Every finding on record at Butler County

The recertification survey, conducted from 10/9/22 through 10/11/22, identified the following standard level deficiencies related to emergency preparedness.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] 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:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the agency's policies and procedures for their emergency preparedness plan and staff interview, the agency failed to ensure the development of a policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Failure to have a policy and procedure in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency's policies, titled Emergency Operations Plan, dated September, 2023, identified the policies failed to include a policy and procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. On 10/11/23 at 1:05 PM, during an interview, the Director reported an inability to find a procedure included in the policy for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Agency staff provided no further information prior to the end of the survey.

The Iowa Department of Inspections and Appeals conducted a Recertification Survey from 10/9/23 through 10/11/23. 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 census of 54 patients at the time 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 and home visit observation, the agency failed to provide services only as ordered by the physician for 1 of 7 sampled patients (Patient #2). Failure to ensure staff followed physician orders for provision of services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency's policy, titled Physician Orders, dated 7/2010, identified drugs and treatments shall be administered by agency staff only, as ordered by the physician. Patient #2 had a start of care date of 7/6/17. Review of the clinical record revealed the following: The Plans of Care (POCs), dated 8/4/23 to 10/2/23 and 10/3/23 to 12/20/23, included a physician order for the skilled nursing services 1 to 2 times weekly. The POC included orders for the skilled nurse to apply Cerave healing ointment to the bilateral lower extremities when no open wounds are noted. The POC also included an order for wound treatment to cleanse the open wound with soap apply silvadene cream, cover with gauze and secure with tape or coban. The skilled nurse visits, dated 8/8, 8/22, 9/5, 9/12, 9/29 and 10/3/23, included documentation both treatments including Cerave healing ointment and Silvadene cream with dressings performed on the patient's bilateral lower extremities. During an interview during a home visit observation with Staff C, RN, no treatment of the bilateral lower extremities was observed and Staff C RN reported the patient did not have open areas on his/her legs for a long time. The silvadene cream had not been used in a long time. The RN failed to complete treatments per physician orders on the POC. The Director and Clinical Manager received the above findings and home health staff provided no further information prior to the end of the survey.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record, agency policy, and staff interview, the facility failed to obtain orders for a medication and for a procedure for 1 of 1 patient reviewed (Patient #1). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medication and/or treatments according to assessed needs and physician orders. Findings include: The Physician Orders Policy date July 2010 directed that all treatments and care must be ordered, dated, and signed by the physician. The orders may be initiated via telephone or in writing and must be countersigned by the physician. The Visit Note Addendum signed by Staff C, Registered Nurse (RN), on 10/10/23 revealed that epsom salts were listed as Durable Medical Equipment (DME). The Clinical Record lacked an order for Epsom salts. The Verbal Order signed by a physician on 10/4/23 lacked orders for the patient to soak his feet before application of silver sulfadiazine cream. The Verbal Order signed by a physician on 9/26/23 revealed: silver sulfadiazine 1% topical cream; Apply 1 application topical once a day for 15 day(s); Starting 9/20, Apply to wound bed of the left great big toe once a day after soaking for twenty minutes, bandage it after application. Until follow appt. 10/3. In an interview with the Clinical Manager 10/11/23 at 12:06 PM, she reported that Staff C forgot to include the procedure for foot soaking along with the rest of the procedure order when the frequency of silver sulfadiazine cream increased to twice per day and the cream was ordered to be applied to both great toes. In the same interview, the Clinical Manager reported that she was unable to find an order for epsom salts. The above findings were reviewed with the Director and Clinical Manager and no further information provided prior to the end of the survey.

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 clinical record review, agency policy review, patient and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 4 sampled patients receiving home health aide services (Patients #2, #4 and #7) and a home visit observation. 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. Findings include: The agency policy, titled Home Care Aide Assignment, dated July, 2010, identified any change in the assignment must be approved by the Registered Nurse (RN) supervising the Home Care Aide under physician's orders. The client/caregiver will be notified of all changes. 1. Patient #2 had a start of care date of 7/6/17. The Plans of Care (POCs), dated 8/4/23 to 10/2/23 and 10/3/23 to 12/1/23, included physician orders for skilled nursing and home health aide services. The POC included an order to shampoo hair per patient request. Review of the clinical record revealed the following: The home health aide care plan, dated 3/1/22, included RN instructions to the aide to complete the assigned tasks of shampoo hair per patient request. Home Health Aide visit notes, dated 8/8, 8/15, 8/22, 8/29, 9/5, 9/12, 9/19, 9/26 and 10/3/23, lacked documentation shampoo the patient's hair completed or not completed. The clinical record lacked documentation the aide addressed the task of shampoo the patient's hair. 2. Patient #4 had a start of care date of 9/27/23. The POC, dated 9/27/23 to 11/25/23, included physician orders for skilled nursing and home health aide services. The POC included an order to perform catheter cares. Review of the clinical record revealed the following: The home health aide care plan, dated 9/27/23, included RN instructions to the aide to complete the assigned tasks of catheter cares. Home Health Aide visit notes, dated 9/29/23 and 10/3/23, lacked documentation catheters cares were completed. The clinical record lacked documentation the aide addressed the task of catheter cares. 3. Patient #7 had a start of care date of 3/24/21. The POCs, dated 7/28/23 to 9/25/23 and 9/26/23 to 11/24/23, included physician orders for skilled nursing and home health aide services. The POC included an order for bed bath or shower per patient request. Review of the clinical record revealed the following: The home health aide care plan, dated 7/28/23, included RN instructions to the aide to complete the assigned tasks of bed bath or shower per patient request. Home Health Aide visit notes, dated 8/9, 8/14, 8/15, 8/24, 9/5, 9/7, 9/14, 9/21 and 9/26/23, lacked documentation of which type of bath completed, bed bath or shower. The clinical record lacked documentation the aide addressed the task of completed bed bath or shower. The Director and Clinical Manager received the above findings and home health staff provided no further information prior to the end of the survey.