Every finding on record at Burgess Health Center

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 2/5/24 through 2/7/24 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 2/5/24 through 2/7/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 74 patients at the time of the survey. Including 71 patients receiving services from the parent office in Onawa and 3 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to notify the physician of changes in patient condition or needs that suggest an alteration to the Plan of Care for 2 of 3 sampled patients with medications set up/monitoring (Patient #1 and #2) and 3 of 4 sampled patients with monitoring of weights (Patient #2, #6 and #7). The deficient practices was identified in the Onawa parent office. Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: According to the agency policy, titled Documentation-Patient Plan of Care, dated 11/2017, the physician that is primarily involved will have an opportunity to review all orders. The agency will be responsible for assuring communication with all physicians involved in the plan of care as well as integrating orders to assure the coordination of all services and interventions are provided to the patient. 1. Patient #1 had a start of care date of 2/21/22. Clinical record review revealed: Plan of Care, dated 12/13/23-2/10/24, included physician orders for skilled nursing services 1-2 times a week for medication set up. Home visit observation and Interview on 2/5/24 at 1:30 PM with Staff C, Registered Nurse (RN) reported the medication set up in the medication planner was 2 times a week due to Patient #1’s noncompliance with taking medications. a. Skilled nursing visit note, dated 12/19/23, documentation included missed 2 morning prefilled medication slots in 3 days. b. Skilled nursing visit note, dated 1/2/24, documentation included missed 1 morning and 1 evening prefilled medication slots. c. Skilled nursing visit note, dated 1/23/24, documentation included did not take any medications for Sunday, Monday, Tuesday or Saturday bedtime prefilled medication slots. d. Skilled nursing visit note, dated 1/26/24, documentation included missed 3 bedtime and 1 morning prefilled mediation since 1/23/24. e. Home visit observation and Skilled nursing visit note, dated 2/5/24, documentation included missed 1 morning prefilled medication. The HHA failed to notify the physician when Patient #1 had missed taking their medications as ordered. 2. Patient #2 had a start of care date of 6/2/23. Clinical record review revealed: Plan of Cares, dated 11/29/23-1/27/24 and 1/28/24-3/7/24, included physician orders for skilled nursing services 2-3 times that included weigh patient weekly on routine visits. Report weight gain of 4 pounds in 1 week or 2 pounds in 24 hours. Home visit observation and Interview on 2/5/24 at 11:30 AM with Patient #2, reported their mother helps with setting up their medications and the Lasix medication is set up a noon, so they remember to take the Lasix. Interview on 2/5/24 during home visit with Staff D, Licensed Practical Nurse (LPN), reported the Lasix and weight are monitored because of Patient #2’s swelling in their legs. a. Skilled nursing visit note, dated 12/29/23, documentation included Lasix not taken on Tuesday or Thursday. b. Skilled nursing visit note, dated 1/2/24, Patient #2’s weight 360.8 pounds, up 5 pounds 4 ounces. c. Skilled nursing visit notes, dated 1/15/24, Patient #2’s weight 363 pounds, up 3 pounds. The HHA failed to notify the physician when Patient #2 had missed taking Lasix as ordered and when Patient #2 had an increase in their weight. 3. Patient #6 had a start of care date of 10/19/23. Clinical record review revealed: Plan of Care, dated 10/19/23-12/18/23, included physician orders for skilled nursing services 1-2 times a week that included to check weight every visit. a. Skilled nursing visit note, dated 10/24/23, documentation lacked a weight. b. Skilled nursing visit note, dated 10/29/23, documentation lacked a weight. The HHA failed to notify the physician when Patient #6 weight was not obtained as ordered. 4. Patient #7 had a start of care date of 7/11/23. Clinical record review revealed: Plan of Care, dated 7/11/23-9/8/23, included physician orders for skilled nursing services 1-2 times a week that included to check weight every visit. Skilled nursing visit note, dated 7/31/23, documentation included assisted living staff weighed Patient #7, weight down 5 pounds. The HHA failed to notify the physician when Patient #7 weight had decreased. The above findings were reviewed with the Administrator and Staff B, Clinical Manager. The agency provided no further information prior to the end of the survey.

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 wound assessment as required by agency policy and expectation for 1 of 2 sampled patients with wounds (Patient #2). The agency reported a current census of 108 patients at the time of the survey, including 7 patients who had a wound. Including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa parent office. Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. Findings include: According to the agency policy, titled Wound Assessment and Photography, dated 6/2020, wounds will be measured weekly and more often if wound deterioration is noticed. Do depth measurement first. Complete measurement with length and width. During an interview on 2/5/24 at 2:30 PM, Staff B, Clinical Manager, reported wound measurements should be completed weekly. The measurements include depth, length and width of the wound. The wound measurements would be documented in the clinical record under assessment. Patient #2 had a start of care date of 6/2/23. Clinical record review revealed: Plan of Care, dated 11/29/23-1/27/24 and 1/28/24-3/7/24, included physician orders for skilled nursing services 2-3 times a week that included wound care to left lower extremity. Home visit observation and Interview on 2/5/24 at 11:30 AM with Patient #2, reported they take a shower before the skilled nurse visit and removed the dressing on the wound when they shower. Interview during home visit with Staff D, Licensed Practical Nurse (LPN) reported wounds are measured at the first visit of the week a. Skilled nursing visit note, dated 12/11/23, documentation included a length and width of the wound, but lacked a depth measurement. b. Skilled nursing visit notes, dated 1/7/24 and 1/10/24, documentation did not include a length, width and depth of the wound. No wound measurements were completed for the week of 1/7/24. c. Skilled nursing visit note, dated 1/22/24, documentation included a length and width of the wound, but lacked a depth measurement. d. Skilled nursing visit note, dated 2/5/24, documentation included a length and width of the wound, but lacked a depth measurement. Home visit observation with Staff D, LPN, of wound measurements did not include a depth measurement. The agency RN/LPNs failed to follow their agency policy and measure wounds weekly. The above findings were reviewed with the Administrator and Staff B, Clinical Manager. The agency provided no further information prior to the end of the survey.

The recertification survey, conducted 2/8/21 through 2/11/21 found the agency operating out of compliance with the following requirements of the Establishment of Emergency Preparedness:

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on clinical record review, policy review and staff interview the home health agency failed to ensure the clinician assessed the patient's individualized needs related to emergency preparedness with each comprehensive assessment for 2 of 7 sampled patients (Patients #3 and #5). The agency reported a current census of 108 patients, including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa branch office. Failure to ensure the agency maintained a copy of the patient's individualized emergency plans developed as part of the comprehensive assessment and failure to ensure the patient has knowledge of the identified Plan placed patients at risk for staff being unaware and unprepared to respond in a timely and effective manner to potential health and safety hazards the patient may encounter. Findings include: Review of the agency policy titled Emergency Preparedness Plan, dated 1/12/21, the home health maintains an emergency manual in the department should the electronic medical record not be available, which includes: current patient list, patient's demographic information, patient's evacuation plan and patient's emergency contact. During an interview on 2/11/21 at 8:30 AM, the Administrator stated staff in the past have used the paper Emergency Plan pan as a tool when they go over the plan with the patients. 1. Patient #3 had a start of care date of 10/9/2020. The patient's update to the comprehensive assessment at recertification of care, dated 2/8/21 failed to include an individualized emergency plan. The Individual Patient Emergency Preparedness Plan was not scanned into the electronic health care system of a copy provided in the patient's hard chart. 2. Patient #5 had a start of care date of 10/23/2020. The patient's initial comprehensive assessment at start of care, dated 10/23/2020 included documentation the nurse reviewed the home health agency packet including emergency preparedness patient education with the patient. The patient's update to the comprehensive assessment at recertification of care, dated 12/20/2020, failed to include an individualized emergency plan. The Individual Patient Emergency Preparedness Plan was not scanned into the electronic health care system of a copy provided in the patient's hard chart. During a home visit on 2/10/21 at 8:30 AM, with Staff RN, the patient's individual Patient Emergency Preparedness Plan not completed. The agency failed to provide the patient with a completed emergency preparedness plan individualized for the patient. The above findings were reviewed with the Administrator and Staff C, Registered Nurse. The agency provided no further information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey combined with a recertification survey was conducted by the Department of Inspections and Appeals completed on 2/8/21 through 2/11/21. The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The survey identified the following standard deficient practices occurring at the time of the recertification survey.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). The agency reported a current census of 108 patients, including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa and Decatur branch office. Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: During an interview on 2/11/2020 at 8:30 AM, the Administrator stated staff indicate that the insurance will pay for the entire amount. 1. Patient #1 had a start of care of date of 12/18/2020. The Plan of Care, dated 12/18/2020 to 2/16/21, included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. The Admission Consent form, dated 12/18/2020, included documentation the patient had received a copy of the patient's rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through medicare, but failed to identify the charges for services that may not be covered by insurance. 2. Patient #2 had a start of care of date of 10/9/2020. The Plan of Care, dated 10/9/2020 to 12/7/2020, included physician orders for skilled nursing services. The Admission Consent form, dated 10/9/2020, included documentation the patient had received a copy of the patient's rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through medicare, but failed to identify the charges for services that may not be covered by insurance. 3. Patient #3 had a start of care of date of 11/6/2020. The Plan of Care, dated 11/6/2020 to 1/4/21, included physician orders for skilled nursing services. The Admission Consent form, dated 11/6/2020, included documentation the patient had received a copy of the patient's rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through medicare, but failed to identify the charges for services that may not be covered by insurance. 4. Patient #4 had a start of care of date of 1/22/21. The Plan of Care, dated 1/22/21 to 3/22/21, included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. The Admission Consent form, dated 1/22/21, included documentation the patient had received a copy of the patient's rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through medicare, but failed to identify the charges for services that may not be covered by insurance. 5. Patient #5 had a start of care of date of 10/23/2020. The Plan of Care, dated 10/23/2020 to 12/21/21 and 12/22/2020 to 3 /10/21, included physician orders for skilled nursing and home health aide services. The Admission Consent form, dated 12/18/2020, included documentation the patient had received a copy of the patient's rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through medicare, but failed to identify the charges for services that may not be covered by insurance. 6. Patient #6 had a start of care of date of 11/17/2020 and date of discharge of 1/8/21. The Plan of Care, dated 11/13/2020 to 1/15/21, included physician orders for skilled nursing, physical therapy and home health aide services. The Admission Consent form, dated 11/17/2020, included documentation the patient had received a copy of the patient's rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through medicare, but failed to identify the charges for services that may not be covered by insurance. 7. Patient #7 had a start of care of date of 1/1/2020 and date of discharge of 1/19/21. The Plan of Care, dated 1/1/21 to 3/1/21, included physician orders for skilled nursing, services. The Admission Consent form, dated 1/1/21, included documentation the patient had received a copy of the patient's rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through medicare, but failed to identify the charges for services that may not be covered by insurance. The above findings were reviewed with the Administrator and Staff C, RN. The agency provided no further information prior to the end of the survey.

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 staff interview, the agency failed to accurately complete a drug regimen review (DRR), including completion of all required components and identification of any findings within the required time frames as part of the comprehensive assessment for 2 of 7 sampled patients (Patients #2 and #7). The agency reported a current patient census of 108 patients including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa office. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: According to the agency policy, titled Drug Interaction Review/Drug Therapy Monitoring, dated 7/14/2020, the medication profile includes a listing of all patient medications, dose, frequency, route, time and the date the medication was initiated. All new, changed or revised medications will be entered into home health electronic record and new medication profile printed as necessary. During an interview on 2/8/21 at 3:00 PM the Clinical Manager stated a DRR is completed with any comprehensive assessment and discharge. The DRR also expected to be completed with every medication change. 1. Patient #3 had a start of care date of 11/6/2020. The Plans of Care (POC), dated 11/6/2020 to 1/4/2020 and 1/5/21 to 3/5/21, included orders for skilled nursing services. During an home visit on 2/9/21 at 10:00 AM with Staff D, RN (Registered nurse), the patient identified he/she took tramadol 50 mg (milligram) every 8 hours as needed for pain. The patient stated he/she started taking the medication mid-December. The comprehensive assessment, completed at recertification of care, dated 12/31/2020, documented the medication profile was reviewed for new or changed medications. The DRR failed to identify tramadol medication as needed for pain. 2. Patient #5 had a start of care date of 10/23/2020. The POCs, dated 10/23/2020 to 12/22/2020, included orders for skilled nursing services and home health aide. During an home visit on 2/10/21 at 8:30 AM with Staff E, RN, the patient identified he/she took extra strength Tylenol 650 mg every 8 hours every for hours as needed for pain. The patient stated he/she had been taking the medication once and a while throughout the years. The initial comprehensive assessment, completed at start of care, dated 10/23/2020, documented the medication profile was reviewed. The DRR failed to identify extra strength Tylenol medication as needed for pain. The comprehensive assessment, completed at recertification of care, dated 12/31/2020, documented the medication profile was reviewed for new or changed medications. The DRR failed to identify tramadol medication as needed for pain. The above findings were reviewed with the Administrator and Staff C, RN. The agency provided no further information prior to the end of the survey.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient/caregiver interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 5 of 7 sampled patients (Patients #1, #2, #3 #5 and #6). The agency reported a current census of 108 patients, including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa and Decatur branch office. 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: According to the agency policy, titled Patient Plan of Care (POC) last revised 5/12/2020, the POC is the multidisciplinary plan and may address physical, emotional, social, spiritual, level of risk, and/or educational needs. These goals will be reasonable, measurable and individualized to address specific patient needs based on assessment and will be developed in partnership with the patient. The plan of care will include patient services, supplies and equipment needed. 1. Patient #1 had a start of care date of 12/19/2020 and received skilled nursing services from the agency. The Plan of Care, dated 12/19/2020 to 2/16/21, documented a primary diagnosis of compound fracture. a. The Start of Care Comprehensive Assessment, dated 12/19/2020, documented Patient #1 declined use of a lifeline. b. The Plan of Care, dated 12/19/2020 to 2/16/2020, included documentation of a television tray, arm sling, medication cassette, oxygen and supplies and 4 wheeled walker with a seat to meet his/her medical needs. c. The skilled nurse visit, dated 1/10/21, identified the patient had a lifeline to meet his/her medical needs. The updated Plan of Care failed to include to include the lifeline. 2. Patient #2 had a start of care date of 10/9/2020 and received skilled nursing services from the agency. The POC, dated 10/9/2020 to 12/7/2020, documented a primary diagnoses of chronic ulcer of the lower leg. a. The skilled nurse note, dated 12/10/2020, documented Patient #2 used oxygen 2 liters per nasal cannula and compression hose. b. The Plan of Care, dated 12/8/2020 to 2/5/2021, included documentation of a commode, wheelchair, walker, medication cassette, shower bench, chair on the landing, hospital bed, eggcrate mattress and EZ stand. The updated POC failed to include oxygen or compression stockings. 3. Patient #3 had a start of care date of 11/6/2020 and received skilled nursing services from the agency. The POC, dated 11/6/2020 to 1/4/21, documented a primary diagnoses of compression fracture. a. During a home visit on 2/9/21 at 10:00 AM with Staff D, Registered Nurse (RN), the patient noted to have lifeline on a necklace on his/her neck. The patient stated he/she had the lifeline prior to the start of home health services. b. The Plan of Care, dated 11/6/2020 to 1/4/2021 and 1/5/21 to 3/5/21, included documentation of a walker, cane, medication planner, shower seat, grab bars, incontinent products and glasses. The POCs failed to include lifeline. 4. Patient #5 had a start of care date of 10/23/2020 and received skilled nursing and home health aide services from the agency. The POC, dated 10/23/2020 to 12/22/22020 and 12/23/2020 to 2/19/21 documented a primary diagnoses of pulmonary disease. a. During a home visit on 2/10/21 at 8:30 AM with Staff E, RN, the patient noted to have lifeline on a necklace on his/her neck. The patient stated he/she had the lifeline approximately 6 months. b. The Plan of Care, dated 10/23/2020 to 12/22/2020 and 12/23/2020 to 2/19/21, included documentation of a walker, cane, distilled water, grabber, inhaler spacer, liquid oxygen, medication cassette, nasal cannula, nebulizer/tubing and oxygen concentrator. The POCs failed to include lifeline. 5. Patient #6 had a start of care date of 11/17/2020 and date of discharge of 1/8/21 and received skilled nursing, physical therapy and home health aide services from the agency. The POC, dated 11/17/2020 to 1/15/21, documented a primary diagnoses of cellulitis. a. The initial comprehensive assessment at start of care, dated 11/17/2020, documented the patient incontinent and required incontinent products. b. The Plan of Care, dated 11/17/2020 to 1/15/21, included documentation of a shower chair, grab bars, walker, lifeline, medication cassette, toilet riser, handheld shower and back scratcher. The POCs failed to include incontinent products. The above findings were reviewed with the Administrator and Staff C, RN. The agency provided no further information prior to the end of the survey.

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 wound assessment as required by agency policy and expectation for 1 of 4 sampled patients with wounds (Patient #6). The agency reported a current census of 108 patients at the time of the survey, including 7 patients who had a wound. Including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa branch office. Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. Findings include: During agency staff interview on 2/8/2020 at 3:00 PM, the Clinical Manager reported an expectation that clinicians measure all wounds every week and measure length, width and depth. The measurements are documented in the assessment. Patient #6 had a start of care date of 11/17/2020 and date of discharge of 1/8/21. Clinical record review revealed the following: 1. The chart/clinical note, dated 12/7/2020, documented Patient #6 had a new stage 3 open area to the bilateral buttocks area. The areas cleansed and mepilex dressing applied to cushion and protect the areas. The right buttock measured 1 cm by 1.2 cm by 0.1 cm and pink to beefy red. The left buttock measured 0.4 cm by 0.5 cm by 0.1 cm and pink to beefy red. 2. The chart/clinical note, dated 12/11/2020, documented the wound care to the bottom done during the visit. The note failed to include assessment or measurements of the wound. 3. The chart/clinical note, dated 12/16/2020, documental the wound to the bottom area clean, dry and small open area. The note failed to include measurements of the wound. The above findings were reviewed with the Administrator and Staff C, RN. The agency provided no further information prior to the end of the survey.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to complete and send a transfer summary and discharge to the physician or other health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of knowledge of the occurrence of the transfer for 2 of 3 sampled patients with transfers to an inpatient facility or discharge form the agency (Patients #1 and #7). The agency reported a current census of 108 patients, including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa office. Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up after transfer. Findings include: 1. Patient #1 had a start of care date of 12/19/2020. The patient's clinical record included the following: a. The transfer OASIS (outcome and assessment information set), dated 12/29/2020, identified the patient transferred to the hospital on 12/28/2020. The transfer summary, dated 12/29/2020, failed to identify the summary sent to the receiving facility. During an interview on 2/10/21 at 1:55 PM the Administrator stated the transfer summary had been completed but unable to identify the document had been sent to the hospital. 2. Patient #7 had a start of care date of 1/1/21 and date of discharge of 1/19/21. The patient's clinical record included the following: a. The discharge OASIS, dated 1/19/21, identified the patient discharged form home health services effective 1/19/21. The patient's clinical record lacked documentation of a completed discharge summary. The above findings were reviewed with the Administrator and Staff C, RN. The agency provided no further information prior to the end of the survey.