Every finding on record at Childserve Home Care Inc

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 10/28/24 through 10/30/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 10/28/24 through 10/30/24. 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 8 patients at the time of the survey

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 name, title, date and time of the signature for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #5). 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. 4. Patient #1 had a start of care date of 2/19/24. Clinical record review revealed: a. Plan of Care, dated 10/16/24 to 12/14/24, included orders for skilled nursing services. b. Skilled nurse visit notes, dated 10/17/24, 10/22/24, 10/24/24, and 10/28/24 included electronic signatures with skilled nurse name, date and time but lacked a discipline title. 5. Patient #2 had a start of care date of 3/20/23. Clinical record review revealed: a. Plan of Care, dated 9/10/24 to 11/8/24, included orders for skilled nursing services. b. Skilled nurse visit notes, dated 10/23/24, 10/24/24, and 10/25/24 included electronic signatures with skilled nurse name, date and time but lacked a discipline title. The above findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager. Findings include: According to the agency's policy, titled Care Records, dated 12/14/23, all service documentation must include staff providing service, including first and last name, signature and professional credentials. 1. Patient #3 had a start of care date of 6/5/24. Clinical record review revealed: a. Plan of Care, dated 10/3/24 to 12/1/24, included orders for skilled nursing services. b. Skilled nurse visit notes, dated 10/14/24, 10/15/24, 10/21/24 and 10/22/24, included electronic signatures with skilled nurse name, date and time but lacked a discipline title. 2. Patient #4 had a start of care date of 8/12/24. Clinical record review revealed: a. Plans of Care, dated 8/12/24 to 10/10/24 and 10/11/24 to 12/9/24, included orders for physical therapy services. b. Physical therapy visit notes, dated 9/5/24, 9/24/24 and 10/22/24, included electronic signatures with physical therapist name, date and time but lacked a discipline title. 3. Patient #5 had a start of care date of 5/1/19. Clinical record review revealed: a. Plans of Care, dated 8/22/24 to 10/20/24 and 10/21/24 to 12/19/24, included orders for skilled nursing services. b. Skilled nurse visit notes, dated 10/14/24, 10/16/24, 10/18/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24 and 10/25/24, included electronic signatures with skilled nurse name, date and time but lacked a discipline title.

The recertification survey, conducted 11/29/21 through 12/01/21, found the agency operating in compliance with the Condition of Participation 42 CFR 484.102 Emergency Preparedness.

The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 11/29/21 through 12/01/21. The home health agency was found to be in substantial compliance in relation to CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey found the home health agency operating out of compliance with the following standard level home health regulations:

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to provide services only as ordered by the physician for 1 of 7 sampled patients (Patient #3). The agency reported a current census of 13 patients at the time of the survey. Failure to ensure staff obtain physician orders for provision of services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency's policy, titled Care Assessment and Care Planning, dated 10/28/2020, identified each patient will receive a comprehensive care assessment at the time of admission to identify service needs and care priorities for the development of a plan of care 1. Patient #3 had a start of care date of 7/3/21.. Review of the clinical record revealed the following: A Plans of Care (POC), dated 9/19/21 to 11/17/21 and 11/18/21 to 1/16/22, included a physician order for the skilled nursing services with orders to check g-tube (gastrostomy tube) place with administration of medications and tube feedings. The Physician's order dated 11/6/21 included the order for ofloxacin 0.3 % otic solution (antibiotic) administer 5 drops in affected ear twice daily times 7 days as needed for bloody ear drainage. Notify physician when starting treatment including previous treatment date. Review of the medication administration record (MAR), dated 11/1/21 to 11/7/21 and 11/8/21 to 11/14/21, included the medication ofloxacin administered by nursing staff 2 times a day on 11/6 and 11/7/21 and the morning of 11/8/21. Agency staff documented the medication not available to administer the evening of 11/8/21 and the morning of 11/9/21. The clinical record contained no documentation of administration of the medication for the remaining scheduled 3 days (11/10, 11/11 and 11/12/21) or physician notification of lack of medication. Agency staff failed to administer the patient's medication per the physician's order. The above stated findings were reviewed with the Administrator and Operations Coordinator. The agency provided no additional information prior to the end of the survey.

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 clinical record review, 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 2 of 2 sampled patients with wounds (Patients #5 and #7). The agency provided services to 13 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patient's 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: 2. Patient #7 had a start of care date of 12/28/2020. Clinical record review revealed: a. The POC, dated 12/28/2020 to 2/25/2021, included orders for skilled nursing visits 2 to 3 times a week. The POC included orders to measure the wound on each visit, irrigate wound with saline, pack the wound with wet gauze and apply silver mepliex dressing. b. The initial comprehensive skilled nursing visit note, dated 12/28/2020 included documentation of measure of the wound to the coccyx. The wound measured 1 cm (centimeter) by 0.5 cm with 0.5 cm depth. The note included documentation the wound irrigated, packed and dressing applied. c. The skilled nursing visit note, dated 12/31/2020, included measurements of 0.5 cm by 0.5 cm with depth measure "0". The note included documentation wound irrigated, packed and dressing applied. d. The skilled nursing visit note, dated 1/5/2021, lacked documentation of wound measurements. The nurse documented "unable to measure wound, hardly present and identified very small area of granulation at center of wound. The note included documentation the wound irrigated, packed and dressing applied. The agency staff failed to complete wound measurements every visit. The above stated findings were reviewed with the Administrator and Operations Coordinator. The agency provided no additional information prior to the end of the survey. The policy labeled Childserve Clinical Practice Manual Wound Assessment/Care Pediatric dated 1/5/2021 identified the nurse inspect the wound bed, assess the wound’s size, color, borders, exudate and odor, the type of tissue in the wound’s base, the condition of the surrounding tissue, and the presence of pain. Measure the wound dimensions using width, length and depth. 1. Patient #5 had a start of care date of 08/08/21. Clinical record review revealed: a. The Plan of Care (POC), dated 10/07/21 to 12/05/21, included orders for skilled nursing to monitor and assess integumentary system. b. The skilled nursing visit notes, dated 10/20, 10/21, and 10/27/21 identified a blister on the patient's left foot under the little toe. c. The skilled nursing visit notes, dated 10/20, 10/21, 10/26, 11/27, 11/3, 11/8, 11/10 and 11/15/21 lacked documentation of the wound’s size, color, borders, exudate and odor, the type of tissue in the wound’s base, the condition of the surrounding tissue, the presence of pain and wound measurements. During an interview on 11/30/21 at 3:10 PM Staff B, the clinical manager, identified the nurse would use the wound flowsheet for new wounds. The clinical record lacked documentation of required wound assessment and wound measurements.