Every finding on record at Community Health Services

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 4/1/24 through 4/3/24 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 4/1/24 through 4/3/24. 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 49 patients at the time of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, and staff interview, the agency failed to complete a drug regimen review with each comprehensive assessment and identify patient specific medication issues for 2 of 7 sampled patients (Patients #1 and #2). Failure to complete a drug regimen review with each comprehensive assessment placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency's policy titled Medication Profile, dated 11/9/23, all patients will have a current, accurate medication profile in their clinical record. The medication profile will be updated for each patient to reflect current medications, and new or discontinued medications. The drug regimen review (DRR) includes a review of all medications the patient is currently taking. A DRR will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication. During an interview on 4/3/24 at 10:55 AM, the Administrator reported DRRs are completed with the comprehensive assessments at start of care, resumption of care, recertification, discharge, and when new medication is added. The nurse facilitating the visit completes the DRR. 1.Patient #1 had a start of care (SOC) date of 1/8/2024 and received services from the agency. Clinical record review and patient interview revealed the following: a. The Plans of Care (POC) dated 1/8/24 to 3/7/24 and 3/8/24 to 5/8/24 included orders for Melatonin 3 milligram (MG) oral tablet to be taken at bedtime as needed for sleep. b. The medication profile report dated 4/1/24 identified Melatonin 3mg oral tablet to be taken as needed for sleep as a active medication for the patient. c. The recertification comprehensive assessment visit note, dated 3/4/24, included documentation a DRR had been completed. During a home visit observation on 4/1/24 at 1:00 PM with Staff C, Registered Nurse (RN), an interview with the patient revealed the patient has not taken the melatonin in months and does not have it at the residence. The DRR failed to include an accurate list of prescribed and over the counter medications for the patient. 2. Patient #2 had a SOC date of 6/7/2022 and received services from the agency. Clinical record review and patient interview revealed the following: a. The Plan of Care (POC) dated 3/28/24 to 5/26/24 included orders for Brimonidine 0.2% solution ophthalmic (eye) drops with instructions to put 1 drop in the right eye three times daily for glaucoma. b. The recertification comprehensive assessment visit note, dated 3/26/24, included documentation a DRR had been completed. During a home visit observation on 4/2/24 at 8:15 AM with Staff C, Registered Nurse (RN), an interview with the patient revealed the patient was also utilizing Dorzolamide 22.3mg-Timolol 6.8mg/millimeters 22.3-6.8% solution with instructions to put 1 drop in both eyes two times a day and Latanoprost .005% solution with instructions to put 1 drop in right eye at bedtime. Patient reported she had been taking these for a long time. The DRR failed to include an accurate list of prescribed and over the counter medications for the patient. The above findings were reviewed with the Administrator and Clinical Manager. The agency did not provide any 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 observation, clinical record, agency policy and patient interview, the agency failed to include all Durable Medical Equipment (DME) and treatments in Plans of Care for 4 of 7 sampled patients (Patients #1, #3, #4, and #6). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. 2. Patient #1 had a start of care date of 1/8/24 and received services from the agency. The POC, dated 3/8/24 to 5/8/24, included the following DME: stool riser, cardiac monitor, cane, CPAP, B/P Cuff, shower chair, scale, nebulizer, med box, lift chair, grabber-reacher and grab bars. During an observation home visit on 4/1/24 at 1:00 PM with Staff C, RN, the surveyor observed an oxygen concentrator and portable oxygen in the patient's home. During the same home visit, the patient stated he/she started using the oxygen about a month ago and he uses it as needed. The POC failed to include the DME oxygen and supplies. 3. Patient #4 had a start of care date of 3/14/24 and received services from the agency. Review of the clinical record revealed the following: a. The POC, dated 3/14/24 to 5/12/24, included the following DME used by the patient: walker, cane, med planner, oxygen and supplies, grab bars, hand held shower, and incontinent supplies. b. The initial and comprehensive assessment, dated 3/14/24 identified the patient had a wound to the left ankle that required weekly wound care by the nurse. c. The physical therapy note, dated 3/15/24 identified the patient was walking with a walking boot. The POC failed to identify the DME wound supplies and walking boot. 4. Patient #6 had a start of care date of 2/20/21 and received services from the agency. Review of the clinical record revealed the following: The POC, dated 2/10/23 to 4/10/23, included the following DME: hand held shower, grab bars-toilet, grab bars-shower/tub, diabetic supplies, automatic med planner, wheelchair, shower chair, scale, pill cutter, med box, lift chair, and lifeline. The nurse visit note, dated 3/6/23, identified the patient was using an ace wrap to her right knee for support. The POC failed to identify the DME ace wrap. The above information was provided to the Administrator and Clinical Manager. The agency did not provide any additional information prior to the end of the survey. According to the agency policy, titled Home Health Plan of Care, dated 11/10/23, the clinical plan of care incudes: medications, treatments, supplies and equipment required. 1. Patient #3 had a start of care date of 10/14/21 and received services from the agency. The plan of care (POC), dated 2/1/24 to 3/31/24, included the following DME: long handle shoehorn, cane, CPAP, bath bench, B/P cuff, walker, nebulizer, lifeline, incontinent supplies, grab bars-shower/tub, glucose monitor and supplies, diabetic supplies. During an observation home visit on 4/2/24 at 1:00 PM with Staff D, Registered Nurse (RN) the surveyor observed the patient utilized a cushion in his/her recliner and a reacher. During the same home visit the patient stated he/she used the equipment for 10 to 13 years. The POC failed to include the DME chair cushion and reacher utilized by the patient.

The recertification survey, conducted 4/12/2021 through 4/14/2021, found the agency operating in substantial compliance with the regulatory requirements of the Establishment of Emergency Preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 4/12/21 through 4/14/21 . The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey, conducted 4/12/2021 through 4/14/2021, found the agency operating out of compliance with the following standard level regulatory requirements.

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 and patient 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 and accurate medication orders for 5 of 7 sampled patients (Patients #2, #3, #4, #5 and #6). The agency reported a current census of 45 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy, titled Home Health Plan of Care and dated 11/24/2020, the individualized plan of care must include the following: all pertinent diagnoses, the patient's mental, psychosocial and cognitive status, the types of services, supplies and equipment required, the frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, all medications and treatments used by the patient, safety measures to protect against injury, a description of the patient's risk for emergency hospitalization and hospital readmission, discharge planning, patient-specific interventions and education and measurable outcomes and goals and information related to advance directives. 1. Patient #2 had a start of care date of 11/18/2020. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The initial comprehensive assessment at the time of admission to home health services, dated 11/18/2021, documented Patient #2 utilized a glucometer (portable hand held machine used to test sugar in a blood sample) to monitor blood sugars. b. On 4/14/2021 at 1:30 PM, the surveyor accompanied Staff E, Registered Nurse (RN), to Patient #2's home. During the home visit the surveyor noted the patient had a glucometer. c. During patient interview while in the patient's home, Patient #2 reported monitoring his/her blood sugars routinely since admission to the agency. d. The Plans of Care, dated 11/18/2020 to 1/16/2021 and 1/17/2021 to 3/17/2021, lacked inclusion of a glucometer as equipment used to meet the needs of Patient #2. 2. Patient #4 had a start of care date of 3/6/2020. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission to home health services, dated 3/6/2020, documented Patient #4 utilized an elevated toilet seat to assist with transfers on and off the toilet for elimination and had a walk in tub for bathing to increase safety with transfers in and out of the tub. b. The update to the comprehensive assessment at the time of recertification, dated 2/25/2021, documented the patient's continued use of the walk in tub and the elevated toilet seat. d. The Plans of Care, dated 12/31/2020 to 2/28/2021 and 3/1/2021 to 4/29/2021, lacked inclusion of a walk in tub or an elevated toilet seat as equipment used to meet the needs of Patient #4. 3. Patient #5 had a start of care date of 2/27/2021. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission to home health services, dated 2/27/2021, documented Patient #5 utilized bed rails on the bed for safety. b. The Occupational Therapy Evaluation, dated 3/4/2021, documented Patient #5's use of a long handled sponge for bathing, a sock aide to assist with independent application of compression stockings and shoe horns used to assist with independent application of the patient's shoes. c. The Plan of Care, dated 2/27/2021 to 4/27/2021, lacked inclusion of a long handled sponge, sock aide or shoe horns used by Patient #5 to meet his/her needs. 4. Patient #6 had a start of care date of 10/25/2020 and a discharge date of 11/20/2020. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission to home health services, dated 10/25/2020, documented Patient #6 a brace/orthotic and required the use of a gait belt (a belt worn around the patient's waist and held onto by another person during ambulation to prevent falls) for safety when ambulating. b. The skilled nurse visit note, dated 11/10/2020, documented the patient's continued use of the gait belt for safety with ambulation. c. The skilled nurse visit note, dated 11/13/2020, documented the patient climbed over the bed rails used to prevent unaccompanied ambulation and falls, resulting in a fall with laceration to the forehead. d. The Plan of Care, dated 10/25/2020 to 12/23/2020, lacked inclusion of a gait belt or bed rails as equipment used to meet Patient #6's needs. 5. Patient #3 had a start of care date of 7/8/2020. Clinical record review, surveyor observation and patient interview revealed the following: a. On 4/14/21 at 11:30 AM, during a home visit observation with the patient, Staff N, Registered Nurse (RN), the surveyor observed staff complete the medication set up. Medication set up included Staff N fill the medication box with omeprazole 40 mg, 1 capsule 2 times a day. Observation of the prescription bottle identified the order for 1 capsule 2 times a day. b. During an interview at the same home visit observation, the patient reported he/she had always taken 1 capsules of omeprazole 2 times a day. The patient also reported he/she had not used the lidocaine patch for a long time due to difficulty applying the patch. c. The POC, dated 3/5/21 to 5/3/21, included orders for omeprazole, 40 milligrams (mg) capsule, delayed release, 1 capsule every morning for stomach pain and lidoderm 5% topical adhesive patch, 1 patch every morning for pain. The POC failed to include current and accurate medication orders. The above stated findings for Patients #2, #3, #4, #5 and #6 were reviewed with the agency Administrator and Staff A, Electronic Medical Record Manager. The agency provided no additional 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 agency policy review, clinical record review and agency staff interview, the agency skilled professionals failed to follow the physician ordered Plan of Care for 4 of 7 sampled patients receiving a skilled service (Patients #1, #2, #3 and #4). The agency reported a current census of 45 patients, including 34 who received skilled services. Failure to ensure that skilled professionals provided care only as ordered by the physician increased the risk that patients' health care needs would not be adequately met in a safe manner. Findings include: According to the agency's undated policy, titled Home Health Plan of Care and dated 11/24/2020, each patient's Plan of Care will be based on based on the patient's diagnosis and assessment of needs and resources. The Plan of Care will be approved by the primary care provider and reviewed at least every 60 days or more often if needed. Care will follow the primary care provider's orders. Clinician's will inform the patient's primary care provider of any changes that suggest a need to alter the Plan of Care and such changes will be put into writing and signed/dated by the professional making the change. According to the agency's undated policy, titled Standard Reporting Parameters, the skilled professionals should report any blood sugar levels below 60 and above 200 to the patient's physician if the physician does not give patient specific reporting parameters to the agency. On 4/12/2021 at 11:50 AM, the Clinical Manager reported all documentation with the physician would be documented either in the visit note, in the communication notes or sent to the physician by facsimile. 1. Patient #1 had a start of care date of 10/12/2020. Clinical record review revealed the following: The Plans of Care, dated 12/11/2020 to 2/8/2021 and 2/9/2021 to 4/9/2021, documented Patient #1's primary home health diagnosis was Type 1 diabetes with secondary diagnoses of hypertensive heart disease and chronic kidney disease with heart failure. The Plans of Care directed the skilled nurse to visit the patient once weekly to instruct/reinforce blood sugar testing and assess blood glucose record and report a pattern of blood sugars outside of established parameters. a. The update to the comprehensive assessment at the time of recertification, dated 2/7/2021, documented the patient's blood sugar ranges since the last home visit fell between 40 and 190. The note indicated communication occurred with the physician and were documented in a clinical note. The clinical record lacked any such clinical note reporting the low blood sugars falling outside of the agency established parameters. b. The skilled nurse visit notes, dated 2/15/2021, 3/2/2021 and 4/6/2021, lacked documentation of monitoring of the patient's blood glucose level during the visit and lacked documentation of review of the patient's blood glucose records to determine a pattern outside of the established parameters. c. The skilled nurse visit notes, dated 3/9/2021, 3/15/2021 and 3/22/2021, documented the nurse assessed the patient's blood sugar while in the home; however, the note lacked documentation of the nurse's review of the patient's blood glucose records to determine a pattern outside of the established parameters. d. The skilled nurse note, dated 3/29/2021, stated "patient reporting having low (blood) sugars at night and needs to snack". The note lacked documentation indicating the nurse monitored the patient's blood sugar during the visit or reviewed the patient's blood glucose records to determine a pattern outside of the established parameters. Surveyor observation revealed the following: e. On 4/13/2021 at 10:00 AM, the surveyor accompanied Staff D, Registered Nurse (RN) to the patient's home. During the visit, the surveyor requested to review the patient's blood sugar reports. The surveyor noted during the time period of 3/15/2021 and 4/13/2021 the patient had 15 "low glucose events". The patient's clinical record lacked documentation indicating the RN was aware of the 15 events and lacked documentation of physician notification of the pattern outside of the agency established parameters. Clinical record review and patient interview revealed the following: The Plans of Care as dated above also directed the skilled nurse to visit the patient once weekly to assess the patient's cardiovascular system each visit. f. The skilled nursing visit note, dated 3/2/2021, documented the patient's weight as 222 pounds. g. The skilled nursing visit notes, dated 3/9/2021 and 3/15/2021, lacked documentation of the RN's assessment of the patient's weight. h. The skilled nursing visit note, dated 3/22/2021, documented one of the patient's physician's discontinued Lasix, a diuretic, from the patient's medication regimen. The note lacked documentation indicating the RN assessed the patient's weight during the visit. i. The skilled nursing visit note, dated 3/29/2021, included an assessed weight of 224 pounds. j. The update to the comprehensive assessment at the time of recertification, dated 4/6/2021, lacked documentation of the RN's assessment of the patient's weight. k. The agency medication list, printed 4/13/2021, included a new medication ordered by a second physician on 4/6/2021- Bumetanide, a diuretic. l. During the same home visit, Patient #1 reported he/she "ballooned up after the physician discontinued Lasix". The patient reported increased swelling in the lower extremities requiring use of edema wear on both legs to attempt to control the swelling. The patient reported "it's starting to come down now. I weighed 234 pounds yesterday at the doctor's office." The RN did not monitor the patient's weight routinely as part of the cardiovascular assessment. The RN did not assess the weight after the discontinuation of the Lasix. The patient experienced swelling and weight gain. The RN did not identify the early symptoms that may lead to an exacerbation. 2. Patient #2 had a start of care date of 11/18/2020. Clinical record review revealed the following: The Plans of Care, dated 1/17/2021 to 3/17/2021 and 3/18/2021 to 5/16/2021, documented Patient #2's primary home health diagnosis was Covid 19 with secondary diagnoses of paroxysmal atrial fibrillation and hypertension. The Plans of Care directed the skilled nurse to visit the patient once weekly to assess the patient's cardiovascular system each visit. a. The update to the comprehensive assessment at recertification, dated 1/13/2021, documented the physician discontinued the patient's Lasix, a diuretic. The physician gave direction for the patient to monitor his/her weight daily, reporting any weight gain of more than 3 pounds in 24 hours or 5 pounds in one week. The assessment documented the patient weighed 198 pounds. b. The skilled nursing visit note, dated 1/20/2021, documented the patient weighed 200 pounds and the skilled nursing visit note, dated 2/27/2021, documented the patient's weight range was 198 to 200 pounds. c. The skilled nursing visit note, dated 2/3/2021, documented the patient began experiencing trace edema bilaterally with mild dyspnea. The RN did not weigh the patient or document an assessment of the patient's recorded weights from the previous week. d. The skilled nursing visit note, dated 2/10/2021, documented the patient had 1+ non-pitting edema in both legs and was experiencing dyspnea with exertion, resulting in a pulse oxygen level of 93% and mild dyspnea at rest. The RN did not weigh the patient or document an assessment of the patient's recorded weights from the previous week. f. The update to the comprehensive assessment at resumption of care, dated 2/17/2021, documented the patient was hospitalized on 2/12/2021 with a diagnosis of congestive heart failure and returned home on 2/15/2021. The RN did not monitor the patient's weight routinely as part of the cardiovascular assessment. The RN did not assess the weight after the discontinuation of the Lasix. The patient experienced swelling and dyspnea/shortness of breath, both signs of potential congestive heart failure. The RN did not identify the early symptoms that may lead to an exacerbation of congestive heart failure. 3. Patient #3 had a start of care date of 7/8/2020. The clinical record review revealed the following: The Plan of Care, dated 11/5/2020 to 1/3/2021, documented Patient #3's primary home health diagnosis was Type 2 diabetes. The Plan of Care directed the skilled nurse to visit the patient once every other week to instruct/reinforce blood sugar testing and assess blood glucose record and report a pattern of blood sugars outside of established parameters. a. The skilled nurse visit notes, dated 11/11/2020 and 11/25/2020, lacked documentation of monitoring of the patient's blood glucose level during the visit and lacked documentation of review of the patient's blood glucose records to determine a pattern outside of the established parameters. The Plan of Care, dated 3/5/2021 to 5/3/2021, directed the skilled nurse to visit the patient once every other week to instruct/reinforce blood sugar testing and assess blood glucose monitoring. b. The skilled nurse visit notes, dated 3/17/2021 and 3/31/2021, documented the nurse assessed the patient's blood sugar while in the home; however, the note lacked documentation of the nurse's review of the patient's blood glucose records to determine a pattern outside of the established parameters. 4. Patient #4 had a start of care date of 3/6/2020. Clinical record review revealed the following: The Plan of Care, dated 3/1/2021 to 4/29/2021, documented Patient #4's primary home health diagnosis was Dementia with a secondary diagnosis of Type 2 diabetes with unspecified complications. The Plan of Care directed the skilled nurse to visit the patient once every other week to instruct/reinforce blood sugar testing and assess blood glucose record and report a pattern of blood sugars outside of established parameters. The skilled nurse visit notes, dated 3/10/2021 and 3/24/2021, lacked documentation of monitoring of the patient's blood glucose level during the visit and lacked documentation of review of the patient's blood glucose records to determine a pattern outside of the established parameters. The above stated findings for Patients #1, #2, #3 and #4 were reviewed with the agency Administrator and Staff A, Electronic Medical Record Manager. The agency provided no additional information prior to the end of the survey.