Every finding on record at Carroll Area Nursing Services, Inc.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing completed on 11/4/24 through 11/6/24 and the agency was found to be operating out of compliance with the following standard level requirements of the Establishment of Emergency Preparedness.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on agency staff interview, agency policy review and review of emergency preparedness testing documentation, the agency failed to ensure participation in emergency preparedness exercises annually included an after action report. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: According to the agency policy, titled Emergency Preparedness Operating Plan, dated 11/28/23, after each full-scale exercise, tabletop exercise/workshop, mock disaster drill or actual events, the agency will analyze the response, identify areas for improvement and update the emergency preparedness operating plan, if required. Emergency preparedness testing documentation included an actual emergency preparedness exercise, dated 11/30/22, and table top exercise, dated 12/13/23. The agency lacked documentation of an after action report for the exercises. During an interview on 11/6/24 at 9:10 AM, The Administrator stated she could not locate an after action report for the testing. The above findings were reviewed with the Administrator.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification survey from 11/4/24 to 11/6/24. 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 172 patients at the time of the survey, including 39 patients in the parent Carroll office, 20 patient's in the Coon Rapids branch office, 22 patients in the Denison branch office, 81 patients in the Elk Horn branch office and 15 patients in the Manning branch office.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency staff interviews, clinical record review and policy review, the agency failed to complete an accurate drug regimen review within the required time frame as part of the comprehensive assessment at the time of admission, resumption of care, or discharge from agency services in 3 of 13 sampled patients. (Patient # 1, #2 and #11) 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. 3.Patient #2 had a start of care date of 10/16/24 and received services out of the Manning office. The clinical record review revealed: a. The POC, dated 10/16/24 to 12/14/24, included orders for skilled nursing and physical therapy services and medications. b. The start of care comprehensive assessment, completed by Staff E, Registered Nurse (RN), identified potential adverse effects and drug reactions including significant drug interactions between Warfarin (blood thinner) and Allopurinol (uric acid reducer) and Aspirin (anti-inflammatory and blood thinner) and Tylenol (pain reliever, fever reducer). The agency nurse failed to include documentation of communication to the patient's physician regarding the significant drug interactions identified. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse. 2. Patient #1 had a start of care date of 10/25/24 and received services out of the Coon Rapids office. a. The POC, dated 10/25/24 to 10/24/24, included orders for skilled nursing and physical therapy services and medications. b. The comprehensive skilled nurse visit note at admission, dated 10/25/24, revealed a DRR completed that included prescription and over the counter medications the patient took. c. During a home observation visit on 11/5/24 at 2:00 PM with Staff C, Clinical Manager, the surveyor observed the patient had the following medications in the home: milk of magnesia, 2 tablespoons every hour of seep as needed for constipation, lidocaine 4% patch to the left shoulder as needed for pain and glucosamine chondroitin triple strength (supplement for bone health) 2 times a day. d. Interview during the same home visit, the patient and patient's spouse stated the medications had been used "for years". The agency nurse failed to identify the medications milk of magnesia, lidocaine and glucosamine chondroitin during the DRR. According to agency policy titled Medication Profile, dated April 2018, a drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. Interview 11/5/24, at 3:05 PM with Staff Q, Clinical Supervisor, reported the Registered Nurse, (RN) completed the drug regimen review at all assessment time points including admission, resumption of care and discharge. After completion, the RN contacted the physicians with any discrepancies noted. 1.Patient #11 had a start of care date of 5/21/24 and received services out of the Carroll office. The clinical record review revealed: a. Start of Care comprehensive assessment, dated 05/21/24, completed by Staff D, RN, included documentation of noncompliance, duplicate drug therapy, potential drug interactions and ineffective drug therapy, but lacked documentation of specific side effects. The RN failed to complete a drug regimen review that included 1 of the 5 required components, significant side effects.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home visit observations, patient interviews, clinical record reviews and policy review, 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 4 of 13 sampled patients (Patients #1, #5, #7 and #10). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #1 had a start of care date of 10/25/24 and received services out of the Coon Rapids office. Clinical record review revealed the following: a. The POC, dated 10/25/24 to 12/23/24, included the following DME and supplies used by the patient: probe covers, grab bars, exam gloves, walker, leg brace, diabetic meter and strips, insulin pen needles and lift chair. b. During a home visit observation on 11/4/24 at 2:00 PM, with Staff C, Clinical Manager, the surveyor identified the following DME in the home: TENS (transcutaneous electrical nerve stimulation) unit. The patient and patient's spouse stated the TENS unity used to the left shoulder as needed for for pain for years. The agency failed to include the TENS unit on the patient's POC. 3. Patient #7 had a start of care date of 2/15/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The POCs, dated 8/13/24 to 10/11/24 and 10/12/24 to 12/10/24, included the following DME and supplies used by the patient: cane, probe covers, grab bars, exam gloves, tub/shower bench and walker. b. The skilled nurse visit note, dated 8/17/24, identified the patient utilized a medication planner. c. The comprehensive skilled nurse visit note at recertification, dated 10/9/24, identified the patient utilized edema wear and a scale for daily weights. The agency failed to include the medication planner, edema wear and scale used by the patient on the POC. 4. Patient #10 had a start of care date of 11/3/23 and received services out of the Elk Horn office. Clinical record review revealed the following: a. The POC, dated 11/3/23 to 1/1/24 and 1/2/24 to 2/15/24, included the following DME and supplies used by the patient: grab bar and tub/shower. b. The skilled nurse note, dated 1/2/24, identified the patient required wound care and identified wound supplies utilized by the patient. The agency failed to include wound supplies used by the patient on the POC. The above findings shared with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse. According to the agency policy titled Care Planning Process, dated April 2018, the patient Plan of Care (POC) will be developed or revised within five working days of initiation of each service or within 5 working days of the reassessment of the patient. The POC includes but is not limited to: All pertinent diagnoses, all patient care orders including verbal orders, measurable outcomes and goals, functional limitations, medications including dose/frequency/route and supplies and equipment required. 1.Patient #5 had a start of care date of 9/27/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The POC, dated 9/27/24 to 11/25/24, included the following durable medical equipment (DME) and supplies used by the patient: Cane, wheelchair, probe covers, elevated toilet seat, bedside commode, dressing supplies, grab bars, chucks pads, incontinence briefs, medication planner, reacher tool, eye glasses, personal cell phone, compression wraps and lymphedema pumps. b. The initial comprehensive assessment, dated 9/27/24, completed by Staff K, Registered Nurse (RN), identified the patient utilizes a glucometer to monitor blood sugars. c. During a home visit observation on 11/5/24 at 1:00 PM, with Staff K, RN, the surveyor identified the following DME in the home: wheelchair cushions (one to sit on and one to rest back on). During an interview at this same visit, Patient #5 stated he had been utilizing the glucometer for several months and the wheelchair cushions for greater than a year. The POC failed to include the DME of glucometer and wheelchair cushions.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on patient and agency staff interview, home observation visit, clinical record review and agency policy review, the agency failed to update the Plan of Care with all new physician orders for 2 of 8 sampled patients with interim orders. (Patients #3 and #9). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to agency policy, titled Care Planning Process, dated April 2018, the patient-specific clinical plan of care includes all patient care orders including verbal orders. 1.Patient #9 had a start of care date of 5/10/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 9/7/24 to 11/5/24, included physician orders for skilled nursing and home health aide services. b. Interim physician order, dated 10/22/24, included order for skilled nursing services 1-2 times per week for 2 weeks. c. Updated plan of care, printed on 11/5/24, failed to include the skilled nursing frequency order, dated 10/22/24. During an interview on 11/6/24 at 10:20 AM with Staff B, Clinical Manager, confirmed the skilled nurse frequency was missing from the updated plan of care printed on 11/5/24 and was unsure why it did not print. Staff B reported she was unable to reprint an updated plan of care since the new certification period started on 11/6/24. The agency failed to include all interim physician orders in an updated plan of care. 2. Patient# 3 had a start of care date of 8/2/24 and received services out of the Coon Rapids office. Clinical record review revealed the Plans of Care, dated 8/2/24 to 9/30/24 and 10/1/24 to 11/29/24, included physician order for midodrine. During a home observation visit on 11/5/24 at 11:00 AM with Staff S, RN (registered nurse), surveyor reviewed medications with Staff S and patient. Patient and Staff S reported the midodrine had been discontinued about 1 month ago. Staff S instructed surveyor the discontinue order was in electronic medical record with multiple orders on one page and was overlooked. During an interview on 11/6/24 at 10:10 AM with Staff T, Quality Assurance Nurse, she reported physician orders are obtained from the office and then entered on the medication profile, she would review clinical record for discontinue midodrine order. The skilled nurse failed to obtain interim physician order for medication discontinued and update the patient medication list and plan of care. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency staff interview, home observation visit, clinical record review and agency policy review, the agency failed to provide services and treatments are administered only as ordered by the physician for 2 of 13 sampled patients (Patient's #3 and #13). Failure to ensure staff obtain physician orders for administration of services and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Clinical/Service Data Collection, dated April 2018, a clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies and will include physician orders and changes to the plan of care. 1. Patient# 3 had a start of care date of 8/2/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 10/1/24 to 11/29/24, included physician order for skilled nurse to perform skin care to bilateral lower extremities 1-2 times per week as follows: cleanse areas with wound cleanser and gauze, pat dry, cover open areas, weeping sites with a foam bordered dressing until resolved. b. Interim physician order, dated 10/7/24, included skilled nurse to apply Coflex TLC Zinc Lite (or similar) two-layer lite compression wraps (20-30 mmHg) to bilateral lower extremities, cover wraps to bilateral lower extremities with Nylon Stocking, wraps to be changed 1-2 times weekly. During a home observation visit on 11/5/24 at 11:00 AM with Staff S, RN (registered nurse), the surveyor observed Staff S cleanse bilateral lower extremities with gauze and wound cleanser and apply Coflex TLC Zinc Lite two-layer lite compression wraps to bilateral lower extremities. During an interview on 11/5/24 during home observation visit with Staff S, RN, Staff S reported she was unsure if there was an order to cleanse bilateral lower extremities as of 10/7/24 when the treatment changed, she continued to cleanse bilateral lower extremities after the initial order for wound care was obtained. Staff S will check clinical record for physician order to cleanse wounds after visit. Skilled nurse failed to follow physician ordered wound care. 2. Patient #13 had a start of care date of 3/3/23, a discharge date of 10/27/23 and received services out of the Carroll office. Clinical record review revealed: a. Plan of Care, dated 8/30/23 to 10/28/23, included physician order to weigh patient every visit. b. Skilled nurse visit notes, dated 9/21/23 and 10/5/23, failed to include a weight for patient or a reason why weight not obtained. c. Discharge comprehensive assessment, dated 10/27/23, failed to include a weight for patient or a reason why weight not obtained. Skilled nurse failed to obtain a patient weight every visit as ordered by physician. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse.

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 agency staff interviews, clinical record review, and agency policy review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 6 sampled patients receiving home health aide services (Patients #9,#10 and #11). Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. 3. Patient #9 had a start of care date of 5/10/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 9/7/24 to 11/5/24, included physician orders for skilled nursing and home health aide services. b. The home health aide care plans, dated 9/7/24 and 10/22/24, directed the aides to report red/open areas to RN-each visit, provide shower-each visit, shampoo-each visit, sponge bath-per RN request, catheter care-each visit, assist with bilateral knee high edema wear-each visit, and ensure catheter securement device in place and resecure if not-each visit. c. The home health aide visit note, dated 9/20/24, failed to document if the task ensure catheter securement device in place and resecure if not-each visit was completed or a reason why the task was not completed. d. The home health aide visit note, dated 10/25/24, failed to document if the tasks report red/open areas to RN-each visit, provide shower-each visit, shampoo-each visit, sponge bath-per RN request and catheter care-each visit were completed or a reason why the tasks were not completed. e. The home health aide visit note, dated 11/1/24, failed to document if the task assist with bilateral knee high edema wear-each visit was completed or a reason why the task was not completed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse. 2. Patient #10 had a start of care date of 11/3/24 and received services out of the Elk Horn office. Clinical record revealed: a. The POCs, dated 11/3/24 to 1/1/24 and 1/2/24 to 2/15/24, included physician orders for skilled nursing and home health aide services. b. The home health aide care plans, dated 11/3/24 and 1/3/24, directed the home health aide to complete a shower every visit and may complete a sponge bath per nurse direction. c. Home Health Aide visit note, dated 12/18/24, failed to include documentation the aide performed the task of shower, and failed to document why the task was not performed. The document also failed to include direction given for the sponge bath by the nurse. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. According to the agency policy, Home Health Aide Plan of Care, dated 4/2018, The home health aide plan of care will be individualized to the specific patient and will include the type of services/procedures to be provided, such as hands on personal care, and Specific procedure to be performed, including amount, frequency, and duration. Interview 11/5/24, at 3:05 PM with Staff Q, Clinical Supervisor, reported if the aide is unable to complete an assigned task, the aide performing the visit will contact the case manager. 1.Patient #11 had a start of care date of 5/21/24 and received services out of the Carroll office. Clinical record review revealed: a. The Plan of Care (POC), dated 5/21/24 to 7/19/24, included direction to the aide to perform a shower every visit. b. Home Health Aide visit notes, dated 5/21/24 and 5/28/24, completed by Staff R, Home Health Aide, failed to include documentation the aide performed the task of shower, and failed to document why the task was not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observations, clinical record reviews, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 4 of 8 sampled patients (Patients #3, #4, #5 and #10) with wounds. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: 4. Patient# 3 had a start of care date of 8/2/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 8/2/24 to 9/30/24, included physician order for skilled nurse to instruct on disease management for hepatic encephalopathy and diabetic management. b. Skilled nurse visit note, dated 9/16/24, included documentation of open wounds assessed to both lower extremities along with areas of dried serosanguineous drainage, right lower extremity has a few scattered fluid filled areas assessed, areas of drainage cleansed from the skin with warm soap and water, pat dried. c. Interim physician order, dated 9/16/24, included skilled nurse to perform skin care to bilateral lower extremities 1-2 times per week as follows: cleanse areas with wound cleanser and gauze, pat dry, cover open areas, weeping sites with a foam bordered dressing until resolved. d. The Plan of Care, dated 10/1/24 to 11/29/24, included physician order for skilled nurse to perform skin care to bilateral lower extremities 1-2 times per week as follows: cleanse areas with wound cleanser and gauze, pat dry, cover open areas, weeping sites with a foam bordered dressing until resolved. e. Interim physician order, dated 10/7/24, included skilled nurse to apply Coflex TLC Zinc Lite (or similar) two-layer lite compression wraps (20-30 mmHg) to bilateral lower extremities, cover wraps to bilateral lower extremities with Nylon Stocking, wraps to be changed 1-2 times weekly. f. Skilled nurse visit note, dated 10/23/24, included documentation bilateral lower extremities much more red and irritated appearing today verses last week. Patient not compliant with amoxicillin for open wounds on legs, physician notified. Areas of diffuse impaired skin integrity assessed at this visit. Multiple areas of dried, serosanguinous scabbed areas assessed throughout lower extremity. Right posterior lower extremity deep red in color with open, pin-point wounds assessed. g. Skilled nurse visit note, dated 10/25/24, included documentation patient’s right lower extremity has multiple open wounds draining small to moderate amounts of serosanguinous drainage. Open wounds assessed throughout right shin and medial lower extremity, wound beds bright red in color. Left lower extremity has some red, open, draining wounds, less then right lower extremity. Left lower extremity has multiple scabbed wounds. The skilled nurse failed to measure open wounds per agency policy. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse 3. Patient #4 had a start of care date of 9/20/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The POC, dated 9/20/24 to 11/18/24, included physician orders for skilled nursing services 1-2 times weekly for assessment and management of patient with chronic venous stasis ulcers on both lower extremities. b. Skilled Nurse visit notes, dated 9/23/24, 9/30/24,10/8/24, 10/10/24,10/14/24,10/22/24, and 10/29/24, revealed the patient had multiple open ulcers on both lower extremities, included multiple photographs of open wounds, but failed to include measurements of the open areas. Skilled nurse failed to document wound measurements for the opened areas on both of the patients lower legs. 2. Patient #10 had a start of care date of 11/3/24 and received services out of the Elk Horn office. Clinical record review revealed the following: a. The POCs, dated 11/3/23 to 1/1/24 and 1/2/24 to 2/15/24, included physician orders for skilled nursing services 1-2 times weekly for assessment of patient with cellulitis of groin, cellulitis of abdominal wall localized adiposity, very low level of personal hygiene, other reduced mobility and pressure ulcer of unspecified part of back, stage 2. b. Skilled Nurse visit notes, dated 12/26/23, 1/2, 1/10, 1/17, 1/30/24 and 2/5/24, revealed the patient had a wound on the right mid flank, open stage 2 with a small amount serosanguineous drainage. The documents failed to include measurements of the open areas. Skilled nurse failed to document wound measurements for the opened areas on the patient's According to the agency policy titled Wound Monitoring Guidelines, dated 4/11/24, all wounds or areas of impaired skin integrity will be assessed with each visit until healed unless care is planned otherwise. The nurse creates a wound on the wound worksheet for any of the following: any open wound, any scabbed or necrosis caused by trauma or surgery, any pressure ulcer and any surgical incision until attachment devices are out and there is no longer any inflammation. Wounds are to be measured (length by width by depth in centimeters) weekly. 1.Patient #5 had a start of care date of 9/27/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/27/24 to 11/25/24, included physician orders for skilled nursing services 1-2 times weekly for observation, assessment and education for wound management related to diabetic and vascular ulcers. b. Skilled Nurse visit notes, dated 10/1/24, 10/4/24, 10/11/24, 10/18/24, 10/22/24, 11/1/24 and 11/5/24 revealed pictures to the left distal lower leg and identified wound care was completed per orders on the POC. c. During a home visit observation on 11/5/24 at 1:00 PM with Staff K, Registered Nurse (RN), Staff K provided wound care and identified Patient #5 had newly opened areas to the left lower leg. During an interview at this same visit, Staff K stated we don't measure diffused open areas as they change frequently. We take photographs but don't measure each open area. Skilled nurse failed to document wound measurements for the existing and newly opened areas on the patient's left distal lower leg.

The recertification survey, conducted from 2/7/2022 through 2/9/2022, found the agency operating in substantial compliance with the requirements of the Appendix Z Establishment of Emergency Preparedness. The agency reported a current total census of 251 patients, including 65 patients receiving services from the parent office in Carroll; 111 patients receiving services from the Elk Horn branch office; 34 patients receiving services from the Manning branch office; 26 patients receiving services from the Coon Rapids branch office; and 15 patients receiving services from the Denison branch office.

The recertification survey, conducted 2/7/2022 through 2/9/2022, found the agency operating out of compliance with the following standard level deficiencies:

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to assess each patients medications for duplication, side effects, ineffectiveness, actual or potential interactions and non-compliance within the required time frames, identifying medication discrepancies, as part of the initial comprehensive assessment at admission and as part of the updates to the comprehensive assessment at the time of recertification, resumption of care and discharge for 11 of 13 sampled patients (Patients #1, #2, #4, #5, #6, #7, #8, #9, #11, #12 and #13). The survey found the deficient practice occurring at the parent office and the Coon Rapids, Elk Horn, Denison and Manning branch offices. Failure to identify actual/ potential issues at the time of each comprehensive assessment increased the potential for unidentified medication interactions and side effect risks to the patient. Findings Include: 4. Patient #4 had a start of care date of 5/20/19 and received services from the Carroll parent office. Clinical record review revealed: a. The Plans of Care dated 9/6/21 to 11/4/21 and 11/5/21 to 1/3/22, included orders for several medications including Aripiprazole and Fluoxetine (both medications used to treat depression). b. The update to the comprehensive assessment at the time of recertification, dated 11/2/21, included a drug regimen review, that included all of the components, however identified duplicate drug therapy as multiple cardiovascular medication therapies. The review lacked identifying the duplicate medications used to treat depression. c. The clinical lacked completion of the Medication Profile form that was also to be completed at the time of the comprehensive assessment. 5. Patient #5 had a start of care date of 6/19/21 and received services from the Carroll parent office. Clinical record review revealed: a. The Plans of Care dated 8/20/21 to 10/18/21, 10/19/21 to 12/17/21 and 12/18/2to 2/15/21, included orders for several medications including Calmoseptine and Nystatin (both topical ointments/creams) Milk of Magnesia and Glycolax (both bowel medications) and Aspirin and Warfarin (both blood thinners). b. The updates to the comprehensive assessment at the time of recertification, dated 8/6/21, 10/15/21, and 12/15/21, included a drug regimen review, that included all of the components, however identified no duplicate drug therapy. The review lacked identifying the duplicate medications used as topical creams/ointments, bowel medications and blood thinners. c. The clinical record lacked completion of the Medication Profile form that was also to be completed at the time of the comprehensive assessments. 6. Patient #7 had a start of care date of 1/7/22 and received services from the Elk Horn branch office. Clinical record review revealed: a. The Plan of Care dated 1/7/22 to 3/7/22, included orders for several medications including Lantus insulin, Glipizide, and Metformin (all used for diabetes). b. The initial comprehensive assessment at the time of start of care, dated 1/7/22, included a drug regimen review, that included assessment of drug interactions only. The review lacked assessment of potential adverse effects and reactions, ineffective drug therapy, significant side effects, duplicate drug therapy and compliance with drug therapy. c. The clinical record lacked completion of the Medication Profile form that was also to be completed at the time of the comprehensive assessment. 7. Patient #8 had a start of care date of 5/25/17 and received services from the Elk Horn branch office. Clinical record review revealed: a. The Plans of Care dated 9/10/21 to 10/30/21, 10/31/21 to 12/29/21 and 12/30/21 to2/27/22, included orders for several medications including Colace and Dulcolax (both bowel medications) and Alogliptin and Pioglitazone (both used to treat diabetes). b. The updates to the comprehensive assessment at the time of recertification, dated 8/29/21, 10/28/21, and 12/28/21, included a drug regimen review, that included all of the components, however lacked identification of the duplicate bowel and diabetes medications. c. The clinical record lacked completion of the Medication Profile form that was also to be completed at the time of the comprehensive assessment on 12/28/21. According to the agency policy, titled Medication Profile and dated 4/2018, the nurse will perform a drug regimen review at the time of admission and with updates to the comprehensive assessments and with each new medication to identify drug/food allergies, potential adverse effects and reactions, ineffective drug therapy, duplicative drug therapy and patient non-compliance with medications. According to the agency policy, titled Initial and Comprehensive Assessment and dated 4/2018, each initial comprehensive assessment will include a review of prescription, over-the-counter medications and herbal medications for allergies, significant drug interactions, duplicative drug therapy, potential adverse effects and drug reactions ineffective drug therapy, unusual or unexpected effects, significant side effects, patient non-compliance with medication regimen, lab monitoring needs and changes in patient condition indicating medication contraindication. According to the agency policy, titled Reassessment and Recertification and dated 4/2018, each reassessment will include a review of all medications for drug interactions, potential adverse effects/reactions, duplicative drug therapy, ineffective drug therapy, significant side effects and significant drug interactions. During staff interview on 2/7/2022 at 10:02 AM, the Clinical Manager reported each registered nurse (RN) must complete a drug regimen review at start of care, resumption of care, recertification and discharge. The nurses update the medication profile and assess the medications for duplication, ineffectiveness, side effects, contraindications and non-compliance. The drug regimen review is documented on a "medication reconciliation snapshot form" and then document the results of the medication assessment in the narrative section of the skilled nurse/comprehensive assessment note. 1. Patient #1 had a start of care date of 8/30/2021 and received skilled nursing services from the Coon Rapids branch office. Clinical record review revealed the following: a. The Plans of Care, dated 8/30/2021 to 10/28/2021 and 10/29/2021 to 12/27/2021, documented the patient took Milk of Magnesia and Miralax, both laxatives used to treat constipation. The initial comprehensive assessment taken at the time of admission, dated 8/30/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the two laxatives as duplicate drug therapy. The update to the comprehensive assessment at the time of recertification, dated 10/25/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the two laxatives as duplicate drug therapy. b. The update to the comprehensive assessment at the time of recertification, dated 12/23/2022, lacked documentation of an assessment of the patient's medications for duplication, ineffectiveness, significant side effects, actual or potential medication interactions and non-compliance with the medications as physician directed. The electronic clinical record lacked documentation of the "medication reconciliation snapshot form". During staff interview on 2/8/2022 at 11:30 AM, Staff C, RN/Quality Improvement Director, reported she was unable to find documentation of the drug regimen review within the 12/23/2021 comprehensive assessment and found no "medication reconciliation snapshot form" when reviewing Patient #1's electronic clinical record. 2. Patient #11 had a start of care date of 11/29/2020, previously received skilled nursing and home health aide services from the Elk Horn branch office and was transferred to inpatient care without return on 5/25/2021. Clinical record review revealed the following: a. The Plans of Care, dated 1/28/2021 to 3/28/2021 and 3/29/2021 to 5/25/2021, documented the patient took magnesium hydroxide (Milk of Magnesia), Miralax (polyethylene glycol with docusate sodium) and docusate sodium for constipation, all three laxatives/stool softeners used to treat constipation. The updates to the comprehensive assessment at the time of recertification, dated 1/27/2021 and 3/25/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the three medications used to treat constipation as duplicate drug therapy or identify the duplication of docusate sodium in two medications taken by the patient. 3. Patient #13 had a start of care date of 4/7/2021, previously received skilled nursing, therapy and home health aide services from the Denison branch office, and was discharged on 9/29/2021. Clinical record review included the following: The Plans of Care, dated 4/7/2021 to 6/5/2021, 6/6/2021 to 8/4/2021 and 8/5/2021 to 10/3/2021, documented the patient took Senna and Miralax, both laxatives taken to treat constipation. The initial comprehensive assessment taken at the time of admission, dated 4/7/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the two laxatives as duplicate drug therapy. The update to the comprehensive assessment at the time of recertification, dated 8/3/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the two laxatives as duplicate drug therapy. The update to the comprehensive assessment at the time of recertification, dated 9/29/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the two laxatives as duplicate drug therapy. 8. Patient #2 had a start of care date of 10/29/21, and received skilled nursing and physical therapy services from the Manning branch office. Clinical record review revealed the following: a. The Plans of Care, dated 10/25/21 to 12/27/21 and 12/28/21 to 2/25/21, documented the patient took tramadol, Tylenol and gabapentin used to treat pain. The updates to the comprehensive assessment at the time of recertification, dated 12/27/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the three medications used to treat pain as duplicate drug therapy. 9. Patient #6 had a start of care date of 4/10/21, and received skilled nursing and home care aide services from the Dennison branch office. Clinical record review revealed the following: a. The Plans of Care, dated 12/6/21 to 2/3/22 and 2/4/22 to 4/4/22, documented the patient took used to treat pain and miralax, stool softener and milk of magnesia for constipation. The updates to the comprehensive assessment at the time of recertification, dated 2/3/2021, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the three medications used to treat constipation as duplicate drug therapy. 10. Patient #9 had a start of care date of 1/5/22, and received skilled nursing, occupational therapy, home care aide and physical therapy services from the Manning branch office. Clinical record review revealed the following: a. The Plans of Care, dated 1/5/22 to 3/5/22, documented the patient took pulmicort flexhaler and ipratropium-albuterol inhalation used to treat respiratory symptoms. The comprehensive assessment at the start of care, dated 1/5/22, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the two medications used to treat respiratory symptoms as duplicate drug therapy. 11. Patient #12 had a start of care date of 4/22/21 and discharge date of 9/30/21, and received skilled nursing and home health services from the Elk Horn branch office. Clinical record review revealed the following: a. The Plans of Care, dated 6/21/21 to 8/19/21 and 8/20/21 to 10/18/21, documented the patient took tramadol and Tylenol used to treat pain. The updates to the comprehensive assessment at the time of recertification, dated 8/16/21, included documentation of the drug regimen review in the narrative section. The narrative failed to identify the two medications used to treat pain as duplicate drug therapy. The surveyors reviewed the above findings for Patients #1, #2, #4, #5, #6, #7, #8, #9, #11, #12 and #13 with the Administrator, Quality Improvement Director, Staff M, Registered Nurse and Clinical Manager. Agency staff 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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation, patient interview and 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 to meet individualized needs, specific treatments and patient-specific interventions/education for 10 of 13 sampled patients (Patients #1, #2, #4, #5, #7, #8, #9, #11, #12 and #14). The survey identified the deficient practice occurring at the parent office in Carroll and the Coon Rapids, Manning and Elk Horn branch offices. 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: 8. Patient #2 had a start of care date of 10/29/21 and received services from the Manning branch office. Review of the clinical record revealed the following: The POC, dated 10/29/21 to 12/27/21 and 12/28/21 to 2/25/22, identified the patient used the following medical equipment and supplies: wound care dressings, medication lanner, walker, elevated toilet seat, grab bars, exam gloves, tub/shower bench, a shower bench, shoe horn, medication bubble packs, lift chair, ramp, prosthetic leg, saline solution and peritoneal dialysis supplies. On 2/822 at 8:30 AM, during a home visit observation with Staff E, Registered nurse (RN), the surveyor observed the patient utilized a cane. Interview with the patient during the home visit revealed the patient had utilized the cane since the start of home health services. The POC failed to identify the patient used a cane. 9. Patient #9 had a start of care date of 1/5/22 and received services from the Manning branch office. Review of the clinical record revealed the following: The POC, dated 1/5/22 to 3/5/22, identified the patient used the following medical equipment and supplies: probe covers, nebulizer, diabetic supplies, grab bars, exam gloves, tub/shower chair, bench, walker, sharps container and medication planner. The occupational therapy visit note, dated 1/7/22, identified the patient utilized a toilet safety frame and bed rails. The POC failed to identify the patient used a toilet safety frame and bed rails. 10. Patient #12 had a start of care date of 4/22/21 and discharge date of 9/30/21 and received services from the Elk Horn branch office. Review of the clinical record revealed the following: The POC, dated 6/21/21 to 8/19/21 and 8/20/21 to 10/18/21, identified the patient used the following medical equipment and supplies: ace wrap, gauze, dressing supplies, diabetic supplies, grab bars, exam gloves, tub/shower bench, walker, kerlix, medication planner, shower wand, glucometer and hearing aides. The skilled nurse visit note, dated 8/16/21, identified the patient utilized a surgical shoe and incontinent supplies. The POC failed to identify the patient used a surgical shoe and incontinent supplies. The surveyors reviewed the above findings for Patients #1, #2, #4, #5, #7, #8, #9, #11, #12 and #14 with the Administrator, Quality Improvement Director, Staff M and Clinical Manager. Agency staff provided no further information prior to the end of the survey. 4. Patient #5 had a start of care date of 4/22/21 and received services from the Carroll parent office. Clinical record review revealed the following: a. The Plans of Care, dated 8/20/21 to 10/18/21,10/19/21 to 1217/21,and 12/18/21 to 2/15/22, identified the following medical equipment and supplies used by the patient: cane, tape, elevated toilet seat, dressing supplies, grab bars, exam gloves, tub/shower bench, walker, personal cell phone, assisted living alert device, and incentive spirometer. During home visit observation on 2/9/22 at 8:05 AM, with Staff H, RN, the surveyor observed the patient's lift chair had a pressure relieving cushion on it. The patient was unable to recall how long has had the pressure relieving cushion. Staff H, RN, revealed the patient has had the cushion since the RN started caring for the patient in July. The patient then stated has had the cushion for about a year. b. The Plans of Care lacked identification of the pressure relieving cushion as equipment used to meet the patients needs. During the same home visit observation on 2/9/22 at 8:05 AM, with Staff H, RN, the surveyor observed the patient's bathroom and a hand held shower. The patient revealed moved to the assisted living facility last March and has used the hand held shower with the home health aide's assistance ever since. c. The Plans of Care lacked identification of the hand held shower as equipment used to meet the patients needs. During the same home visit observation on 2/9/22 at 8:05 AM, with Staff H, RN, the surveyor observed a sock aide device on a lower shelf of the patient's bedside stand in the patient's bedroom. The patient revealed use of the sock aide since breaking a hip, "a long time ago". 5. Patient #4 had a start of care date of 5/20/19 and received services from the Carroll parent office. Clinical record review revealed the following: The Plans of Care, dated 9/6/21 to 11/4/21, 11/5/21 to 1/3/22, and 1/4/22 to 3/4/22 identified medical equipment and supplies used by the patient including a Life Line alert device. During home visit observation on 2/8/22 at 8:28 AM, with Staff D, Registered Nurse (RN), the surveyor reviewed the medical equipment and supplies used by the patient. The patient revealed does not have a Life Line alert device and has never had. The Plan of Care incorrectly identified a Life Line alert as equipment used by the patient. 6. Patient #7 had a start of care date of 1/7/22 and received services from the Elk Horn branch office. Clinical record review revealed the following: The Plan of Care, dated 1/7/22 to 3/7/22 identified the following medical equipment and supplies used by the patient: cane, wheelchair, diabetic supplies, exam gloves, walker, walk in tub/shower, cell phone, glucometer, lift chair, hover round, med planner, reacher, and grabber. a. Licensed practical nursing visit notes dated 1/10/22, documented the nurse assisted the patient in applying edema. b. Licensed practical nursing visit notes dated 1/27/22, documented edema is stable and compression stockings are in place. Interview on 2/9/22 at 11:59 AM with Staff L, Licensed Practical Nurse (LPN), revealed the nurse put on compression stockings that are non prescription. c. The Plan of Care lacked identification of compression socks as equipment used to meet the patient's needs. 7. Patient #8 had a start of care date of 5/25/17 and received services from the Elk Horn branch office. Clinical record review revealed the following: The Plan of Care, dated 19/1/21 to 10/30/21, 10/31/21 to 12/29/21 and 12/30/21 to 2/27/22 , included orders for the nurse or caregiver to irrigate the indwelling foley catheter with sterile water as needed if the catheter was not draining properly. The Plans of Care lacked identification of the amount of sterile water to be used to irrigate the foley catheter. The Plans of Care, dated 9/1/21 to 10/30/21, 10/31/21 to 12/29/21 and 12/30/21 to 2/27/22, identified the following medical equipment and supplies used by the patient: cane, wheelchair, diabetic supplies, sterile gloves, bedside commode, insertion kit, foley cath, exam gloves, tub/shower bench, drainage bag, chux/underpads, alcohol pads, hospital bed, glucometer, lancets, and med planner. b. The Aide Care Plan for the period of 10/3/21 to 12/29/21 and 12/30/21 to 2/27/22, included the task for the aide to apply ted hose stockings to bilateral lower extremities monthly with foot soaks the last Thursday of the month and per patient request. Interview on 2/9/22 at 10:28 AM with Staff M, RN, revealed the patient wears ted hose. c. The Plan of Care lacked identification of Ted hose as equipment used to meet the patient's needs. According to the agency policy, titled Care Planning Process and dated 4/2018, Each individualized patient-specific plan of care will include patient specific medications/treatments, patient specific interventions and education and supplies/equipment required by the patient based on the assessment and conclusions of the clinician. The Plan of Care will be based upon the physician's orders and will encompass the equipment, supplies and services required to meet the patients' needs. 1. Patient #1 had a start of care date of 8/30/2021 and received skilled nursing services from the parent office. Clinical record review, home visit observation and associated interviews revealed the following: a. The Plans of Care, dated 8/30/2021 to 10/28/2021, 10/29/2021 to 12/27/2021 and 12/28/2022 to 2/25/2022, included physician orders for skilled nursing visits for wound care, patient education and general assessment of the patient's body systems associated with the diagnoses of Stage 3 pressure ulcer on the heel, chronic right heart failure, chronic diastolic congestive heart failure, pulmonary hypertension, chronic kidney disease and a history of falls. The Plans included an intervention for the nurses to educate the patient to weigh daily as part of a self-monitoring program using the same hard, flat surface floor each morning before breakfast and after urination and the skilled nurse would review the weight logs during each home visit. The Plans also included identification of the patient's use of a walker, hospital bed, a scale, life line emergency response system, dressing change supplies and Tubigrip Size F compression stockings. b. During observation on 2/8/2022 at 12:30 PM while accompanying Staff E, Registered Nurse (RN) to the patient's home, the surveyor observed Patient #1 sitting in a lift recliner. The surveyor noted a heating pad plugged into the electrical socket on the wall next to the recliner and resting over the recliner arm. The surveyor also observed a quad cane and walker positioned next to the recliner. During patient interview while in the home, Patient #1 reported using the heating pad "all the time" for relief of back pain resulting from a fall with resulting back fracture in the past . The patient reported using the walker for safety with ambulation and was "learning to use" quad cane when others were in the home. "I use the walker when I am alone or on days when I am a little off." The surveyor observed the patient use the remote on the lift recliner to move the chair up and back whenever getting in and out of the chair for ambulation to the bedroom for wound care by the nurse and into the kitchen when the nurse weighed the patient. The above stated Plans of Care did not include the lift recliner, the heating pad or the quad cane as equipment used by the patient to meet his/her needs. c. During the same home visit, the surveyor observed the patient had an elevated toilet seat and wore incontinence briefs. During interview while in the home, the patient reported using the briefs for urinary incontinence but used the toilet for bowel movements. "I don't have much control over my bowels since I broke my back so I know when gotta go I have to move now to get there." The above stated Plans did not include the elevated toilet seat or the incontinence briefs as equipment or supplies used by the patient to meet his/her toileting needs. d. During the home visit, the patient requested a visiting family member bring the scale from another room to the kitchen where the patient reported routinely being weighed. The patient used the walker to go to the kitchen and centered the walker over the scale once placed on the floor by the family member. The RN turned the scale on and the patient stepped on the scale. The patient then returned to sit in the lift recliner. The surveyor requested to look at the weight logs kept by the patient as part of the self-monitoring program of daily weights. The patient denied monitoring his/her own weights. During staff interview while in the home, Staff E, RN, reported the patient did not keep logs of self weights. The RN reported the nurse assesses the weight during each home visit and documents the weight in the clinical note. During staff interview on 2/8/2022 at 2:30 PM, Staff G, RN, reported she had been Patient #1's past case manager and still makes occasional visits to provide care to the patient. Staff G, RN, reported the patient does not check own weights. The nurses monitor the weight in the patient's home during visits and document in the vital sign section of the visit note. The RN reported there are no weight logs kept by the patient so the nurse cannot review the weight logs as directed in the Plans of Care. The Plans as stated above did not accurately reflect how the patient's weight was being monitored. The patient did not weigh daily and maintain logs of the weights. The patient experienced an inability to move the scale from room to room while using the walker and the patient had a history of falls in the past, with one resulting in major injury of a fracture. The nurses did not have the capability of monitoring logs kept by the patient as indicated in the Plans. (See G710 for associated information). 2. Patient #11 had a start of care date of 11/29/2020, previously received skilled nursing and home health aide visits from the Elk Horn branch office and was transferred to inpatient care with no return to services on 5/25/2021. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission, dated 11/29/2020, and the updates to the comprehensive assessment at the time of recertification, dated 1/27/2021 and 3/25/2021, documented the patient used a nebulizer for the administration of the inhalant medication Budesonide; used a CPAP (Continuous Positive Airway Pressure) machine at night for sleep apnea; performed self-catheterization with a 14 Fr straight urinary catheter 6-8 times daily. b. The home health aide care plans, dated 11/29/2020 to 1/27/2021, 1/28/2021 to 3/2/2021 and 3/29/2021 to 5/25/2021, documented the patient used grab bars in the bathroom; used a tub bench to shower; and used an elevated toilet seat. c. The Plans of Care, dated 11/29/2020 to 1/27/2021, 1/28/2021 to 3/28/2021 and 3/29/2021 to 5/25/2021, did not include the nebulizer (portable machine to administer inhalant medications), grab bars, elevated toilet seat or tub bench as equipment used by the patient to meet his/her needs. The Plans as dated above also documented the patient's self-catheterization but failed to include the size of the urinary catheter or the frequency of self-catheterization. 3. Patient #14 had a start of care date of 3/16/2021 and received home health aide services with provision of skilled services from the Coon Rapids branch. Clinical record review and associated staff interviews revealed the following: a. The update to the comprehensive assessment at the time of recertification, dated 9/8/2021, documented the patient was incontinent of urine. The assessment also indicated the patient was awaiting the delivery of a hospital bed. b. The updates to the comprehensive assessment at the time of recertification, dated 11/5/2021 and 1/7/2022, continued to document the patient's incontinence and did not address the hospital bed as being delivered or used by the patient. c. The home health aide care plans, dated 9/12/2021 to 11/10/2021, 11/11/2021 to 1/9/2022 and 1/10/2022 to 3/10/2022, included documentation of the patient's use of the hospital bed. During staff interview on 2/8/2022 at 3:07 PM, Staff F, Home Health Aide, reported she routinely provides home health aide services to Patient #14. Staff F, Home Health Aide, reported the patient does have a hospital bed and has had for many months and did use a large incontinence brief and opens to lay on the seat of the wheelchair to catch incontinent urine. d. The Plans of Care, dated 9/12/2021 to 11/10/2021, 11/11/2021 to 1/9/2022 and 1/10/2022 to 3/10/2022, did not include the patient's use of incontinence products for urination or the use of a hospital bed.

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 and agency staff interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 2 of 2 sampled patients experiencing a change in condition requiring physician notification (Patients #1 and #7). The survey identified the deficient practice occurring at the Coon Rapids and Elk Horn branch offices. 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: 2. Patient #7 had a start of care date of 1/7/22 and received skilled nursing services from the Elk Horn branch office. Clinical record review revealed the following: The Plan of Care, dated 1/7/22 to3/7/22, documented the patient's diagnoses included type 2 diabetes, hypertensive chronic kidney disease with stage 4 chronic kidney disease. The same Plan directed the skilled nurse to perform observation and assessment of diabetic and cardiovascular management a. The licensed practical nurse visit notes, dated 1/10/2022, documented the patient's blood pressure as 142/98 with +2 pitting edema in the left lower extremity and +3 pitting edema in the right lower extremity. The note documented the licensed practical nurse conferenced with the Registered Nurse. b. The licensed practical nurse visit notes, dated 1/24/2022, documented the patient's blood pressure as 142/98 with +2 pitting edema in bilateral lower extremities. The note documented the licensed practical nurse conferenced with the Registered Nurse (RN). The nurse did not document identification of the elevated blood pressures or document contact with the physician to report any concern with the elevated blood pressures. Interview with Staff M, RN revealed physician notification of a weight gain on 2/4/22 and send all prior blood pressure readings to the physician at that time as well. The RN revealed timely notification of the elevated blood pressures did not occur. The surveyors reviewed the above findings with agency Administrator, Clinical Manager, and Quality Improvement Director. Agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Physician Participation in Plan of Care and dated 4/2018, the physician will direct the care of every home health patient admitted for service. Orders will be reviewed and revised by the physician with change in care or service provided; patient response to care; and any patient outcome related to treatment or services. According to the agency policy, titled Care Planning Process and dated 4/2018, clinicians will inform patient physicians of any changes that suggest a need to alter the plan of care. Changes will be written, dated and signed by the professional making the changes. According to the agency policy, titled Care/Service Coordination and dated 4/2018, timely and ongoing communication is the responsibility of every team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient and relevant to the care/services provided. 1. Patient #1 had a start of care date of 8/30/2021 and received skilled nursing services from the Coon Rapids branch office. Clinical record review revealed the following: The Plan of Care, dated 12/28/2021 to 2/25/2022, documented the patient's diagnoses included chronic right heart failure, chronic diastolic congestive heart failure and chronic kidney disease. The same Plan directed the skilled nurse to instruct the patient on daily weight monitoring and the skilled nurse would review the weight logs every visit. The skilled nurse visit note, dated 1/14/2022, documented the patient's weight as 130 pounds. The skilled nurse visit note, dated 1/19/2022 (5 days later), documented the patient's weight as 135 pounds, a five pound weight gain in 5 days. Fast weight gain often indicates early congestive heart failure. The nurse did not document identification of the weight gain or document contact with the physician to report any concern with the 5 pound weight gain.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and home visit observation, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 1 of 5 sampled patients (Patient #2) with home visits. The survey identified the deficient practice occurring at the Manning branch office. Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. According to the agency policy titled Standard precautions, dated April 2018, gloves are to be changed after removing an old dressing. According to the agency policy titled Bag Technique, when the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed and equipment and supplies will be returned to the bag. Patient #2 had a start of care date of 10/29/21. The surveyor accompanied Staff E, Registered Nurse (RN), to a home visit on 2/8/22 at 8:30 AM. During the home visit the RN washed her hands at the sink and completed the assessment including temperature, pulse oximeter and blood pressure and documented on the computer tablet. She donned gloves and removed the patient's dressing from the wound on the right side of the patient's abdomen. She then cleaned the wound with a gauze pad and normal saline without changing her gloves. Staff E sanitized the equipment with Lysol wipes and returned them to her bag. She returned the computer tablet to the bag without sanitizing the tablet. Staff E failed to change her gloves after removing the soiled dressing and failed to sanitize the tablet. The above findings were reviewed with the Administrator, Quality Improvement Director, Staff M, Registered Nurse and Clinical Manager. 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 perform ongoing interdisciplinary assessments of the patient for 1 of 6 sampled patients with alteration of skin integrity (Patient #7). The agency reported providing wound care to 35 patients at the time of the survey. The survey identified the deficient practice occurring at the Elk Horn branch office. Failure to ensure staff obtain physician orders for administration of treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Wound Monitoring Guidelines, dated 12/17/21, all wounds are to be photographed on admit, ROC, Recert, and as there are significant changes. All wounds or areas or impaired skin integriry will be assessed with each visit until healed unless care is planned otherwise. The wound should be created on the wound worksheet and measured weekly on the 1st visit of the week for any of the following wounds: any open wound, any scab or necrosis caused by trauma or surgery, any pressure ulcer, and any surgical incision. Measurements will include length (head to toe), width (side to side), and depth if open record depth of 0.1 or greater. On 2/7/2022 at 9:30 AM, interview with the Administrator revealed that wound measurements are documented within the first visit of the week and include length, width, and depth. Patient #7 had a start of care date of 1/7/22 and received services from the Elk Horn branch office. The Plan of Care, dated 1/7/22 to 3/7/22, included orders for skilled nursing services 1-2 times per week and ordered the nurse to perform wound care 1-2 times per week to the patient's left great toe until healed. Clinical record revealed: a. The initial comprehensive assessment, completed at start of care, dated 1/7/22, documented the patient's skin was pink and within normal limits and dry, but had a left foot small toe wound from earlier in the week that was not healed. b. The skilled nursing visit note, dated 1/14/22, included documentation the patient had multiple areas on the toes from running into cabinets with patient's scooter with no symptoms of infection. The nurse was going to have the wound care ostomy nurse (WOCN) evaluate and recommend ongoing treatment. The visit note lacked documentation of measurement of the open areas to toes, knees, and legs. c. The skilled nursing visit note, dated 1/18/22, included documentation the WOCN made the visit and the patient's toes had been banged and injured from the patient running the scooter into cabinets. The nurse assessment identified the following wounds and measurements: Left upper knee burn with length of 3 centimeters (cm), width of 2.2 cm and a depth of 0.2 cm, left lower knee traumatic wound with a length of 7 cm, width of 5 cm and no depth, right knee traumatic wound measured length of 2.5 cm, width of 5.0 cm and no depth. d. The skilled nursing visit note, dated 2/3/22, included documentation all wounds almost healed with no drainage and the nurse performed wound cares. The visit note lacked documentation of wound measurements. The visit was the first and only visit of the week. The clinical record lacked documentation of weekly wound measurements completed by agency staff, the weeks of 1/9/22 and 2/3/22. Interview on 2/9/22 at 10:15 AM with Staff M, Registered Nurse (RN), revealed the patient is always bumping into things and getting new sores and agency staff was not measuring those sores. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Improvement Director. 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, surveyor observation, patient interview and agency staff interview, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 4 of 11 sampled patients (Patients #1, #9, #11 and #12). The survey identified the deficient practice occurring at the Coon Rapids, Manning and Elk Horn branch offices. 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: 3. Patient #9 had a start of care date of 1/5/22 and received services out of the Manning branch office. Clinical record review revealed: a. The POC, dated 1/5/22 to 3/5/22, included orders for skilled nursing services to instruct patient on daily weight self-monitoring program where the patient utilizes the same scales on a hard, flat surface each morning prior to breakfast and after urination. b. The skilled nursing visit notes, dated 1/13, 1/17, and 2/1/22, revealed no documentation of the patient's daily weight measurements. The nurse failed to follow the physician order for instructing on patient daily weights. 4. Patient #12 had a start of care date of 4/22/21 and a discharge date of 9/30/21 and received services from the Elk Horn branch office. Clinical record review revealed: a. The POC, dated 8/20/21 to 9/30/21, included orders for skilled nursing services to assess the patient's blood sugars weekly. b The skilled nurse note for the week of 8/29/22 to 9/4/22, dated 8/30/29, revealed no documentation of blood sugar assessment. The skilled nurse failed to assess the patient's blood sugars. The surveyors reviewed the above findings for Patients #1, #9, #11 and #12 with the Administrator, Quality Improvement Director, Staff M, Registered Nurse and Clinical Manager. Agency staff provided no further information prior to the end of the survey. 1. Patient #1 had a start of care date of 8/30/2021 and received skilled nursing services from the parent office. Clinical record review and associated interviews revealed the following: a. The Plans of Care, dated 8/30/2021 to 10/28/2021, 10/29/2021 to 12/27/2021 and 12/28/2022 to 2/25/2022, included physician orders for skilled nursing visits for wound care, patient education and general assessment of the patient's body systems associated with the diagnoses of Stage 3 pressure ulcer on the heel, chronic right heart failure, chronic diastolic congestive heart failure, pulmonary hypertension, chronic kidney disease and a history of falls. The Plans included an intervention for the nurses to educate the patient to weigh daily as part of a self-monitoring program using the same hard, flat surface floor each morning before breakfast and after urination and the skilled nurse would review the weight logs during each home visit. b. During observation on 2/8/2022 at 12:30 PM while accompanying Staff E, Registered Nurse (RN) to the patient's home, the patient requested a visiting family member bring the scale from another room to the kitchen where the patient reported routinely being weighed. The surveyor observed the patient used the walker to go to the kitchen and centered the walker over the scale once placed on the floor by the family member. The RN turned the scale on and the patient stepped on the scale. The patient then returned to sit in the lift recliner. The surveyor requested to look at the weight logs kept by the patient as part of the self-monitoring program of daily weights. During interview while in the home, the patient denied monitoring his/her own weights. During staff interview while in the home, Staff E, RN, reported the patient did not keep logs of self weights. The RN reported the nurse assesses the weight during each home visit and documents the weight in the clinical note. During staff interview on 2/8/2022 at 2:30 PM, Staff G, RN, reported she had been Patient #1's past case manager and still makes occasional visits to provide care to the patient. Staff G, RN, reported the patient does not check own weights. The nurses monitor the weight in the patient's home during visits and document in the vital sign section of the visit note. The RN reported there are no weight logs kept by the patient so the nurse cannot review the weight logs as directed in the Plans of Care. c. The skilled nurse visit notes, dated 12/6,8,15,20,23,29/2021; 1/5,7,10,12,14,19,25/2022 and 2/1/2022, all documented the nurse reviewed the weight logs in the patient's home, determining the weights were stable. The Plans as stated above did not accurately reflect how the patient's weight was being monitored. The nurses were documenting following physician direction on the Plan of Care; however, the patient did not weigh daily and maintain logs of the weights. The nurses did not review weight logs from a self-monitoring weight program each visit as ordered by the physician on the Plan of Care. 2. Patient #11 had a start of care date of 11/29/2020, previously received skilled nurse and home health aide services from the Elk Horn branch office and was transferred to an inpatient facility with no return on 5/25/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/29/2021 to 5/25/2021, documented Patient #14's diagnoses included diabetes and hypertensive heart disease with heart failure and directed the skilled nurse to visit the patient 1-2 times weekly. The Plan included an intervention for the nurse to monitor the patient's weight each visit, reporting a gain of 3 pounds in 24 hours or a gain of 5 pounds in 1 week to the physician. The Plan also included an intervention to assess diabetic management each visit. b. The skilled nurse visit note, dated 4/8/2021, lacked documentation of the nurse's assessment of the patient's diabetic management or blood sugar readings. c. The skilled nurse visit note, dated 4/29/2021, lacked documentation of the nurse's assessment of the patient's diabetic management or blood sugar readings. The note also lacked documentation indicating the nurse weighed the patient and no weight reading was documented.

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 agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 4 of 8 sampled patients receiving home health aide services (Patients #6 #7, #11 and #12). The survey identified the deficient practice occurring at the Denison and Elk Horn branch offices. 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: 3. Patient #6 had a start of care date of 4/10/21 and received services out of the Denison branch office. Clinical record review revealed the following: The POC, dated 12/6/21 to 2/3/2, included physician orders for home health aide visits 1 to 2 times a week. The Plans identified the diagnoses of Parkinson's disease and schizoaffective disorder. a. The skilled nurse comprehensive assessment, dated 12/29/21, identified the patient alert and oriented with forgetfulness. b. The home health aide assignment for the period of 12/6/21 through 2/3/22, directed the following: shower every visit, assist to dress per patient request, comb hair per patient request, shampoo hair per patient request, incontinent care per patient request, oral hygiene denture care per patient request, sponge bath per patient request and shave per patient request. c. The nurse directed the aide to perform the task "as requested". Patient #6 identified with forgetfulness and would have been unable to request the task completion due to the decreased mental capacity. The nurse failed to provide aide assignment individualized to the patient's needs. 4. Patient #12 had a start of care date of 4/22/21 and discharge date of 9/30/21 and received services out of the Elk Horn branch office. Clinical record review revealed the following: The POC's, dated 6/21/21 to 8/19/21 and 8/20/21 to 10/18/21, included physician orders for home health aide visits 1 to 2 times a week. The Plans identified the diagnoses of Parkinson's disease and schizoaffective disorder and identified the patient oriented and forgetful with impaired decision making. a. The skilled nurse comprehensive assessment, dated 12/29/21, identified the patient alert and oriented with forgetfulness. b. The home health aide assignment for the period of 6/21/21 through 8/19/21 and 8/20/21 to 10/18/21, directed the following: shower every visit, check pressure areas each visit, partial bath per patient request, shampoo per patient request and shave per patient request. c. The nurse directed the aide to perform the task "as requested". Patient #12 identified with forgetfulness and impaired decision making would have been unable to request the task completion due to the decreased mental capacity. The nurse failed to provide aide assignment individualized to the patient's needs. The surveyors reviewed the above findings for Patients #6, #7, #11 and #12 with the Administrator, Quality Improvement Director, Staff M, Registered Nurse and Clinical Manager. Agency staff provided no further information prior to the end of the survey. 2. Patient #7 had a start of date of 1/7/2022, received skilled nursing and home health aide services from the Elk Horn branch office. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission, dated 1/7/22, documented the patient had demential and anxiety; was oriented to person and place, was forgetful, had impaired decision making, poor recall of recent events, was repetitive with conversation, required assistance and some direction in specific situations (for example, involving shifting of attention) or requires low stimulus environment due to distractibility, memory deficit:failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required, and impaired decision making: failure to perform usual ADL's or IADLs, inability to appropriately stop activities, jeopardizes safety through actions. b. The home health aide care plan, dated 1/7/22 to 3/7/22, directed the home health aide to perform walk in tub, report reddened and open areas and foot care every visit. The same care plans directed the aide to perform shampoo and shaving "per patient request"; thereby requiring the patient to request assistance with the grooming tasks. The care plan did not direct the aide to assist the patient with undressing and dressing despite the identification of the patient's need in this area at the time of the comprehensive assessments as stated above. According to the agency policy, titled Home Health Aide Plan of Care and dated 4/2018, the home health aide plan of care will be individualized to the specific patient and will include types of services/procedures to be provided and specific tasks to be performed including frequency of completion. The home health aide plan of care will be revised with each recertification based on the professional reassessment of the patient and at any time the patient's change in condition warrants revision. 1. Patient #11 had a start of date of 11/29/2020, previously received skilled nursing and home health aide services from the Elk Horn branch office and transferred to an inpatient facility with no return on 5/25/2021. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission, dated 11/29/2020, documented Patient #11 experienced mental health issues resulting in non-compliance with therapeutic health regime; difficulty remember past and recent events; required considerable assistance in routine situation; is not alert and oriented or unable to shift attention and recall direction at least half of the time; experienced memory deficit and impaired decision making abilities; failed to perform usual activity of daily living; required assistance of another person to dress, bathe, assist with toilet hygiene, groom and transfer from one surface to another. b. The updates to the comprehensive assessment at the time of recertification, dated 1/27/2021 and 3/25/2021, documented Patient #11 experienced a decline in mental, emotional or behavioral status in the previous 3 months; experienced a history of non-compliance with medical instructions; experienced forgetfulness; had poor coping skills and impaired decision making; and continued to require assistance of another person to dress, bathe, assist with toilet hygiene, groom and transfer from one surface to another. c. The home health aide care plan, dated 11/29/2020 to 1/27/2021 and 1/28/2021 to 3/2/2021, directed the home health aide to shower the patient every visit. The same care plans directed the aide to perform oral hygiene, shampoo and shaving "per patient request"; thereby requiring the patient to request assistance with the grooming tasks. The care plan did not direct the aide to assist the patient with undressing and dressing despite the identification of the patient's need in this area at the time of the comprehensive assessments as stated above. The care plan was updated on 2/11/2021, adding assistance with dressing every visit and apply over-the-counter lotion to intact skin "per patient request". The update continued to direct the aide to perform the task only if requested by the patient. d. The clinical record lacked a home health aide care plan for the time period of 3/3/2021 through 3/24/2021. The home health aide visit notes, dated 3/4,8, 11,16,18, 22, 25/2021, documented the home health aides continued to provide care to the patient as directed in the 2/11/2021 update. e. The home health aide care plan, dated 3/29/2021 to 5/25/2021, directed the home health aide to shower the patient and assist with dressing every visit. The same care plans directed the aide to perform oral hygiene, shampoo, shaving, and application of over-the-counter lotion to intact skin "per patient request"; thereby requiring the patient to request assistance with the grooming tasks. f. The transfer summaries, dated 1/21/2021, 2/18/2021 and 5/25/2021, documented hospitalization for observation were required due to the patient forgetting to take evening dose of medications- then combining the evening medications with the morning medications resulting in accidental overdose of the medications. Patient #11 experienced poor coping skills, mental health issues resulting in non-compliance, poor decision making skills, forgetfulness and poor recall. The patient was hospitalized 3 times while being cared for by the agency for accidental overdose of medications re: to forgetting to take the medications and doubling up on the pills. The RN determined the patient required assistance with all of the grooming tasks identified as "per patient request" on the aide care plans. The aide care plans were not individualized to Patient #11's needs.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure clinician's completed routine visit notes in a timely manner according to the agency policy and administrative expectations for 6 of 14 sampled patients (Patients #1, #5, #6, #7 #8 and #12). The survey identified the deficient practice occurring at the parent office in Carroll and the Coon Rapids, Denison and Elk Horn branch offices. Failure of the agency to ensure the clinical record included current documentation placed agency patients at risk to receive care or not receive care meeting the needs of the patient. Findings include: 4. Patient #8 had a start of care date of 5/25/2017 and received services from the Elk Horn branch office. The Plans of Care, dated 10/31/21 to 12/29/21 and 12/30/21 to 2/27/22, included orders for skilled nursing services and home care aide services. Clinical record review revealed: a. A skilled nursing visit note, included documentation the visit occurred on 12/6/21, with an electronic signature indicating completion on 12/12/21, 4 days late according to agency expectation. b. A skilled nursing visit note, included documentation the visit occurred on 12/9/21, with an electronic signature indicating completion on 12/12/21, 1 day late according to agency expectation. c. A skilled nursing visit note, included documentation the visit occurred on 12/12/21, with an electronic signature indicating completion on 12/15/21, 1 day late according to agency expectation. d. A skilled nursing visit note, included documentation the visit occurred on 12/18/21, with an electronic signature indicating completion on 12/21/21, 1 day late according to agency expectation. e. A skilled nursing visit note, included documentation the visit occurred on 12/30/21, with an electronic signature indicating completion on 1/2/22, 1 day late according to agency expectation. f. A skilled nursing visit note, included documentation the visit occurred on 1/5/22, with an electronic signature indicating completion on 1/10/22, 3 days late according to agency expectation. g. A skilled nursing visit note, included documentation the visit occurred on 1/11/22, with an electronic signature indicating completion on 1/14/22, 1 day late according to agency expectation. 5. Patient #7 had a start of care date of 1/7/2022 and received services from the Elk Horn branch office. The Plan of Care, dated 1/7/22 to 3/7/22, included orders for skilled nursing services and home care aide services. Clinical record review revealed: a. The Aide Care Plan, dated 1/13/22 for the time period of 1/7/22 to 3/7/22, included the aide assignment to remind the patient to check blood sugar each visit and report to the nurse if less than 80 and greater than 300. b. The home health aide visit notes, dated 1/11/22, 1/21/22, 1/28/22, 2/1/22, 2/4/22, documented the aide reminded the patient to check blood sugar, however, lacked documentation of the patient's blood sugar. On 2/9/22 at 2:05 PM interview with Staff M, Registered Nurse (RN), revealed the nurse aide documents the blood sugars at the end of the visit note. Surveyor informed the RN the surveyor only found documentation once on aide notes. The RN brought the surveyor a copy of glucose monitoring log left in the home with the documentation of the blood sugars. The aide lacked documentation of the blood sugar readings in the patient's clinical record. c. The skilled nursing visit note, included documentation the visit occurred on 1/20/22, with an electronic signature indicating completion on 1/30/22, 8 days late according to agency expectation. 6. Patient #5 had a start of care date of 4/22/2021 and received services from the Carroll parent office. The Plan of Care, dated 12/19/21 to 2/15/22, included orders for skilled nursing services and home care aide services. Clinical record review revealed a skilled nursing visit note, included documentation the visit occurred on 1/7/22, with an electronic signature indicating completion on 1/17/22, 8 days late according to agency expectation. The agency failed to follow agency policy of filing all documentation within 48 hours of occurrence. The surveyors reviewed the above findings with the Administrator, Clinical Manager, and Quality Improvement Director. Agency staff provided no further information prior to the end of the survey. 2. Patient #6 had a start of care date of 4/10/21 and received services from the Denison branch office. The POC, dated 12/6/21 to 2/3/21, included orders for skilled nursing and home care aide services. Clinical record review revealed: A skilled nursing visit note, included documentation the visit occurred on 1/5/22, with an electronic signature indicating completion on 1/10/22, 3 days late according to agency expectation. The agency failed to follow agency policy of filing all documentation within 48 hours of occurrence. 3. Patient #12 had a start of care date of 4/22/21 and discharge date of 9/30/21 and received services from the Elk Horn branch office. The POC, dated 8/20/21 to 10/3/21, included orders for skilled nursing and home care aide services. Clinical record review revealed: a. A skilled nursing visit note, included documentation the visit occurred on 9/10/21, with an electronic signature indicating completion on 9/17/21, 5 days late according to agency expectation. b. A skilled nursing visit note, included documentation the visit occurred on 9/13/21, with an electronic signature indicating completion of 9/17/21, 2 days late according to agency expectation. The agency failed to follow agency policy of filing all documentation within 48 hours of occurrence. According to the agency policy, titled Clinical/Service Data Collection and dated 4/2018, entries into the clinical/service record must be made on the day care/service is provided to the patient and completed/submitted no later than the end of the business day following the work day for that employee. Home health aide will only make entries on the aid visit form and the case conference form. During staff interview on 2/7/2022 at 9:30 AM, the Administrator reported skilled nursing routine visit notes, therapy routine visit notes and home health aide visit notes must all be completed within 48 hours after the visit. 1. Patient #1 had a start of care date of 8/30/2021 and received skilled nursing services from the Coon Rapids branch office. Clinical record review revealed the following: a. The skilled nurse visit note, dated 12/15/2021, was electronically signed as complete on 12/22/2021, 7 days after the date of the visit. b. The skilled nurse visit note, dated 12/20/2021, was electronically signed as complete on 12/28/2021, 8 days after the date of the visit. c. The skilled nurse visit note, dated 12/29/2021, was electronically signed as complete on 1/11/2022, 13 days after the date of the visit. d. The skilled nurse visit note, dated 1/14/2022, was electronically signed as complete on 1/31/2022, 17 days after the date of the visit. The nurses did not complete documentation of routine skilled visit notes according to the agency's policy or Administrator's reported expectation.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure authentication of electronic entries made in each patient's clinical record included the employee's signature, title, date and time of the signature for 2 of 4 sampled patients with therapy services (Patients #2 and #9). The survey identified the deficient practice occurring at the Manning branch office. Failure to maintain timely, accurate and appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. According to the agency's policy, titled Clinical/Service Data Collection, dated April, 2018, the clinical/service note will include: what care/service was provided, treatment and/or invasive procedures performed, patient response to treatment and/or procedures, the date the service was provided (month, day, year) and signature of clinician and his/her credentials. During an interview on 2/9/22 at 10:50 AM, the Quality Improvement Director concurred the physical therapy staff signature failed to include a title. 1. Patient #2 had a start of care date of 10/29/21 and received services from the Manning branch office. The patient received skilled nurse and physical therapy services from the agency. The patient's clinical record included the following: The physical therapy visit notes, dated 1/10 and 1/13/22 and 2/4/22, included the physical therapist signature, date and time title but lacked the staff's title. 2. Patient #9 had a start of care date of 1/5/22 and received sevices from the Manning brach office. The patient received skilled nurse, occupational therapy, home care aide and physical therapy services from the agency. The patient's clinical record included the following: The physical therapy visit notes, dated 1/10, 1/12, 1/17, 1/19/22 and 2/3/22, included the physical therapist signature, date and time title but lacked the staff's title. The above findings were reviewed with the Administrator, Quality Improvement Director, Staff M, Registered Nurse and Clinical Manager. Agency staff provided no further information prior to the end of the survey.