Every finding on record at Cargivers of Chariton LLC

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 1/23/25 through 1/29/25/24 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 1/23/25 through 1/29/25. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 132 patients at the time 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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home observation visits, staff and patient/family interview, clinical record review, and policy review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 2 of 4 sampled patients with home observation visits. (Patients #1 and #2). 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 policy titled Plan of Care, dated 9/9/20, the Plan of Care (POC), will be individualized and completed in full to include all medical supplies and equipment required in the home. 1.Patient # 1 had a start of care date of 7/11/22, with diagnosis of chronic kidney disease, and hypertension (high blood pressure). Clinical record review, home visit observation and accompanying interviews revealed the following: a. The POC, dated 12/27/24 to 2/24/24, included physician orders for Durable Medical Equipment (DME) that included the following: adaptive living aides, blood pressure cuff, pulse oximeter, and personal protective equipment. b. During a home observation visit on 1/23/24 at 11:30 AM, with Staff B, RN. The patient had a discussion about the progress of their Peritoneal dialysis (treatment for kidney failure that uses the lining of the abdomen to filter the blood) conducted by the patient in his/her home. Staff B, RN also filled two medication planners for the patient during the same home visit. The POC failed to identify dialysis equipment and medication planner as DME utilized by the patient in the home. 2. Patient #2 had a start of care date of 4/25/24 with diagnosis of long term urinary catheter use, obesity, and type two diabetes. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The POC, dated 12/21/24 to 2/18/25, included physician orders for DME and included the following: briefs, catheter supplies, blood pressure cuff, compression wraps, cushion, elevated toilet seat, feeding bags/extension tubing, glucometer, grab bars, lift chair, shower chair, walker, wheelchair and wound care supplies. b. During a home observation visit on 1/23/24 at 10:30 AM, with Staff A, RN, the surveyor observed a Sequential Compression Device (used with air sleeves that provide gentle and consistent compression to the legs). Patient #2 reported the staff at the assisted living facility help her/him with this machine and to get the leg wraps in place and run the machine while she/he sits in the recliner. The POC failed to identify the Sequential Compression Device and accessories as DME utilized by the patient in the home. The findings were reviewed with the Administrator and the Clinical Manager.

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 home visit observations, agency staff and patient interviews, agency policy review and clinical record review, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 3 sampled patients with wounds. (Patients #1 and #4). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the policy titled The Plan of Care, dated 9/9/20, Home care services are furnished under the supervision and direction of the patient's physician and includes the type, frequency and duration of all visits and services. The Plan of Care (POC), will include physician orders for all medications, treatments, and procedures. The POC will be consistently reviewed and updated as necessary with the physician. During interview on 1/29/25, at 12:00 PM, Administrator, stated interim physician orders are incorporated into an updated POC, and acknowledged the POC should have all wound care orders included and current with the treatment that is being provided in the patient's home. 1.Patient #2 had a start of care date of 4/25/24 with diagnosis of long term use of urinary catheter, obesity and type 2 diabetes. Clinical record review revealed the following: a. The POC, dated 12/21/24 to 2/18/25, included orders for skilled nursing services to assess patient's skin integrity and instruct patient /caregiver on measures to prevent pressure ulcers. b. Interview on 1/23/25 at 10:25 AM, Administrator stated Patient #2 had intermittent skin issues on her buttocks and that foam dressings were routinely used for treatment and/or prevention of wounds to the patient's buttock. Administrator stated patient has difficulty getting around and sleeps in the recliner and has a risk of developing pressure areas. c. During home observation visit on 1/23/25 at 10:45 AM, Staff A, RN , removed a large foam dressing from the right buttock and the left buttock, and noted 2 open areas to the left buttock, the first measured at 1 centimeter (cm) in length, by 0.7 cm width, and a depth of 0.2 cm. The second open area measured 0.7 cm length, 0.5 cm width, and 0.2 cm depth. Staff A, RN applied skin prep and then placed large foam dressings over the right and the left buttock. An order was later obtained from the physician to cleanse wounds in the shower and cover with foam dressings twice a week and as needed if dressing becomes soiled or loose. The agency failed to obtain physician orders for wound cares prior to provide wound cares. 2.Patient #4 had a start of care date of 10/14/24 with a diagnosis of diabetic ulcer to the right great toe. Clinical record review revealed the following: a. The POC, dated 10/14/24 to 12/12/24, included all physician orders which included wound orders to the patient's great toe on the right foot secondary to type 2 diabetes as follows: Cleanse and irrigate the toe with wound cleanser, pat dry, apply non adherent dressing over the wound and wrap with Coban (self stick adhesive wrap), weekly by skilled nurse. b. The skilled nurse note, dated 11/4/24, Staff B, RN, documented the right foot was soaked in epson salt for ten minutes, patted dry and the right great toe wrapped with the dressing. c. The skilled nurse note, dated 11/11/24, Staff B, RN documented the right foot was soaked in epson salt and warm water, patted dry and the right great toe wrapped with the dressing. d. The skilled nurse note dated 11/18/24, Staff B, RN documented the great toe on the right foot was cleansed with wound cleanser, patted dry and wrapped with the dressing. e. The skilled nurse notes, dated 11/25/24 and 12/02/24, Staff B, RN failed to document what wound care was provided to patients right great toe. The agency failed to follow the physician wound care orders for patient's right great toe. The above findings were reviewed with the Administrator and the Clinical Manager.

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 agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 1 of 4 sampled patients with home observation visits. (Patient #1) Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Medical Supervision, dated 11/12/20, physicians will be contacted when any of the following occurs: condition changes, unexpected response to treatment or medication changes, laboratory results are received, caregiver support or home environment changes and/or any change in client condition or agency services, including non-compliance of the client related to the Plan of Care (POC). If the client is under the care of more than one physician, the agency is responsible to the referring physician until such time as a change in care is agreed to by the client/family and the physician. 1.Patient # 1 had a start of care date of 7/11/22, with diagnosis of chronic kidney disease, and hypertension (high blood pressure). Clinical record review, home visit observation and accompanying interviews revealed the following: a. The POC, dated 12/27/24 to 2/24/24, included physician orders for skilled nurse for assessment and education, to establish support measures to minimize the risk of hospitalization and emergency room use, and to assess pain management and effectiveness of medications. b. The care coordination note dated 1/8/25, Staff B, RN documented Patient #1 was not feeling well today, complained of headache, nausea, dizziness and lethargy. Orthostatic Blood Pressures (taking the blood pressure sitting down and then upon standing to assess for a drop in the readings) were obtained with the patient seated of 120/62 and upon standing was 83/53. Staff B, RN, documented the nurse at the dialysis center was contacted and stated she would call to check on the patient. The clinical record lacked documentation the primary physician was notified. c. During a home observation visit on 1/23/24 at 11:30 AM, with Staff B, RN , Patient expressed concern over dizziness and reported some near falls because of the dizziness, and reported this was more significant lately. Patient also complained about having headaches. Staff B, RN, did obtain orthostatic blood pressure readings, the reading when patient was seated was 112/60 and upon standing dropped to 86/57. Staff B, RN documented the dialysis center nurse had been updated 2 weeks prior about significant drop in orthostatic blood pressures and were aware. The documentation lacked notification to the physician of a condition change and an increased risk for falls. The agency failed to notify the primary physician with a condition change. The above findings were reviewed with the Administrator and the Clinical Manager.

The recertification survey, conducted 2/7/22 through 2/9/22, identified the agency was in compliance with emergency preparedness regulations.

The Iowa Department of Inspections and Appeals conducted a recertification survey, dated 2/7/22 through 2/9/22. Agency staff reported a census of 206 patients at the time of the survey. The recertification survey identified the following standard level deficient practices:

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, assisted living facility medication administration record, patient interview, caregiver interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 4 of 4 sampled patients (Patients #1, #2, #3 and #4) with a home visit observation. 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 undated policy, titled Physician Orders/Plan of Care, identified the Registered Nurse (RN) Case Manager sets up the Plan of Care which is individualized to meet the needs of the patient and under the direction of the physician. The Plan of Care includes an order for each service, goals to be accomplished, drugs and equipment used by the patient. 1. Patient #1 had a start of care date of 7/12/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 11/9/21 to 1/7/22 and 1/8/22 to 3/8/22, included physician orders for skilled nursing services, home health aide services and occupational therapy (OT) services. The POCs included interventions and goals for nursing services and directions for personal cares for home health aide services, but lacked any specific information regarding OT services. The POC included the following; OT to continue per OT care plan. 1) OT visit notes, dated 11/4 and 12/3/21, included documentation of OT evaluation, identified the patient's ongoing need for OT services and a physician order to continue with services. 2) An interim physician order, dated 1/7/22, included orders for OT services 1 to 2 times per week for 30 days and included OT specific goals and interventions. The POCs failed to include scope and frequency orders, goals and interventions related to OT services. b. The POC, dated 1/8/22 to 3/8/22, included the following medication orders: Citalopram 10 milligrams (mg) 1 tab every other day by mouth until gone and then discontinue; Sennosides-Docusate 8.6- 50 mg 1 capsule daily by mouth; and, Miralax 17 grams daily in water or juice. On 2/8/22 at 11:34 AM, in an interview, during a home visit observation with the Administrator, the patient reported setting up and administering his/her own medications. The patient reported not taking Citalopram since around July of 2021 and the Sennosides-Docusate had been discontinued since he/she had started taking Miralax. On 2/9/22 at 8:38 AM, during an interview, the Administrator reported she may have created an order to discontinue the Citalopram. 2. Patient #2 had a start of care date of 5/14/09. Review of the clinical record revealed the following: The POCs, dated 11/7/21 to 1/5/22 and 1/6/22 to 3/6/22, included physician orders for skilled nursing services and medications. The POC identified the patient took Lisinopril (a medication to treat high blood pressure) 2.5 milligrams (mg) 1 tablet every day by mouth and Calcium Carbonate 500 mg with Vitamin D 400 mg tablets, one tablet daily by mouth. On 2/8/22 at 9:30 AM, in an interview, during a home visit observation with the Administrator and patient's Supported Community Living (SCL) worker, the SCL worker reported setting up and administering the patient's medications. The SCL worker reported the patient had not taken Lisinopril since she had started working with the patient on 6/7/21. She also reported the patient had been taking Calcium Carbonate 600 mg (not 500 mg) with 400 mg Vitamin D since she had started working with the patient. On 2/9/22 at 8:38 AM, during an interview, the Administrator reported the SCL workers in the patient's home were not good about communicating the patient's medication changes and agency staff needed to figure out a better system to ensure they got this information. 3. Patient #3 had a start of care date of 5/7/2020. Review of the clinical record revealed the following: The POCs, dated 10/29/21 to 12/27/21 and 12/28/21 to 2/25/22, identified the patient received medical oversight from the assisted living facility staff and included orders for skilled nursing services and medications. On 2/8/22 at 2:12 PM, during an interview, the patient reported the assisted living facility staff set up and assisted the patient with medication administration. a. The POC, dated 12/28/21 to 2/25/22, included the following medication discrepancies from the assisted living facility's medication orders for the patient: 1) The POC included 2 different orders for Levemir: Levemir Flextouch subcutaneous 100 units/milliliter (ml), 60 units twice per day and Levemir Flextouch 100 units/ml, 65 units twice per day. The assisted living facility's medication orders for the patient included an order for Levemir FlexPen Solution 100 units/ml, 60 units 2 times per day and a start date of 9/23/21. 2)The POC included an order for Novolog subcutaneous 100 units/ml 45 units three times per day with meals; hold if blood sugar readings are below 120 and additional insulin with sliding scale; patient takes between 45 to 65 units per patient's report. The assisted living facility's medication orders for the patient included an order for Novolog FlexPen Solution 100 units/ml, inject 45 units before meals; hold insulin administration if the blood sugar reading is below 140 (not 120 as identified on the POC) and a start date of 10/20/21. The assisted living facility's medication orders also included a separate order for Novolog FlexPen solution 100 units/ml; hold if blood sugar is below 140; if blood sugar is 146 to 150, give 2 units; if 151 to 155, give 3 units; if 156 to 160, give 4 units; 161 to 165, give 5 units, 166 to 170, give 6 units; 171 to 175, give 7 units; 176 to 180, give 8 units; 181 to 185, give 9 units; 186 to 190, give 10 units; 191 to 195, give 11 units; 196 to 200, give 12 units; 201 to 205, give 13 units; 206 to 210, give 14 units; 211 to 215, give 15 units; 216 to 220, give 16 units; 221 to 225, give 17 units; 226 to 230, give 18 units; 231 to 235, give 19 units; 236 to 500, give 20 units before meals subcutaneously and a start date of 10/20/21. The POC failed to identify the specific sliding scale for Novolog insulin administration based on the patient's blood sugar readings before meals. 3) The POC included an order for Guaifenesin extended release oral 1200 mg, one tab every 12 hours as needed. The assisted living facility's medication orders included an order for Guaifenesin extended release 12 hour 600 mg tablets; take 1200 mg (2 tablets) every 12 hours as needed. b. The POC, dated 12/28/21 to 2/25/22, identified the patient used the following medical equipment and supplies: diabetic supplies, catheter supplies, grab bars, hospital bed, walker, shower bench, wheelchair, edema wraps and a continuous positive airway pressure (CPAP) machine. On 2/8/22 at 2:12 PM, during a home visit observation with Staff C, RN, the surveyor observed the patient used an overhead trapeze to help position the patient in bed. In an interview, during the same home visit observation, the patient reported he/she had been using a trapeze to help with getting in and out of bed for several years. The POC failed to identify the patient used a trapeze device. On 2/9/22 at 9:04 AM, during an interview, the Clinical Manager reported a problem with the new electronic medical record system with discontinued medication orders not dropping off of the POC. She explained the medication list would update with new orders, but not always the POC. This was why there were 2 orders for Levemir on the POC. 4. Patient #4 had a start of care date of 1/25/22. Review of the clinical record revealed the following: The POC, dated 1/25/22 to 3/25/22, included physician orders for medications, skilled nursing and physical therapy services. On 2/8/22 at 10:27 AM, during a home visit observation with Staff D, Physical Therapist, the surveyor observed the patient had a bottle of Vitamin D3. In an interview, during the same home visit observation, the patient reported taking Vitamin D3 1000 units, 2 tablets (for a total of 2000 units) every day per the patient's physician's direction since prior to the start of agency services. The POC failed to include a physician order for the Vitamin D3. The Administrator and Clinical Manager received the above concerns and agency staff provided no further information prior to the end of the survey.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of the patient clinical record review, agency policy review, family/caregiver interview, assisted living medication orders, assisted living staff interview and agency staff interview, the agency failed to ensure agency staff coordinated the delivery of care in a way to meet patient individualized needs for 1 of 4 sampled patients (Patient #3) with a home visit observation. Failure to ensure agency staff effectively coordinated the delivery of care placed the patient at risk for not receiving care to meet individualized patient needs. Findings include: Review of the agency's undated policy, titled Physician Orders/Plan of Care, identified the Registered Nurse (RN) Case Manager sets up the Plan of Care which is individualized to meet the needs of the patient and under the direction of the physician. The Plan of Care includes an order for medications used by the patient. Patient #3 had a start of care date of 5/7/2020. Review of the clinical record revealed the following: a. The comprehensive assessment, dated 5/7/2020, identified the patient was dependent on the assistance of 1 to 2 persons to complete activities of daily living and the patient's family member was the Durable Power of Attorney (DPOA). b. The patient signed the agency service agreement, dated 5/7/2020, and signed a release for the family member to receive healthcare information from the agency. c. The Plans of Care (POCs), dated 10/29/21 to 12/27/21 and 12/28/21 to 2/25/22, identified the patient received medical oversight from the assisted living facility staff and included orders for skilled nursing services and medications. On 2/8/22 at 2:12 PM, during an interview, the patient reported the assisted living facility staff set up and assisted the patient with medication administration. d. The skilled nursing visit notes, dated 1/4, 1/11, 1/18, 1/25 and 2/1/22, included documentation the patient reported use of "Desitin to areas" and identified the patient having "areas" on the buttocks with no open skin. The nurse documented the patient's plan to continue to use Desitin at each of the visits. e. The POC and/or clinical record lacked an order for the use of Desitin. Review of the assisted living medication orders for the patient revealed a lack of an order for Desitin. On 2/8/22 at 2:12 PM, in an interview, during a home visit observation, the patient reported still using Desitin for reddened areas on the buttocks; the patient denied any open areas at this time. Staff C, Registered Nurse (RN), reported she just got an order today to add Desitin to the patient's medications. She explained the Licensed Practical Nurse (LPN) completed the previous visit, and while the LPN had been aware of the patient's use of the Desitin, Staff C, RN, reported she had not been aware. On 2/8/22 at 3:05 PM, during an interview, the Patient Care Coordinator for the assisted living facility reported a family member of the patient's had been putting Desitin on the patient after showers for some time, but she did not know for how long. None of the assisted living aides had been putting Desitin on the patient after assisting the patient. On 2/8/22 at 4:05 PM, during an interview, the patient's family member/caregiver reported the assisted living facility staff had not been helping to take care of sores on the patient's buttocks after the patient's last hospitalization in August 2021, and the family member had been applying Calazime after showers from August 2021 until early January 2022. The family member reported the patient gets showers 3 times per week. The family member assists the patient with showers 1 to 2 times per week and the assisted living staff aides help the patient with showers the other 1 to 2 days. The family member explained in early January 2022, the patient had some open sores on the buttocks, so the family member has been using Desitin since then to treat the areas on the patient's buttocks. The family member reported not understanding why only 1 or 2 of the assisted living aides would apply the Calazime and Desitin when assisting the patient with showering. She reported the patient's assisted living nurse was aware of the patient's use of Desitin. The home health agency nurse failed to coordinate care and treatment of areas of concern on the patient's buttocks with the patient, assisted living staff, patient's family member/caregiver and the patient's physician putting the patient at risk for worsening of pressure areas or ulcers. The Administrator and Clinical Manager received the above findings and agency staff 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 and staff interview, the agency failed to ensure skilled professional staff involved in the patient's plan of care completed an ongoing interdisciplinary assessment for 1 of 2 sampled patients with skilled nursing and occupational therapy services (Patient #1). Failure to complete an ongoing interdisciplinary assessment which included documentation of coordination provided by all disciplines providing services to the patient placed patients at risk for having unidentified or unmet healthcare needs. Findings include: Review of the agency's undated policy, titled Comprehensive Assessment of Patients (OASIS), identified, while one clinician is responsible for completing the comprehensive assessment, if multiple disciplines are providing services, the agency permits and encourages collaboration. On 2/7/22 at 11:12 AM, during an interview, the Clinical Manager reported the electronic system was capable of syncing interventions done by the disciplines providing services into a summary to ensure the ongoing patient assessment is an interdisciplinary process. Patient #1 had a start of care date of 7/12/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 11/9/21 to 1/7/22 and 1/8/22 to 3/8/22, included physician orders for skilled nursing services, home health aide services and occupational therapy (OT) services. The POCs lacked any specific information regarding OT services. The POC included the following; OT to continue per OT care plan. b. OT visit notes, dated 11/4 and 12/3/21, included documentation of OT evaluation, identified the patient's ongoing need for OT services and a physician order to continue with services. c. The updates to the comprehensive assessment completed at the time of recertification, dated 11/8/21 and 1/11/22, lacked documentation of any coordinated assessment or sharing of information with OT services and included the following statement," OT to continue per OT care plan." d. The case conference notes and clinical record lacked documentation of coordination of care and services between the skilled nurse and the occupational therapist. e. An interim physician order, dated 1/7/22, included orders for OT services 1 to 2 times per week for 30 days and included OT specific goals and interventions. The information failed to be included in the POC, dated 1/8 to 3/8/22. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure skilled nursing staff provided care as ordered by the physician in the Plan of Care for 3 of 10 sampled patients (Patients #1, #2 and #3). Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to not receive safe, individualized and consistent care designed to meet each patients' health care needs. Findings include: Review of the agency's undated policy, titled Physician Orders/Plan of Care, identified the Registered Nurse (RN) Case Manager sets up the Plan of Care which is individualized to meet the needs of the patient and under the direction of the physician. 1. Patient #1 had a start of care date of 7/12/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/8/22 to 3/8/22, included physician orders for skilled nursing and home health aide services. The POC included orders for the skilled nurse to notify the physician if either the patient's systolic blood pressure was less than 90 and the diastolic blood pressure was less than 60 millimeters (mm) of Mercy. b. The home health aide assignment, dated 12/20/21, included directions by the RN to the home health aide to report to the RN systolic blood pressures greater than 170 and less than 100, and diastolic blood pressures greater than 100 and less than 60. c. A home health aide visit note, dated 1/12/22, included documentation the home health aide assessed the patient's blood pressure was 94 (systolic)/58 (diastolic). The clinical record lacked documentation of home health aide notified the RN and lacked documentation of physician notification of the low diastolic blood pressure. d. A home health aide visit note, dated 1/31/22, included documentation the home health aide assessed the patient's blood pressure was 98 (systolic)/58 (diastolic). The clinical record lacked documentation of home health aide notified the RN and lacked documentation of physician notification of the low diastolic blood pressure. On 2/8/22 at 11:34 AM, during a home visit observation with the Administrator, the surveyor observed the patient had a automated weight and blood pressure machine. In an interview, during the same home visit observation, the Administrator reported the patient used the auto weight and blood pressure machine which recorded daily and sent the information to the patient's insurance company. On 2/9/22 at 8:38 AM, during an interview, the Administrator and Clinical Manager reported nursing staff did review the home health aide documentation. 2. Patient #2 had a start of care date of 5/14/09. Review of the clinical record revealed the following: a. The POC, dated 11/7/21 to 1/5/22, included physician orders for skilled nursing and for the nurse to report patients pulse greater than 100 beats per minute. b. A skilled nursing visit note, dated 12/7/21, included documentation the nurse assessed the patient's pulse was 104 beats per minute. The visit note and clinical record lacked documentation the nurse followed the physician's order on the POC to notify the patient's physician of a pulse over 100 beats per minute. 3. Patient #3 had a start of care date of 5/7/2020. Review of the clinical record revealed the following: a. The POC, dated 12/28/21 to 2/25/22, identified diagnoses of diabetes with chronic kidney disease, heart failure and chronic obstructive pulmonary disease. The POC included orders for skilled nursing services weekly and to report the following to the physician: temperature greater than 100.3 degrees Fahrenheit, pulse greater than 100 beats per minute, respirations greater than 30 breaths per minute, systolic blood pressure greater than 170 mm of Mercury, diastolic greater than 100 mm of Mercury, oxygen blood saturation less than 93 percent and random blood sugar greater than 300. b. A skilled nursing visit note, dated 1/18/22, included documentation the nurse reported shortness of breath with minimal exertion, and reports from the patient of increased shortness of breath lately. The nurse noted edema (fluid retention) in bilateral lower extremities. The visit note lacked documentation the nurse had assessed the patient's temperature, pulse, respirations, blood oxygen saturation level and blood pressure. The visit note lacked documentation the nurse assessed the patient's blood sugar or reviewed any blood sugar readings taken by the patient. c. A skilled nursing visit note, dated 2/1/22, lacked documentation the nurse assessed the patient's blood pressure. The nurse failed to assess vital signs per the patient's POC in order to determine if the patient had any abnormal findings to report the patient's physician. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on clinical record review, personnel file review and staff interview, the agency failed to ensure 6 of 11 sampled home health aides (Staff E, Staff F, Staff G, Staff H, Staff I, and Staff J), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 5 sampled patients (Patient #1) 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 79 patients at the time of the survey and employed 17 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 agency 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. During an interview on 2/9/22 at 10:21 A.M. with the Administrator, she reported the agency practice is to have the aides perform extra skills up front at the time the aide starts employment with the agency and the aides are not assigned tasks outside these skills that competency was completed. The Administrator reported tubigrip (elasticated multi-purpose tubular bandage requires no pins or tape) competency is part of the compression hose (snug-fitting, stretchy socks that gently squeeze your leg) competency although the agency did not have this in writing. Patient #1 had a start of care date of 7/12/21. Clinical record review revealed: a. An aide care plan, dated 12/20/21, included Registered Nurse instructions to the aide to complete the extra skills task of tubigrip application. b. Staff E, Home Health Aide, independently provided home health aide services to the patient. Staff E had a hire date of 12/16/21. Staff E's personnel file lacked documentation of successful completion of competency training for the skill of applying tubigrip. c. Staff F, Home Health Aide, independently provided home health aide services to the patient. Staff F had a hire date of 4/28/21. Staff F's personnel file lacked documentation of successful completion of competency training for the skill of applying tubigrip. d. Staff G, Home Health Aide, independently provided home health aide services to the patient. Staff G had a hire date of 8/7/20. Staff G's personnel file lacked documentation of successful completion of competency training for the skill of applying tubigrip. e. Staff H, Home Health Aide, independently provided home health aide services to the patient. Staff H had a hire date of 1/18/22. Staff H's personnel file lacked documentation of successful completion of competency training for the skill of applying tubigrip. f. Staff I, Home Health Aide, independently provided home health aide services to the patient. Staff I had a hire date of 6/15/15. Staff I's personnel file lacked documentation of successful completion of competency training for the skill of applying tubigrip. g. Staff J, Home Health Aide, independently provided home health aide services to the patient. Staff J had a hire date of 5/25/21. Staff J's personnel file lacked documentation of successful completion of competency training for the skill of applying tubigrip. Agency staff provided no further information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse to agency home health aides for 1 of 5 sampled patients receiving home health aide services (Patient #1). The agency reported 79 patients received home health aide services at the time of the survey. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: Review of the agency's undated policy, titled Home Health Aide, revealed the registered nurse supervisor provides written instructions for the home health to follow. Patient #1 had a start of care date of 7/12/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 11/9/21 to 1/7/22 and 1/8/22 to 3/8/22, included physician orders for skilled nursing and home health aide services. The POC, dated 11/9/21 to 1/7/22, included RN instructions to the home health aide to assist with personal cares, compression hose or ACE wraps, daily weights, blood pressures and other cares. The POC, dated 1/8/22 to 3/8/22, included orders for the home health aide to assist with personal cares and medications, assist with non-sterile dressing change on the left shin every Friday and if dressing gets wet, saturated or falls off, cleanse wound with wound cleanser, pat dry with gauze, apply skin prep around wound, apply foam dressing with adhesive border, apply Medihoney or Bactroban to left shin wound per patient preference. b. The home health aide assignment, dated 11/15/21, included RN instructions to the home health aide to apply Diclofenac gel to painful joints per patient request and complete wound care to the right shin wound by assisting with a non-sterile dressing, cover right shin wound with gauze and secure with tape. c. A skilled nursing visit note, dated 11/22/21, included documentation the nurse assessed the patient's right shin was healed, but the patient had a wound on the left shin. d. Skilled nursing visit notes, dated 12/7, 12/14, 12/21 and 12/28/21, 1/4, 1/11, 1/18, 1/25 and 2/1/22, included documentation which identified the nurses provided treatment to a left shin wound. e. The clinical record lacked documentation of a nursing signed updated home health aide care assignment until 12/20/21. The home health aide assignment included the following additional RN instructions to the aide: 1) apply Diclofenac gel to painful joints per patient request; 2) assist with non-sterile dressing to right shin wound every Friday and if dressing gets wet/saturated or falls off, cleanse with wound cleanser, pat dry with gauze, skin prep around wound, foam dressing with adhesive border over wound, nurse will change dressing on Tuesdays and home health on Fridays; 3) assist with medication if dressing needs changed, Bactroban ointment to right shin wound under foam dressing per patient request, not with Medihoney; 4) assist with ointment/barrier if dressing needs changed, Medihoney to right shin wound under foam dressing per patient request, not with Bactroban; 5) compression hose - Tubigrip stockings to both lower legs/feet to knee; 6) Ace wrap application to both lower legs/feet to knee if patient refuses Tubigrip stockings. The home health aide assignment included RN instructions to provide wound care to the wrong shin. f. The home health aide daily visit notes, dated 12/9, 12/17, 12/29, 1/7/22, included instructions for wound care to the right shin and documentation the home health aide completed wound care on the right shin. On 2/8/22 at 11:34 AM, during a home visit observation, the surveyor observed the Administrator perform wound care on the patient's left shin. On 2/9/22 at 8:38 AM, during an interview, the Administrator reported you have to manually enter in the home health aide assignment. She confirmed the home health aide assignment should have included wound care instructions to the home health aide for the left shin, not the right shin. The Administrator and Clinical Manager received the above findings and agency staff provided no further information 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 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 1 of 5 sampled patients (Patient #1) receiving home health aide services. 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: Review of the agency's undated policy, titled Home Health Aide, identified the home health aide is to provide care written in the plan of care and provided in writing by the registered nurse (RN). On 2/7/22 at 11:12 AM, during an interview, the Clinical Manager reported if a home health aide was unable to complete an assigned task, the home health aide would document the reason why and notify the patient's primary nurse. Patient #1 had a start of care date of 7/12/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 11/9/21 to 1/7/22 and 1/8/22 to 3/8/22, identified the patient had a diagnosis of heart failure and included physician orders for skilled nursing and home health aide services. The POC, dated 11/9/21 to 1/7/22, included RN instructions to the home health aide to assist with personal cares, compression hose or ACE wraps, daily weights, blood pressures and other cares. The POC instructed the home health aide to notify the RN if the patient's blood pressure was greater than 170/100 or less than 100/60 and if the patient had a 3 pound weight gain in 24 hours or 5 pounds in a week. The POC, dated 1/8/22 to 3/8/22, included orders for the home health aide to assist with personal cares and medications, apply Diclofenac gel to painful joints per patient request, assist with non-sterile dressing change on the left shin every Friday and if dressing gets wet, saturated or falls off, cleanse wound with wound cleanser, pat dry with gauze, apply skin prep around wound, apply foam dressing with adhesive border, apply Medihoney or Bactroban to left shin wound per patient preference. b. The home health aide assignment, dated 11/15/21, included RN instructions for the home health aide to obtain the patient's blood pressure and weight every visit. The assignment included instructions for the home health to notify the RN if the patient's blood pressure was greater than 170/100 or less than 100/60 and if the patient had a 3 pound weight gain in 24 hours or 5 pounds in a week. c. The home health aide visit note, dated 12/9/21, lacked documentation the home health aide obtained a weight and lacked documentation to explain why the home health aide failed to complete the assigned task. d. The home health aide assignment, dated 12/20/21, included RN instructions for the home health aide to obtain a weight and blood pressure every visit. The assignment included instructions for the home health to notify the RN if the patient's blood pressure was greater than 170/100 or less than 100/60 and if the patient had a 3 pound weight gain in 24 hours or 5 pounds in a week. The assignment included written instructions for the home health aide to complete the following wound care: assist with non-sterile dressing to right shin wound every Friday and if dressing gets wet/saturated or falls off, cleanse with wound cleanser, pat dry with gauze, skin prep around wound, foam dressing with adhesive border over wound, nurse will change dressing on Tuesdays and home health on Fridays; assist with medication if dressing needs changed, Bactroban ointment to right shin wound under foam dressing per patient request, not with Medihoney; assist with ointment/barrier if dressing needs changed, Medihoney to right shin wound under foam dressing per patient request, not with Bactroban. e. The home health aide visit note, dated 1/10/22, lacked documentation the home health aide obtained a weight and lacked documentation to explain why the home health aide failed to complete the assigned task. f. The home health aide visit notes, dated 1/14 and 2/4/22 (both Fridays), included documentation the home health aide did not do wound care, as the patient did not need it done. The visit notes lacked documentation of coordination with the RN in regards to not completing the wound care per written instructions and the patient's POC. The home health aide visit notes the weeks of 1/10/22, dated 1/10, 1/11, 1/12, 1/13 and 1/14, and the week of 1/31/22, dated 1/31, 2/1, 2/2, 2/3 and 2/4, lacked documentation the home health aide performed wound care. The home health aide documented on 1/11 and 2/1/22 (both Tuesdays) the nurse was to complete wound care. g. The home health aide visit notes, dated 1/19, 1/20, 1/21, 1/26, 1/27, 1/28 and 2/1/22, lacked documentation the home health obtained the patient's blood pressure and lacked documentation to explain why the home health aide failed to complete the assigned task. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and staff interview, the agency failed to ensure home health aides reported patient concerns to a registered nurse for 1 of 5 sampled patients receiving home health aide services (Patient #1). Failure to ensure that home health aides reported condition changes to a registered nurse (RN) increased the risk of agency staff not meeting the personal care needs of the patients. Findings include: Review of the agency's undated policy, titled Home Health Aide, identified the home health performs tasks per RN written instructions and the patient's POC. The home health aide is required to report changes in the patient's condition to the RN. Patient #1 had a start of care date of 7/12/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 11/9/21 to 1/7/22 and 1/8/22 to 3/8/22, identified the patient had a diagnosis of heart failure and included physician orders for skilled nursing and home health aide services. The POC, dated 11/9/21 to 1/7/22, included RN instructions to the home health aide to assist with personal cares, compression hose or ACE wraps, daily weights, blood pressures and other cares. The POC instructed the home health aide to notify the RN if the patient's blood pressure was greater than 170/100 or less than 100/60 and if the patient had a 3 pound weight gain in 24 hours or 5 pounds in a week. The POC, dated 1/8/22 to 3/8/22, included orders for the home health aide to assist with personal cares and medications. b. The home health aide assignment, dated 11/15/21 and 12/20/21, included RN instructions for the home health aide to obtain the patient's blood pressure and weight every visit. The assignment included instructions for the home health to notify the RN if the patient's blood pressure was greater than 170 (systolic)/100 (diastolic) or less than 100/60 and if the patient had a 3 pound weight gain in 24 hours or 5 pounds in a week. c. A home health aide visit note, dated 12/10/21, included documentation the patient's blood pressure was 86/55. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. d. A home health aide visit note, dated 12/13/21, included documentation the patient's blood pressure was 95/62. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. e. A home health aide visit note, dated 12/17/21, included documentation the patient's blood pressure was 94/67. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. f. A home health aide visit note, dated 12/30/21, included documentation the patient's blood pressure was 90/66. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. g. A home health aide visit note, dated 1/3/22, included documentation the patient's blood pressure was 94/66. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. h. A home health aide visit note, dated 1/7/22, included documentation the patient's blood pressure was 98/56. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. i. A home health aide visit note, dated 1/12/22, included documentation the patient's blood pressure was 94/58. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. j. A home health aide visit note, dated 1/31/22, included documentation the patient's blood pressure was 98/58. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. In the same visit note, the home health aide documented the patient weighed 249.7 pounds. A home health visit note, dated 2/1/22, included documentation the patient weighed 254.3 pounds; a weight gain of 4.6 pounds in 24 hours. The clinical record lacked documentation the home health aide notified the RN of the weight gain. k. A home health aide visit note, dated 2/2/22, included documentation the patient's blood pressure was 98/69. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. l. A home health aide visit note, dated 2/3/22, included documentation the patient weighed 237.2 pounds. A home health visit note, dated 2/4/22, included documentation the patient weighed 243.5 pounds; a weight gain of 6 pounds in 24 hours. The clinical record lacked documentation the home health aide notified the RN of the weight gain. l. A home health aide visit note, dated 2/7/22, included documentation the patient's blood pressure was 98/63. The visit note lacked documentation the home health aide notified the RN of the patient's low blood pressure. On 2/8/22 at 11:34 AM, during a home visit observation with the Administrator, the surveyor observed the patient had an automated blood pressure and weight machine. In an interview, during the same home visit observation, the Administrator reported the blood pressure and weight machine automatically reported the weights and blood pressures to the patient's insurance company. On 2/9/22 at 8:38 AM, during an interview, the Administrator and Clinical Manager, the Administrator reported she thought the patient's automated weight and blood pressure machine had accuracy issues and the battery has been replaced. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.