of care date of 4/14/25 and discharge date of 1/12/25. Clinical record review revealed: a. Plan of Care, dated 12/10/25 to 2/7/25, included a primary diagnosis of Type 2 Benign prostatic hyperplasia and physician orders for skilled nurse and home health aide services. b. Clinical record review lack documentation of a skilled nurse visit during the week of 12/21/25 to 12/27/25. Agency failed to notify the physician of missed skilled nurse visit. The above findings reviewed with the Administrator and Clinical manager.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; 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 failed to ensure skilled professional staff involved in the patient's plan of care completed an ongoing interdisciplinary services as required by agency policy and expectation for 1 of 3 sampled patients (Patient #5), who received wound care. Failure to complete an ongoing interdisciplinary services placed patients at risk not receiving ongoing needs. Findings include: According to the agency policy, titled Documentation of Wounds, reviewed 7/26/24, initial documentation and reassessment documentation should include at minimal: wound type, odor, surrounding skin, wound measurements as indicated bby wound type, wound bed description, clinical evaluation of the wound progress and other basic wound assessment criteria as indicated by wound type. During Interview on 1/14/25 at 10:10 AM, the Director of Patient Services stated the nurse reported during her visit, the family identified the patient wound previously had a nonremovable dressing and when the skilled visit made, the wound had been resolved. Patient #5 had a start of care date of 4/14/25. Clinical record review revealed: a. The Plan of Care (POC), dated 12/26/24 to 2/23/25, identified the patient had a diagnosis of Benign prostatic hyperplasia. Orders included skilled 1 services. b. The skilled nurse visit note, dated 12/29/25, identified the patient had a left eye laceration over the holidays and sutures placed. The note lacked documentation of assessment of the laceration area or dressing in place. The agency nurses failed to provided complete skilled nurse services. The above findings were reviewed with the Administrator and Clinical Manager.

The Department of Inspections and Appeals conducted a recertification survey, dated 12/19/22 to 12/21/22, and found the agency to be operating in substantial compliance with regulations found under the Emergency Preparedness Condition of Participation.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 12/19/22 to 12/21/22. The survey identified the following standard level deficient practices. The agency reported a census of 74 patients at the time of the survey including 48 in the Estherville parent office and 6 in the Rock Valley branch office.

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 and agency staff interview, the agency failed to include a complete drug regimen review within the required time frames with the comprehensive assessments for 8 of 10 sampled patients (Patient #2, #3, #5, #6, #7, #9, #10 and #11). Failure to ensure medications were reviewed at the time of each drug regimen review increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: 6. Patient #6 had a start of care date of 10/8/22 and received services from the parent office in Estherville. Clinical record review revealed: a. Plan of Care, dated 10/8/22 to 12/6/22, included orders for medications. b. Update to the comprehensive assessment completed at the time of resumption of care, dated 10/21/22, included documentation the nurse was unable to reconcile all of the patient's medications. The patient was unable to independently prepare and take all prescribed medications. The skilled nurse failed to complete a drug regimen review that included the required items of ineffective drug therapy, significant side effects, significant drug interactions, and duplicate drug therapy. 7. Patient # 9 had a start of care date of 11/3/22 and received services from the parent office in Estherville. Clinical record review revealed: a. Plan of Care, dated 11/3/22 to 1/1/23, included orders for medications. b. Comprehensive assessment completed at start of care, dated 11/3/22, included documentation the nurse was unable to reconcile all of the patient's medications. The patient was unable to independently prepare and take all prescribed medications. The skilled nurse failed to complete a drug regimen review that included the required items of ineffective drug therapy, significant side effects, significant drug interactions, and duplicate drug therapy. 8. Patient #11 had a start of care date of 5/7/22, a discharge date of 7/5/22, and received services from the parent office in Estherville. Clinical record review revealed: a. Plan of Care, dated 5/7/22 to 7/5/22, included orders for medications. b. Comprehensive assessment completed at start of care, dated 5/10/22, included documentation duplicate drug therapy, no ineffective drug therapy, no significant drug interactions, and no significant side effects. The skilled nurse failed to complete a drug regimen review that included the required items of compliance, ineffective drug therapy, significant side effects, significant drug interactions, and duplicate drug therapy. The surveyors reviewed the above findings with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. 3. Patient #5 had a start of care date of 10/14/2022 and received services from the Rock Rapids branch office. Clinical record review revealed the following: a. The Plans of Care, dated 10/14/22 to 12/12/22 and 12/13/22 to 2/10/23, included orders for Miralax Diphenoxylate-atropine (bowels) , betamethasone dipropionate topical cream and nystatin-triamcinolone topical powder (both topical medications). b. The initial comprehensive assessment completed at start of care, Initial DRR with initial comprehensive assessment 10/14/22, included a completed drug regimen review. The review lacked documentation of duplicate drug therapies for the ordered topicals and bowel medications and assessment of the patient's compliance. c. The update to the comprehensive assessment, dated 12/8/22, completed for recertification, included a completed drug regimen review. The review lacked identification of duplicate drug therapies for topicals and bowel medications and lacked assessment of the patient's medication compliance. 4. Patient #2 had a start of care date of 12/14/2022 and received services from the Rock Rapids branch office. Clinical record review revealed the following: a. The Plan of Care, dated 12/14/22 to 2/11/23, included orders for glucosamine-chondroitin, acetaminophen, diclofenac sodium gel, (all prescribed for pain) and cholecalciferol (vitamin D3 and), magnesium, and multivitamin (all prescribed as supplements). b. The initial comprehensive assessment, dated 12/14/22, completed at the start of care, included a completed drug regimen review. The review lacked identification of duplicate drug therapies for pain and supplements and lacked assessment of the patient's medication compliance. 5. Patient #7 had a start of care date of 11/10/2022 and received services from the Estherville parent office. Clinical record review revealed the following: a. The Plan of Care, dated 11/10/22 to 1/8/23, included orders for Plavix and Aspirin (both prescribed as blood thinners) and Metoprolol and Amlodipine (both prescribed for blood pressure). b. The initial comprehensive assessment, dated 12/14/22, completed at the start of care, included a completed drug regimen review. The review identified duplicate drug therapies for blood pressure, but only identified the two different times of administration of Metoprolol and lacked identification of Metoprolol and Amlodipine as duplicate therapies and the duplicate blood pressure medications. According to the agency policy titled Medication Profile/Drug Regimen Review, dated 6/10/21, 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. According to the agency policy titled Medication Profile, dated 5/14/21, a drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. During an interview on 12/19/22 at 3:49 PM the Clinical Manager stated drug regimen review is completed with any new medications added to the chart, at start of care and recertifications. It is also completed at resumption of care, discharge and significant change of condition. Services that are provided by therapy only have cases opened and drug regimen review completed by the Registered Nurse. 1. Patient #3 had a start of care date of 9/23/22 and received services from the Estherville parent office. Clinical record review revealed the following: a. The plans of care (POC), dated 9/23/22 to 11/21/22 and 11/22/22 to 1/20/23, included orders for duplicate diabetic medications. b. The comprehensive assessment at the time of start of care, dated 9/23/22, included documentation of a completed drug regimen review that included documentation the patient had no duplicate medications. c. An update to the comprehensive assessment, dated 11/21/22, included documentation of a completed drug regimen review that included documentation the patient had no duplicate medications. The comprehensive assessment lacked documentation of the patients duplicate diabetic medications. 2. Patient #10 had a start of care date of 12/7/22 and received services from the Estherville parent office. Clinical record review revealed the following: a. The POC, dated 12/7/22 to 2/4/22, included orders for duplicate diabetic medications and supplements. b. The comprehensive assessment at the time of start of care, dated 12/7/22, included documentation of a completed drug regimen review that included documentation the patient had no duplicate medications. The comprehensive assessment lacked documentation of the patients duplicate diabetic and supplement medications.

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, home visit observation, agency policy review, patient and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 2 of 4 sampled patients with home visits (Patients #2 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive medications or needed medical equipment and supplies according to assessed needs and physician orders. Findings include: 2. Patient #2 had a start of care date of 12/14/22 and received services from the Rock Rapids branch office. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 12/14/22 to 2/11/23, identified the following equipment and supplies as used by the patient to meet the patient's needs: pill packs, grab bar by bed, blood pressure machine, walker, grab bars around toilet/tub and cane. During a home visit observation on 12/20/22 at 12:45 PM, with Staff D, Physical Therapist (PT), the patient's caregiver revealed the patient's use of incontinence pads for about 4 years. The Plan of Care lacked identification of incontinence supplies as supplies/equipment to meet the patient's needs. b. During the same home visit observation on 12/20/22 at 12:45 PM, with Staff D, PT, the patient's caregiver revealed the patient's use of an implanted stimulator for past 5 years. The Plan of Care lacked identification of the implanted stimulator as supplies/equipment to meet the patient's needs. c. During the same home visit observation on 12/20/22 at 12:45 PM, with Staff D, PT, the surveyor observed a hand held shower in the patient's bathroom. The patient's caregiver revealed the patient's use of the hand held shower since they moved in in July 2022. The Plan of Care lacked identification of the patient's use of the hand held shower as supplies/equipment to meet the patient's needs. d. During the same home visit observation on 12/20/22 at 12:45 PM, with Staff D, PT, the surveyor observed a lift chair in the patient's living room. The patient's caregiver revealed the patient's use of the lift chair since they moved in in July 2022. The Plan of Care lacked identification of the patient's use of the lift chair as supplies/equipment to meet the patient's needs. e. During the same home visit observation on 12/20/22 at 12:45 PM, with Staff D, PT, the patient's caregiver revealed the patient's use of the a reacher for a couple of years. The Plan of Care lacked identification of the reacher as supplies/equipment to meet the patient's needs. f. During the same home visit observation on 12/20/22 at 12:45 PM, with Staff D, PT, the patient's caregiver revealed the patient's use of a Lifeline alert since they moved in in July 2022. The Plan of Care lacked identification of the patient's use of the Lifeline alert as supplies/equipment to meet the patient's needs. The surveyors reviewed the above findings with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. Review of the agency policy, titled Home Health Initial & Comprehensive Assessment, dated 9/1/2014, a plan of care will be developed from the information gathered during the initial and comprehensive assessment. The patient's primary care provider is consulted for approval if additions or modifications to the plan of care are required after the assessment is completed. 1. Patient #3 had a start of care date of 9/23/22 and received services from the Estherville parent office. On 12/20/22 at 4:30 PM, during a home visit observation, Staff C, Registered Nurse (RN) completed a skilled visit with the patient. In an interview, during the same home visit observation, the patient reported utilizing a shower chair during bathing and a wheelchair for use during out of home activity. Review of the clinical record revealed the following: The POCs, dated 9/23/22 to 11/21/22 and 11/22/22 to 1/20/23, included durable medical equipment (DME) needs of wound and colostomy supplies, walker, grab bars, glucose monitor and supplies and diabetic supplies. The initial comprehensive assessment dated 9/23/22 identified the patient required the use of a shower chair and a wheelchair. On 12/20/22 at 4:30 PM, during a home visit observation, Staff C, Registered Nurse (RN) completed a skilled visit with the patient. In an interview, during the same home visit observation, the patient reported utilizing a shower chair during bathing and a wheelchair for use during out of home activity. c. The POC, dated 9/23/22 to 11/21/22 and 11/22/22 to 1/20/23, failed to identify the patient required use of a shower chair and wheelchair.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on agency staff interview, home visit observation, patient/ caregiver interview and admission packet review, the agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address). The agency failed to provide this information for 2 of 4 sampled patients with home visits (Patient #1 and #2). The concerns were identified with patients from the Estherville parent office and the Rock Rapids branch office. Failure to provide the contact information for the agency's clinical manager left the patients without the needed information to contact the agency clinical manager for any concerns about their services. Findings include: Review of the agency's admission packet identified forms that lacked the agency clinical manager's name, telephone number and/or email address. 1. Patient #1 had a start of care date of 12/19/22 and received services from the Estherville parent office. On 12/19/22, the surveyor visited the patient for a home visit observation. During review of the folder, which included all paper work given to the patient by the agency, the surveyor found no documentation identifying the name and contact information of the clinical manager. The surveyor observed no documentation including the name and contact information of the clinical manager posted anywhere in the patient's home. 2. Patient #2 had a start of care date of 12/14/22 and received services from the Rock Rapids branch office. On 12/20/222 at 12:45 PM, the surveyor accompanied Staff C, Physical Therapist (PT), to the patient's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. During review of the folder, which included all paper work given to the patient by the agency, the surveyor found no documentation identifying the name and contact information of the clinical manager. The surveyor observed no documentation including the name and contact information of the clinical manager posted anywhere in the patient's home. During findings on 12/21/22 at 8:42 AM with the agency Administrator, the Administrator reported the Clinical Manager's information is not in the admission packet provided to patients and stated will get the Clinical Manager's information added to the sheet given to patient's with the Administrator's information on it.