Every finding on record at County of Iowa

The Department of Inspections, Appeals and Licensing conducted an unannounced complaint survey for incident #112833-C from 2/18/25 to 2/19/25. The complaint survey identified the following: The allegation related to 42 CFR 484.80 Home Health Aide Services, was investigated and no condition level deficiency was identified and one standard level deficiency was identified. (G802) The agency reported a census of 26 patients at the time of the survey.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, staff and patient interview, 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 1 of 5 sampled patients receiving home health aide services (Patient #5). 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. Findings include: According to the agency policy titled Home Health Aide Services, dated 3/20/24, home health aide services will be provided to appropriate clients on an intermittent, part-time or full-time basis, under the direct supervision of an agency Registered Nurse in accordance with a medically approved plan of care. According to the agency policy titled Home Health Aide Care Plan, dated 3/20/24, prior to initiating care, the home health aide shall be oriented by a Registered Nurse, by phone or in person, to the client's care needs and shall be updated on modifications or changes in the client's care. On-sit orientation and return demonstration of skills will be done as determined by client/caregiver request, client needs, or assessment of the nurse. If the home health aide is assigned to provide advanced skills, the home health aide must be oriented to the procedure by a Registered Nurse who documents evidence of competency. The home health aide cannot be responsible for performing any procedure that is not assigned to them in writing by the Registered Nurse or that is beyond their ability. The Home Health Aide tasks must be related to the physical care needs of the client. According to the agency policy, titled Home Heath Aide Competency, dated 3/20/24, a home health aide will not be permitted to provide home health aide services until evidence of adequate training and/or competence has been determined by their individual supervisor. The home health aide must demonstrate evidence of successful completion of a competency evaluation program for any tasks the agency may choose to have home health aide perform as permitted under Iowa law and providing there is evidence of home health aide orientation to and competency in the delegated task. Patient #5 had a start of care date of 11/25/24. Clinical record review revealed the following: 1.The plans of care (POCs), dated 11.25.24 to 1.23.25 and 1.24.25 to 3/24/25, identified the patient had diagnoses that included chronic respiratory failure with hypoxia, shortness of breath, tachycardia and unspecified dementia. The POCs included orders for skilled nurse services 1 time every other week and home health aide (HHA) services 1 time a week. The POCs included physician orders for the HHA to remined the patient to increase oxygen to 4 liters when walking. 2. The home health aide care plan, dated 12/2/24, Staff G, Registered Nurse (RN) included the assigned home health aide task to increase oxygen to 4 liters with ambulation and decrease oxygen to 3 liters when sitting. 3. The home health aide notes, dated 12/26/24, 1/2/25, and 1/9/25, included documentation Staff F, HHA completed the assigned tasks. 4. Review of Staff F, HHA's employee file identified a hire date of 5/26/22. The Home health aide training dated 5/17/24, included procedures that the HHA cannot perform including in part: adjust oxygen rate. The employee file lacked documentation of Staff F competency to adjust oxygen rate. During an interview on 2/20/25 at 4:30 PM, the Administrator stated when she and the Clinical Manger had knowledge that Staff G, RN added the HHA task to adjust the patient's oxygen rate of flow, they instructed Staff G RN to remove the task from the HHA care plan. She further stated it is the agencies policy to not allow HHA to preform adjustments of a patient's oxygen rate of flow. The agency nurse failed to ensure assigned HHA task permitted under state law. The above findings reviewed with the Administrator and Clinical Manager.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 9/9/24 through 9/11/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 9/9/24 through 9/11/24 and found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 33 patients at the time of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician for 3 of 7 sampled patients with wounds. (Patient #1, #6 and #7) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. 3. Patient #6 had a start of care date of 2/2/24. Clinical record review revealed the following: a. The POC, dated 2/2/24 to 4/1/24 included physician orders for skilled nurse to monitor skin and surgical wound. b. Skilled nurse visit notes, dated 2/21/24 and 2/28/24, completed by Staff B, Registered Nurse (RN), noted the appearance of the surgical wound but lacked measurements of the wound. Skilled nurse failed to measure the surgical wound. The above findings were reviewed with the Administrator, Clinical Manager, and Staff C, Registered Nurse. 2. Patient # 1 had a start of care date of 6/24/21. During a home visit observation on 9/10/24 at 11:00 am, Staff C, Registered Nurse, (RN) observed and noted a new wound on the coccyx of patient #1. The RN cleansed the area and placed a foam dressing over the area and stated to patient #1 she would notify the physician of the new wound area following the home visit. The RN did not obtain any measurements of the new wound when assessing the area. During an interview with Staff C, on 9/11/24 at 8:30 AM, stated she has measured enough wounds, she can just approximate the size without using any type of measuring device. Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/7/24 to 10/5/24 included physicians orders for skilled nurse to monitor skin once a week and provide wound care when needed. b. The nurses note, dated 8/12/24, included documentation of a new open area near the patient's rectum that included measurements of length and width, but lacked documentation for the depth of the wound. c. The nurses note dated 8/27/24, included documentation for the established wound and included measurements for length and width, but lacked documentation of the depth. Two new additional wounds to the gluteal area were identified, but only one set of measurements was documented, and lacked documentation specific to each wound assessed. The nurse failed to obtain measurements of a new wound, and failed to measure the depth of an established wound weekly. Findings: According to the agency policy, titled Wound Care, dated 12/14/23, measurements of wound shall be performed by a registered nurse, will include length, width and depth, and will occur at a minimum weekly. During an interview on 9/10/24 at 8:52 AM, Clinical Manager reported wound measurements are completed weekly and include length, width and depth. 1. Patient #7 had a start of care date of 4/25/23 and a discharge date of 4/30/24. Clinical record review revealed: a. Interim physician order, dated 3/20/24, included orders for skilled nursing to start zinc oxide topical ointment, apply thin layer to buttocks as needed for open areas. b. Comprehensive assessment completed at time of Resumption of Care, dated 3/20/24, included documentation the patient had 2 open areas, 1 cm (centimeter) by 2 cm, on the right side of buttocks, spouse is using barrier cream. Skilled nurse failed to identify a wound depth for the 2 open areas on buttocks.

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 and clinical record review, the agency failed to follow physician orders for medication set up and foley catheter placement for 2 of 7 sampled patients (Patient's #3 and #4). Failure to ensure staff obtain and follow physician orders for administration of medications and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 2. Patient #4 had a start of care date of 8/26/24. Review of the clinical record revealed the following: a. The POC, dated 8/26/24 to 10/24/24, included orders for catheter changes via sterile technique 1 time a month. The POC lacked orders to include the size of the catheter and balloon. b. The comprehensive assessment at admission, dated 8/26/24, included documentation the patient required a Foley catheter 16 French, with 10 milliliter balloon to straight drainage. The agency failed to include physician orders for size of catheter. The above findings shared with the Director, Clinical Manager and Staff C, RN. 1.Patient #3 had a start of care date of 6/21/24. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 6/21/24 to 8/19/24 and 8/20/24 to 10/18/24 documented the patient had orders for skilled nurse visits every other week to set up medications in a medication planner per patient request. The orders included the medication Verapamil Hydrochloride 120 milligrams (mg) with instructions to take one tablet two times a day to treat high blood pressure. b. During a home visit observation with Staff B, Registered Nurse (RN) on 9/9/24 at 2:30 PM, the surveyor identified Staff B missed putting a dose of Verapamil Hydrocholoride in the patient's medication planner. An interview with Staff B during this visit confirmed she had missed putting a dose of Verapamil Hydrochloride in an evening slot and corrected the mistake. The RN failed to follow physician orders when setting up the patient's medications. Findings include: According to the agency policy, titled Plan of Care – 485, dated 7/17/24, identified an individualized Plan of Care shall include medications, treatments, procedures, medical supplies and equipment required.

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 staff interview, clinical record reviews and policy review, the hospice failed to ensure all entries were complete and appropriately authenticated with a signature, title, date and time for 5 of 7 sampled patients (Patients #1, #2, #4, #6 and #7). 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. Findings include: 5. Patient #7 had a start of care date of 4/25/23 and a discharge date of 4/30/24. Clinical record review revealed: a. Comprehensive assessment completed at Start of Care, dated 4/25/23, included an electronic signature with nurse name, date and time, but lacked a discipline title. b. Comprehensive assessment completed at Recertifications of Care, dated 12/18/23, 2/15/24 and 4/17/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. c. Comprehensive assessment completed at Resumption of Care, dated 3/20/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. d. Comprehensive assessment completed at Discharge from Care, dated 4/30/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. e. Skilled nurse visit note, dated 4/26/24, lacked documentation of an electronic signature. During an interview on 9/10/24 at 1:48 PM, Clinical Manager reviewed the electronic record and confirmed the skilled nurse visit note, dated 4/26/24, had not been marked as completed with an electronic signature. The agency provided no additional information prior to the end of the survey. 3. Patient #2 had a start of care date of 3/4/24. Clinical record review revealed: a. The comprehensive assessment completed at Recertification of Care, dated 8/27/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. b. The skilled nurse visit notes, dated 7/10, 7/16, 7/22, 7/30/24, 8/6, 8/13, 8/19, 8/17/24 and 9/4/14, lacked documentation of an electronic signature. 4. Patient #4 had a start of care date of 8/26/24. Clinical record review revealed: a. The comprehensive assessment completed at Start of Care, dated 8/26/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. 2. Patient #1 had a start of care date of 6/4/21. Clinical record review revealed the following: a. Comprehensive assessment completed at Recertifications of Care, dated 4/5/24, 6/4/24 and 8/6/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. b. Comprehensive assessment completed at Resumption of Care, dated 4/18/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. c. Skilled nurse visit notes dated, 7/8/24, 7/15/24, 7/22/24, 7/29/24, 8/12/24, 8/27/24, 8/29/24 and 9/3/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. According to the agency policy titled Clinical Documentation, dated 7/17/24, all skilled services provided by nursing or therapy will be documented in the clinical record. A separate note shall be completed for each visit and signed and dated by the appropriate professional within 72 hours of the day service is rendered. 1.Patient #6 had a start of care date of 2/2/24 and a discharge date of 3/15/24. Clinical record review revealed: a. The initial comprehensive assessment dated 2/2/24, completed by Staff C, Registered Nurse (RN), included an electronic signature with a nurse name, date and time, but lacked a discipline title. b. The skilled nurse visit notes, dated 2/5/24, 2/8/24, 2/12/24, 2/16/24 and 2/28/24, completed by Staff C, RN, included an electronic signature with a nurse name, date and time but lacked a discipline title. c. The comprehensive assessment completed at discharge from care, dated 3/15/24, completed by Staff C, RN, included an electronic signature with a nurse name, date and time but lacked a discipline title.

The Department of Inspections, Appeals and Licensing conducted a complaint investigation for complaint #100997-C on 10/10/23 to 10/12/23. The complaint survey identified the following: 1) The Condition of Participation (COP) 484.55 Comprehensive Assessment of Patients was unsubstantiated with unrelated deficiencies (see G0514 and G0536) and 2) The COP 484.60 Care planning, Coordination and Quality of Care was unsubstantiated with unrelated deficiencies (see G0576 and G0580). The survey investigation found the agency to have standard level deficiencies in the above mentioned COPs. The agency reported a census of 35 patients at the time of the survey.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. 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 an initial assessment visit within 48 hours of receipt of referral and/or known discharge date, or on the physician ordered start of care date for 1 of 2 sampled patients (Patient #2) with a start of care in 2023. Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: According to the agency policy titled, Clients Admission Process, dated 12/14/22, the initial assessment will be completed within 48 hours of referral or within 48 hours of the client’s return home, or on the physician ordered start of care date. During an interview on 10/12/23 at 11:13 AM, the Administrator reported referral usually come from family members and may take 2-3 weeks to get the needed information. The back side of the referral intake form documents the dates the agency receives the information. The administrative assistant coordinates with the nurses to set up the admission visits. The administrator reported being aware of the regulation requiring referrals to be completed within 48 hours of the referral intake. Patient #2 had a start of care date of 7/3/23. Clinical record review revealed the following: a. The referral intake form, dated 6/28/23, included documentation the paperwork had been received and sent to the nurse. The nurse will not be able to see the patient until 7/3/23. b. The faxed discharge paperwork, dated 6/28/23, included a faxed date of 6/28/23. c. The Plan of Care, dated 7/3/23 to 8/31/23, identified the start of care date for Patient #2's services was 7/3/23. d. The clinical record lacked documentation of any follow up with the referring physician to report the delay in initial visit. The clinical record lacked documentation of any physician's order to delay the home health initiation of services. The patient was not admitted to service until 5 days after receiving the referral. The above stated findings were reviewed with the Administrator and the agency provided no additional information prior to the end 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 and agency staff interview, the agency failed to identify medication discrepancies when completing a drug regimen review with each comprehensive assessment within the allowed time frames for 2 of 3 sampled patients (Patients #1 and #2). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings include: According to the agency policy, titled Drug Regimen Review, dated 12/14/22, all clients receiving skilled services and/or personal services will receive a drug regimen review by a skilled staff (Registered Nurse/therapist) at the time of all comprehensive assessments. Comprehensive assessments are complete at the following time intervals according to Medicare guidelines: Start of Care, every 56-60 days thereafter for recertification, resumption of care after being discharged from a facility, time of discharge if not in a facility, and any other time when client has a significant change in condition that warrants a reassessment. Drug regimen review includes at a minimum: potential adverse effects, side effects, or drug reactions; significant drug interactions; duplication of medication; ineffective drug therapies; and non-compliance with medication regimen. According to the agency policy, titled Comprehensive Client Assessment, dated 12/14/22, the comprehensive assessment will include a review of all medications the client is using. This assessment will identify potential adverse effects and drug reactions, including: ineffective therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with therapy. During an interview on 10/11/23 at 10:18 AM, Staff F, RN (registered nurse), reported clinicians complete a drug regimen review in the skilled nursing note by checking boxes to indicate the elements completed and duplicate meds are documented in the narrative note box on the same page. 1.Patient #1 had a start of care date of 8/22/23. Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/22/23 to 10/20/23, included orders for the following medications: metformin and glipizide (diabetic medications), Senna and Metamucil (bowel medications) and amlodipine besylate and lisinopril (blood pressure medications). b. The start of care comprehensive assessment, dated 8/22/23, included documentation of no drug interactions and the patient takes duplicate medications for, but lacked documentation of the duplicate medications the patient took. The documentation lacked identification of ineffective drug therapy, significant side effects, compliance and duplicate medications. The clinical record failed to include a completed drug regimen review for the start of care comprehensive assessment. 2.Patient #2 had a start of care date of 7/3/23. Clinical record review revealed the following: a. The Plans of Care (POC), dated 7/3/23 to 8/31/23 and 9/1/23 to 10/30/12, included orders for the following medications: acetaminophen and gabapentin (pain medications), albuterol sulfate, albuterol, Asmanex and Stiolto (shortness of breath medications), B-1, cyanocobalamin, folic acid, iron and multivitamin (supplements), amlodipine besylate and metoprolol succinate (antihypertensive medications) and aspirin and clopidogrel (anticoagulant medications). b. The resumption of care comprehensive assessment, dated 8/24/23, included documentation the patient is compliant with medications and the patient is taking duplicate medications for pain, shortness of breath, supplements, antihypertensives and anticoagulants. The documentation lacked identification of ineffective drug therapy, significant side effects and drug interactions. c. The resumption of care comprehensive assessment, dated 9/12/23, included documentation the patient is compliant with medications. The documentation lacked identification of ineffective drug therapy, significant side effects, drug interactions and duplicate medications. The clinical record failed to include a completed drug regimen review for the resumption of care comprehensive assessments. The above stated findings were reviewed with the Administrator and the agency provided no additional information prior to the end of the survey.

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 clinical record review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 1 of 2 sampled patients with interim physician orders. (Patient #1). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: During an interview on 10/11/23 at 10:18 AM, Staff F, RN (registered nurse), reported the updated Plan of Care is in the electronic medical record system under episode and then the Plan of Care tab, updated plans of care are not sent out for signature. The order is entered in the electronic medical record and a box can be checked on the order to create the updated plan of care. Patient #1 had a start of care date of 8/22/23. Clinical record review revealed the following: a. Plan of Care, dated 8/22/23 to 10/20/23, included orders for skilled nursing, home health aide and physical therapy services. b. Interim physician order for mepilex dressing, dated 9/29/23. The clinical record lacked documentation of a Plan of Care update for the interim physician order, dated 9/29/23. The above stated findings were reviewed with the Administrator and the agency provided no additional information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to obtain physician orders for wound care/treatment for the patient for 3 of 3 sampled patients (Patients #1, #2 and #3). Failure to ensure staff obtain physician orders for administration of medications/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 Physicians Orders, dated 12/14/22, all drugs and treatments, that are part of the patient’s plan of care, must be ordered by the physician. All signed physician orders shall be maintained in the clinical record. During an interview on 10/12/23 at 11:55 AM, Staff B, RN (registered nurse), reported she was unaware of the need for physician interim orders for over the counter medications/creams or treatments provided by the patient/caregiver. During an interview on 10/12/23 at 11:57 AM, Staff F, RN, reported she was unaware of the need for physician interim order for a one time wound care. 1. Patient #1 had a start of care date of 8/22/23. Clinical record review revealed the following: a. Skilled nursing visit note, dated 9/6/23, included documentation the nurse instructed the patient to use over the counter barrier cream to open area on buttocks. b. Skilled nursing visit note, dated 9/13/23, included documentation the patient continued to use zinc barrier cream. The clinical record lacked documentation of a physician interim order for the barrier cream the patient used. 2. Patient #2 had a start of care date of 7/3/23. Clinical record review revealed the following: a. Resumption of care comprehensive assessment, dated 8/24/23. The clinical record lacked documentation of a physician interim order to resume home health care services. b. Recertification comprehensive assessment, dated 8/30/23, included documentation the patient used antibiotic ointment to a skin tear, covered with 4 by 4 gauze and wrapped with kerlix. The clinical record lacked documentation of a physician interim order for 4 by 4 gauze and kerlix to the skin tear. 3. Patient #3 had a start of care date of 5/29/18 and was discharged from agency services on 8/24/23. Clinical record review revealed a skilled nursing visit note, dated 8/21/23, included documentation the nurse instructed the patient to use ice for new report of back pain and continue to monitor. The clinical record lacked documentation of a physician interim order for the ice. The above stated findings were reviewed with the Administrator and the agency provided no additional information prior to the end of the survey.

AMENDED: E037, G850 and G856 The recertification survey, conducted from 11/7/22 through 11/16/22, identified the following deficiencies related to emergency preparedness. The agency reported a current census of 41 patients at the time of the survey.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of the agency's emergency operations plan, related policies and procedures and staff interview, the agency failed to ensure the emergency operations plan authorized in writing who will act in the the administrator's abscence. Failure to ensure the emergency operations plan authorized in writing who will act in the absence of the administrator placed patients at risk for the agency failing to have resources and/or the means to provide services to agency patients during a time of disaster or emergency. Findings include: Interview on 11/9/22 at 11:33 AM with agency Administrator reported she has been having meetings with the county coalition quarterly, but has not made any changes to the agency's emergency operations plan since becoming Administrator on 5/23/22. Review of the Emergency Operations Plan identified 4/20/2020 as the most frequent review and revision date. The Plan listed the former Administrator and the former Home Care Coordinator as key emergency contacts. The agency failed to identify who would act in the absence of the administrator for the operations of the agency. On 11/14/22 at 10:00 AM, the surveyor informed agency Administrator the surveyor would like to give findings for charts reviewed. The Administrator stated the administrator believed there wouldn't be any surprises of what the findings would be and the Administrator could follow along with the report the home health consultants provided to the agency during the mock survey done in late September. The Administrator reported having notes of what needs to be done, but the agency has not implemented or made the recommended changes due to needing to prioritize what needed to be done. Priority was to start OASIS submissions and doing recovery claims of billing that was not done since the fall of 2020.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on review of the agency's emergency operations plan, related policies and procedures and staff interview, the agency failed to ensure the emergency operations plan was updated biannually. Failure to ensure the emergency operations plan was updated biannually placed patients at risk for the agency failing to have current information and/or the means to provide services to agency patients during a time of disaster or emergency. Findings include: Interview on 11/9/22 at 11:33 AM with agency Administrator reported she has been having meetings with the county coalition quarterly, but has not made any changes to the agency's emergency operations plan since becoming Administrator on 5/23/22. Review of the Emergency Operations Plan identified 4/20/2020 as the most frequent review and revision date. The Plan also included a Hazard Vulnerability Analysis last completed 3/2/2020. The agency failed to update the plan every 2 years as required by regulation.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on review of agency's emergency operation plan, review of the agency's admission packet, clinical record review, home visit observation and agency staff interview, the home health agency failed to complete an individualized emergency plan developed as part of the comprehensive assessment, maintaining documentation of the plan in the patient's chart and in the patient's home setting, for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). Failure to ensure the agency completed individualized emergency plans developed as part of the comprehensive assessment and failure to ensure the patient has knowledge of the identified plan placed patients at risk for staff being unaware and unprepared to respond in a timely and effective manner to potential health and safety hazards the patient may encounter. Findings include: Review of the agency's admission packet included a home safety list and an emergency care plan for medical problems, but did not include an individualized emergency plan. Interview on 11:17 AM with the Clinical Manager reported they determine the patient's emergency risk with the initial assessment and review emergency risk with each comprehensive assessment. The do not provide a copy of the patient's risk or plan or review the determined risk or plan with the patient. Interview on 11/9/22 at 11:33 AM with the agency Administrator reported the agency was aware the admission packets did not have a copy of the developed emergency plan and verified the agency did not review the plans or give a copy of the plan to the patients. The agency was made aware of this by hired home health consultants. The Administrator has not made any changes to the EP Plan since becoming Administrator on 5/23/22. 1. Patient #1 had a start of care date of 11/19/2015. Clinical record review revealed the following: a. The Plans of Care, dated 6/5/22 to 8/3/22, 8/4/22 to 10/2/22, and10/3/22 to 12/1/22, included the diagnosis of mood disorder and bipolar disorder. b. The updates to the comprehensive assessment for recertification, dated 6/1/22, 8/4/22 and 9/29/22, identified an emergency preparedness assessment of a low risk. The updates lacked documentation the patient's emergency plan was provided to and reviewed with the patient The patient's clinical record lacked documentation of the agency providing the patient with a written completed individualized emergency plan and review of the plan with the patient at each comprehensive. 2. Patient #2 had a start of care date of 11/16/2018. Clinical record review revealed the following: a. The Plans of Care, dated 6/28/22 to 8/26/22, 8/27/22 to 10/25/22, and 10/26/22 to 12/24/22, included the diagnosis of atrial fibrillation. b. The updates to the comprehensive assessment for recertification, dated 6/24/22, 8/4/22 and 10/24/22, identified an emergency preparedness assessment of a low risk. The updates lacked documentation the patient's emergency plan was provided to and reviewed with the patient. The patient's clinical record lacked documentation of the agency providing the patient with a written completed individualized emergency plan and review of the plan with the patient at each comprehensive. 3. Patient #3 had a start of care date of 10/27/22. Clinical record review revealed the following: a. The Plan of Care, dated10/27/22, included the diagnosis of cerebral infarction. b. The initial comprehensive assessment at start of care, dated 10/27/22, identified an emergency preparedness assessment of a low risk. The assessment lacked documentation the patient's emergency plan was provided to and reviewed with the patient. The patient's clinical record lacked documentation of the agency providing the patient with a written completed individualized emergency plan. 4. Patient #4 had a start of care date of 2/9/21. Clinical record review revealed the following: a. The Plans of Care, dated 2/9/21 to 4/2/22, 6/4/22 to 8/2/22, 8/3/22 to 10/1/22, and 10/22/22 to 11/30/22 included the diagnosis of hydronephrosis. b. The initial comprehensive assessment at start of care, dated 2/9/21, and the updates to the comprehensive assessment for recertification, dated 6/13/22, 8/2/22, and 9/27/22, identified an emergency preparedness assessment of a low risk. The assessment lacked documentation the patient's emergency plan was provided to and reviewed with the patient. The patient's clinical record lacked documentation of the agency providing the patient with a written completed individualized emergency plan and review of the plan with the patient at each comprehensive. 5. Patient #5 had a start of care date of 2/8/21. Clinical record review revealed the following: a. The Plans of Care, dated 2/8/21 to 4/8/21, 6/3/22 to 8/1/22, 8/22/22 to 9/30/22 and 10/1/22 to 11/29/22, included the diagnosis of neuralgia and neuritis. b. The initial comprehensive assessment at start of care, dated 2/8/21, a nd the updates to the comprehensive assessment for start of care identified an emergency preparedness assessment of a low risk. The assessment lacked documentation the patient's emergency plan was provided to and reviewed with the patient. The patient's clinical record lacked documentation of a completed individualized emergency plan for the patient. 6. Patient # 6 had a start of care date of 6/21/22 and was discharged from the agency on 7/1/22. Clinical record review revealed the following: a. The Plan of Care, dated 6/21/22 to 7/20/22, included the diagnosis of right knee replacement aftercare. b. The initial comprehensive assessment at start of care, dated 6/21/22 identified an emergency preparedness assessment of a low risk. The assessment lacked documentation the patient's emergency plan was provided to and reviewed with the patient. c. The discharge assessment , dated 7/1/22 identified an emergency preparedness assessment of a high risk. The assessment lacked documentation the patient's emergency plan was provided to and reviewed with the patient. The patient's clinical record lacked documentation of the agency providing the patient with a written completed individualized emergency plan. 7. Patient #7 had a start of care date of 7/26/22 and discharged from the agency on 8/18/22. Clinical record review revealed the following: a. The Plan of Care, dated 7/26/22 to 8/18/22, included the diagnosis of type 2 diabetes melitis with diabetic polyneuropathy. b. The initial comprehensive assessment at start of care, dated 7/26/22, identified an emergency preparedness assessment of a low risk. The assessment lacked documentation the patient's emergency plan was provided to and reviewed with the patient. The patient's clinical record lacked documentation of the agency providing the patient with a written completed individualized emergency plan.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the agency's emergency operations plan and agency staff interview, the agency failed to have a written policy and procedure for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Failure to ensure the home health agency developed policies and procedures to address the use of volunteers or other emergency staffing strategies during an emergency, placed agency patients at risk for not having help to meet safety and health care needs in the event of a man made or natural disaster. Findings include: Interview on 11/9/22 at 11:33 AM with agency Administrator reported she has been having meetings with the county coalition quarterly, but has not made any changes to the agency's emergency operations plan since becoming Administrator on 5/23/22. The Administrator agreed the agency emergency preparedness plan lacked a policy and procedure for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on review of the agency's emergency operations plan and agency staff interview, the agency failed to have a communication plan, including names and contact information for staff, entities providing services under arrangement, patient's physicians and allowed practitioners, and volunteers, including primary and alternate means for communication. Failure to ensure the home health agency have a communication plan, including names and contact information for staff, entities providing services under arrangement, patient's physicians and allowed practitioners, and volunteers, including primary and alternate means of communication as required by regulation. , placed agency patients at risk for not having help to meet safety and health care needs in the event of a man made or natural disaster. Findings include: Review of the agency's emergency operations plan lacked documentation of communication plan, including names and contact information for staff, entities providing services under arrangement, patient's physicians and allowed practitioners, and volunteers and Federal, state, regional, and local emergency preparedness staff, including primary and alternate means for communication. Interview with the agency Administrator on 11/10/22 at 11:15 AM reported the agency does not have a communication plan, but a communication plan is included in the county coalition's plan. The agency's plan lacked names and contact information for staff, entities providing services under arrangement, patient's physicians and allowed practitioners, and volunteers and Federal, state, regional, and local emergency preparedness staff, including primary and alternate means of communication as required by regulation.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on review of the agency's emergency operations plan and agency staff interview, the agency failed to have a means for providing information about the agency's census, needs, and ability to provide assistance, to the authority having jurisdiction. Failure to ensure the home health agency had a means for providing information about the agency's census, needs, and ability to provide assistance, to the authority having jurisdiction, placed agency patients at risk for not having help to meet safety and health care needs in the event of a man made or natural disaster. Findings include: Review of the agency's emergency operations plan lacked documentation the agency did not have a means for providing information about the agency's census, needs, and ability to provide assistance, to the authority having jurisdiction. Interview with the agency Administrator on 11/10/22 at 11:15 AM reported the agency does not have a communication plan, but a communication plan is included in the county coalition's plan. The agency's plan lacked means for providing information about the agency's census, needs, and ability to provide assistance, to the authority having jurisdiction as required by regulation.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency operation plan and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 9 of 9 sampled employees (Staff A, B, C, D, E, F, G, H, I) and 7 of 7 contracted staff (J, K, L, M, N, O and P). Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to the agency's Emergency Operations Plan, dated reviewed 4/20/2020, ...home health and agency staff receive annual training provided through the agency. All staff receive emergency preparedness training appropriate for their position. Training includes emergency notification and communication, emergeny operations plan training, emergency communication during an evacuation for homebound patients, and fire and tornado drills. Contracted staff will only recieve emergency operations plan training and can complete this remotely. Their oversight for training will be provided by the Director. Training slides and staff training rosters are located in the emergency preparedness binder.... Review of the agency's emergency preparedness training revealed the following: 1. Staff A, Administrator, had a hire date of 5/23/22. The agency was unable to provide documentation of any emergency preparedness training. 2. Staff B, Clinical Manager, had a hire date of 4/9/10. The agency was unable to provide documentation of any emergency preparedness training. 3. Staff C, Registered Nurse (RN), had a hire date of 5/18/22. The agency was unable to provide documentation of any emergency preparedness training. 4. Staff D, Registered Nurse (RN), had a hire date of 10/3/22. The agency was unable to provide documentation of any emergency preparedness training. 5. Staff E, Financial Administrator, had a hire date of 2/28/22. The agency was unable to provide documentation of any emergency preparedness training. 6. Staff F, Administrative Assistant, had a hire date of 5/23/22. The agency was unable to provide documentation of any emergency preparedness training. 7. Staff G, Home Health Aide, had a hire date of 1/19/21. The agency was unable to provide documentation of any emergency preparedness training. 8. Staff H, Home Health Aide, had a hire date of 4/30/22. The agency was unable to provide documentation of any emergency preparedness training. 9. Staff I, Home Health Aide, had a hire date of 5/26/22. The agency was unable to provide documentation of any emergency preparedness training. 10. Staff J, Physical Therapy Assistant, had a hire date of 12/16/13 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any emergency preparedness training. 11. Staff K, Certified Occupational Assistant, had a hire date of 10/27/14 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any emergency preparedness training. 12. Staff L, Physical Therapist (PT), had a hire date of 8/27/2018 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any emergency preparedness training. 13. Staff M, Speech Language Pathologist, had a hire date of 6/5/17 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any of emergency preparedness training. 14. Staff N, PT, had a hire date of 4/1/19 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any of emergency preparedness training. 15. Staff O, PT, had a hire date of 2/18/22 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any of emergency preparedness training. 16. Staff P, Occupational Therapist, had a hire date of 9/30/19 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any of emergency preparedness training. Interview with agency Administrator on 11/14/22 at 2:30 PM reported she does not have any documentation of staff trainings for either direct hired staff or contracted staff.

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), §485.625(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, 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 emergency operations manual, the agency failed to ensure participation in an actual event, a full scale exercise that is community based or when a community based exercise is not accessible, conduct an individual agency based functional exercise, and conduct an additional "exercise of choice" at least every other year, including a second full scale exercise, a mock disaster drill, a tabletop exercise, and analyzation of the agency's response and documentation of any of the above. 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 Operations Plan, dated4/20/2020, the agency would conduct training and testing that complies with federal and state laws and maintain and at minimum update annually. Emergency preparedness training documentation did not include any exercises since 2019. Interview with the Administrator on 11/14/22 at 2:30 PM reported the agency did not participate in any exercises due being in an actual event since COVID began in 2020. The Administrator denied having any documentation of when the actual event was initiated by the agency.

AMENDED: E037, G850 and G856 A recertification survey was conducted by the Department of Inspections and Appeals from 11/7/22 through 11/16/22. The recertification survey found the agency was operating out of compliance with the following Conditions of Participation: 1) Condition of Participation 42 CFR 484.50 Patient Rights (G406), (G412), (G414), (G416), (G430), (G446), (G450), (G452), and (G462), 2) Condition of Participation 42 CFR 484.80 Home health aide services (G750), (G768), and (G800), 3) Condition of Participation 42 CFR 484.100 Compliance with Federal, State and Local Law (G848), (G850), (G852), and (G856), 4) Condition of Participation 42 CFR 484.105 Organization and administration of services (G940), (G942), (G948) and (G952). The survey also found the agency operating out of compliance with multiple other standard level regulatory requirements. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 11/16/22 and ending on 11/16/24. The agency reported a current census of 41 patients at the time of the survey.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, review of additional applicable documents, and agency staff interview, the agency failed to do the following: 1) ensure patients received written notice of the patient's right's and responsibilities under this rule and the agency's transfer and discharge policies as set forth in paragraph d of the regulations. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities (G412) 2) ensure agency patients received contact information for the agency Administrator, including the administrator's name, business address, and business phone number in order to receive complaints (414), 3) ensure agency patients for whom OASIS data is collected received an OASIS privacy notice (G416) 4) ensure the patient has the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect, and misappropriation of property (G430), 4) ensure agency staff patient's be advisied of the names, addresses, and telehphone numbers of the following Federally funded and state funded entities that serve the area where the patient resides: Agency on Agency, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization (G446), 5) ensure patients are informed of the right to access auxiliary aides and language services and how to access these services (G450), 6) ensure patients are informed of the agency's policies for transfer and discharge (G452), and 7) ensure the agency had a policy for addressing discharge for cause if the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired (G462). The cumulative systemic practices resulted in the failure to ensure all home health services of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's current patients.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency admission packet review, and agency staff interview, the agency failed to provide patient's with written notice of the patient's rights and responsibilities and the agency's transfer and discharge policies and ensure the notice is understandable for patient's who have limited English proficiency and accessible to individuals with disabilities for 7 out of 7 patient's sampled. Failure to ensure all patient's received written notice of their rights and responsibilities and the agency's transfer and discharge policies and ensure the notice is understandable for patient's who have limited English proficiency and accessible to individuals with disabilities placed the patient's at risk for receiving information they cannot comprehend and increased the risk of communication problems and ineffective communication techniques. Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, dated last reviewed 3/18/15, the duties and responsibilities of the board shall include....adopt and periodically review and approve the administrative and personnel policy, patient care policies and procedures, by laws required by state regulations.... According to undated agency policy, titled Client Bill of Rights and Responsibilities, the Client Bill of Rights and Responsibilities shall be reviewed with the patient/family/caregiver during the assessment visit prior to the initiation of care/treatment and on an ongoing basis as needed. The form shall be left in the patient's residence in the initial patient information packet. The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare shall present the document to the patient/family/caregiver. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. Interview with the Administrator on 11/7/22 at 11:33 AM reported they have identified the agency admission folder needs to have several changes made, including updating the Client Rights form. The Client rights form included in the admission packets, lacked information for patient's who have limited English proficiency and accessible to individuals with disabilities for 7 out of 7 patient's sampled. On 11/14/22 at 10:00 AM, the surveyor informed agency Administrator the surveyor would like to give findings for charts reviewed. The Administrator stated the administrator believed there wouldn't be any surprises of what the findings would be and the Administrator could follow along with the report the home health consultants provided to the agency during the mock survey done in late September. The Administrator reported having notes of what needs to be done, but the agency has not implemented or made the recommended changes due to needing to prioritize what needed to be done. Priority was to start OASIS submissions and doing recovery claims of billing that was not done since the fall of 2020.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on agency staff interview and admission packet review, the agency failed to provide agency patients with written contact information for the agency's Administrator, including the Administrator's name and contact information (telephone number and/or email address). The agency failed to provide this information for 7 of 7 sampled patients (Patients #1 , #2, #3, #4, #5, #6, and #7). Failure to provide the contact information for the agency's Administrator left the patients without the needed information to contact the agency Administrator for any concerns about their services. Findings include: Review of the agency's admission packet identified forms that lacked the agency Administrator's name, telephone number and/or email address. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. Interview on 11/8/22 at 8:00 AM with the agency Administrator reported the agency's hired home health consultants brought to the agency’s attention the Administrator and Clinical Manager’s name and contact information is not in the admission packet and they plan to get that fixed in the future. The agency provided no further information prior to the end of the survey.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency admission packet review, and agency staff interview, the agency failed to provide patients for whom OASIS data is collected an OASIS privacy notice for 6 out of 6 patient's sampled (Patient #1, #2, #3, #4, #6, and #7). Failure to ensure all patients received patients for whom OASIS data is collected an OASIS privacy notice placed the patient's at risk for not being aware of their privacy rights. Findings include: Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, dated last reviewed 3/18/15, the duties and responsibilities of the board shall include....adopt and periodically review and approve the administrative and personnel policy, patient care policies and procedures, by laws required by state regulations.... According to undated agency policy, titled Client Bill of Rights and Responsibilities, the Client Bill of Rights and Responsibilities shall be reviewed with the patient/family/caregiver during the assessment visit prior to the initiation of care/treatment and on an ongoing basis as needed. The form shall be left in the patient's residence in the initial patient information packet. The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare shall present the document to the patient/family/caregiver. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. The Client Rights form and the agency Admission Packets lacked information provide patients for whom OASIS data is collected an OASIS privacy notice.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency admission packet review, and agency staff interview, the agency failed to provide patient's with written notice of the patient's rights and responsibilities including the patient's right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property for 7 out of 7 sampled patients. Failure to ensure all patient's received written notice of their rights and responsibilities including the patient's right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property placed the patient's at risk for not understanding their rights. Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, dated last reviewed 3/18/15, the duties and responsibilities of the board shall include....adopt and periodically review and approve the administrative and personnel policy, patient care policies and procedures, by laws required by state regulations.... According to undated agency policy, titled Client Bill of Rights and Responsibilities, the Client Bill of Rights and Responsibilities shall be reviewed with the patient/family/caregiver during the assessment visit prior to the initiation of care/treatment and on an ongoing basis as needed. The form shall be left in the patient's residence in the initial patient information packet. The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare shall present the document to the patient/family/caregiver. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. Interview with the Administrator on 11/7/22 at 11:33 AM reported they have identified the agency admission folder needs to have several changes made, including updating the Client Rights form. The Client rights form included in the admission packets lacked information for patient's right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property 7 out of 7 patient's sampled.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency admission packet review, and agency staff interview, the agency failed to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Resource Center, and Quality Improvement Organization for 7 out of 7 patient's sampled. Failure to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Resource Center, and Quality Improvement Organization placed the patient's at risk for not knowing where to seek additional help. Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, dated last reviewed 3/18/15, the duties and responsibilities of the board shall include....adopt and periodically review and approve the administrative and personnel policy, patient care policies and procedures, by laws required by state regulations.... According to undated agency policy, titled Client Bill of Rights and Responsibilities, the Client Bill of Rights and Responsibilities shall be reviewed with the patient/family/caregiver during the assessment visit prior to the initiation of care/treatment and on an ongoing basis as needed. The form shall be left in the patient's residence in the initial patient information packet. The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare shall present the document to the patient/family/caregiver. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. Interview with the Administrator on 11/7/22 at 11:33 AM reported they have identified the agency admission folder needs to have several changes made, including updating the Client Rights form. The Client Rights form and admission packed lacked information for the patient to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Resource Center, and Quality Improvement Organization for 7 out of 7 patients sampled.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency admission packet review, and agency staff interview, the agency failed to inform patients of the right to access auxiliary aids and language services and how to access the services for 7 out of 7 patient's sampled. Failure to inform patients of the right to access auxiliary aids and language services and how to access the services, placed the patient's at risk for receiving information they cannot comprehend and increased the risk of communication problems and ineffective communication techniques. Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, dated last reviewed 3/18/15, the duties and responsibilities of the board shall include....adopt and periodically review and approve the administrative and personnel policy, patient care policies and procedures, by laws required by state regulations.... According to undated agency policy, titled Client Bill of Rights and Responsibilities, the Client Bill of Rights and Responsibilities shall be reviewed with the patient/family/caregiver during the assessment visit prior to the initiation of care/treatment and on an ongoing basis as needed. The form shall be left in the patient's residence in the initial patient information packet. The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare shall present the document to the patient/family/caregiver. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. Interview with the Administrator on 11/7/22 at 11:33 AM reported they have identified the agency admission folder needs to have several changes made, including updating the Client Rights form. The Client rights form included in the admission packets lacked information to inform patients of the right to access auxiliary aids and language services and how to access the services for 7 out of 7 patient's sampled.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review, agency admission packet review, and agency staff interview, the agency failed to provide patients with written notice of the patient's rights and responsibilities and the agency's transfer and discharge policies 7 out of 7 patient's sampled. Failure to provide patients with written notice of the patient's rights and responsibilities and the agency's transfer and discharge policies, placed the patient's at risk for not understanding when transfer and discharge may occur. Findings include: Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, dated last reviewed 3/18/15, the duties and responsibilities of the board shall include....adopt and periodically review and approve the administrative and personnel policy, patient care policies and procedures, by laws required by state regulations.... According to undated agency policy, titled Client Bill of Rights and Responsibilities, the Client Bill of Rights and Responsibilities shall be reviewed with the patient/family/caregiver during the assessment visit prior to the initiation of care/treatment and on an ongoing basis as needed. The form shall be left in the patient's residence in the initial patient information packet. The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare shall present the document to the patient/family/caregiver. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. Interview with the Administrator on 11/7/22 at 11:33 AM reported they have identified the agency admission folder needs to have several changes made, including updating the Client Rights form. The Client rights form included in the admission packets lacked information to provide patients with written notice of the patient's rights and responsibilities and the agency's transfer and discharge policies for 7 out of 7 patient's sampled.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency admission packet review, and agency staff interview, the agency failed to have a policy for the purpose of addressing discharge for cause for patients (or other persons in the patient's home) disruptive, abusive, or uncooperative behavior to the extent that delivery of care to the patient or the ability of the agency to operate effectively is serious impaired for 7 out of 7 patient's sampled. Failure to ensure all patients received written notice of their rights and responsibilities placed the patient's at risk for receiving information they cannot comprehend and increased the risk of communication problems and ineffective communication techniques. Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, dated last reviewed 3/18/15, the duties and responsibilities of the board shall include....adopt and periodically review and approve the administrative and personnel policy, patient care policies and procedures, by laws required by state regulations.... According to undated agency policy, titled Client Bill of Rights and Responsibilities, the Client Bill of Rights and Responsibilities shall be reviewed with the patient/family/caregiver during the assessment visit prior to the initiation of care/treatment and on an ongoing basis as needed. The form shall be left in the patient's residence in the initial patient information packet. The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare shall present the document to the patient/family/caregiver. Review of the governing body meeting minutes, dated 6/15/22 documented the Administrator gave a report and stated the policies and procedure manual requires an update. The governing body motioned for the Administrator to review, update, and revise the policies and procedures and bring them to the board for approval. Interview with the Administrator on 11/7/22 at 11:33 AM reported they have identified the agency admission folder needs to have several changes made, including updating the Client Rights form. The Client rights form included in the admission packets lacked inclusion of a policy for the purpose of addressing discharge for cause for patients (or other persons in the patient's home) disruptive, abusive, or uncooperative behavior to the extent that delivery of care to the patient or the ability of the agency to operate effectively is serious impaired 7 out of 7 patient's sampled.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral, within 48 hours of the of the agency's knowledge of the patient's return home from an inpatient facility or on the physician ordered start of care date for 2 of 3 sampled patients with a physician ordered start of care date, (Patients #5 and #7). Failure to provide an initial assessment visit on the physician ordered start of care date put agency patients at risk for not having immediate care needs met. Findings include: 1. Patient #5 had a start of care date of 2/8/21. Clinical record review revealed: a. The intake sheet documented, the referral date was 1/26/21 with a verbal start of care date of 2/1/21. There was no other information documented to show when the physician was notified that care could not be provided on the ordered start of care date. b. The initial comprehensive assessment, dated 2/8/21 identified the patient was initially seen on 2/8/21, seven days after the verbal start of care date. Interview on 1/16/22, at 2:45 PM with the Clinical Manager reported the manager should have documented when the physician was notified of delay of start of care as the Clinical Manager believed the patient requested not to be seen until 2/8/22. The agency failed to complete the initial assessment on the ordered start of care. 2. Patient #7 had a start of care date of 7/26/22 and discharged from the agency on 8/18/22. Clinical record review revealed: a. The intake sheet documented the referral date was 7/19/22 with a verbal start of care date of 7/25/22. There was no other information documented to show when the physician was notified that care could not be provided on the ordered start of care date. b. The initial comprehensive assessment, dated 7/26/22 identified the patient was initially seen on 7/26/22, one day after the verbal start of care date. Interview on 1/16/22, at 2:50 PM with the Staff C, Registered Nurse reported the nurse thought the timing was okay since it was within 48 hours of the start of care date. The agency failed to complete the initial assessment on the ordered start of care. The above findings were reviewed with the Administrator and Clinical Manager and the agency provided no additional information prior to the end 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 agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part the comprehensive assessments for 3 of 7 sampled patients (Patient #1 , #4 and #6). 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. Findings Include: According to the agency policy, titled Drug Regimen Review and dated last review 9/16/15, all patients receiving skilled services and/or personal care services will receive a drug regimen review by a skilled staff (registered nurse, therapist at the time of all comprehensive assessments At the time of the comprehensive assessment the skilled staff will obtain a complete list of all the medications the client is taking, including any over the counter medications and herbal remedies....Drug regimen review includes at a minimum a review of the following items: potential adverse effects, side effects, or drug reaction; significant drug therapist, ineffective drug therapies, client's understanding of the medications and non compliance with medication regimen. Interview with the Clinical Manager on 11/7/22 at 12:07 PM reported each nurse does their own Drug Regimen Review for each patient. The review is in the Electronic Health Record on the side and it is completed Start of Care, Recertification and all time points comprehensive assessments occur. 1. Patient #1 had a start of care date of 11/9/15. Clinical record review revealed: a. The updates to the comprehensive assessment for recertification, dated 6/1/22, 8/2/22, and 9/29/22 revealed the patient had duplicate drug therapies for constipation, mood, anxiety, depression, supplements, pain, and allergies. The assessment lacked identification the patient was on Divalproex and Clonazepam both medications ordered for seizures. The clinical record lacked documentation of a complete drug regimen review identifying all duplicate drug therapies. 2. Patient #4 had a start of care date of 2/9/21. Clinical record review revealed: a. The updates to the comprehensive assessment for recertification, dated 6/1/22,8/2/22 and 9/27/22 revealed the patient had duplicate drug therapies for pain and supplements, constipation, psychotropics, and blood pressure. The assessment lacked identification the patient was on Hydrocortisone and Lotrisone creams both medications ordered for skin. The clinical record lacked documentation of a complete drug regimen review identifying all duplicate drug therapies. 3. Patient #6 had a start of care date of 6/21/21 and discharged from the agency on 7/1/22. Clinical record review revealed: a. The initial comprehensive assessment for recertification, dated 6/21/22 revealed the patient had duplicate drug therapies Duplicate meds for pain, breathing, supplements, psychotropics and blood pressure . The assessment lacked identification the patient was on Senna and Imodium (both meds prescribed for bowels) and Trazodone and Diphenhydramine (both meds may cause drowsiness). The clinical record lacked documentation of a complete drug regimen review identifying all duplicate drug therapies. The above findings were reviewed with agency Administrator and Clinical Manager and agency staff provided no additional 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 and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 sampled patients (Patients #1, #2, and #3) with home visits. 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 Plan of Treatment, date of last revision 9/16/15, The Plan of Treatment shall be completed in full to include:...medications, treatments and procedures....medical supplies and equipment required.... According to agency policy, titled Physician Order, date of last revision 9/16/15, all drugs and care provided to patients must be ordered by a physician....all orders for medications must contain the name of the drug, dosage, route of administration, and directions for use. 1. Patient #1 had a start of care date of 11/9/15 and received weekly skilled nursing services. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 10/3/22 to 12/1/22, included orders for Flonase Allergy relief nasal spray and instructed patient to use 1 spray in each nostril daily as needed. The Client Medication Report, dated 11/7/22, included orders for Flonase Allergy relief nasal spray and instructed patient to use 1 spray in each nostril daily as needed. During a home visit observation on 11/8/22 at 9:00 AM, with agency Clinical Manager, the nurse performed medication set up in a med dispenser and reviewed all meds taken by the patient. In the patient's medication box, the patient had Flunisolide 0.25% nasal spray and the patient reported use of the nasal spray daily for months and denied using Flonase nasal spray. The Flunisolide spray expired 10/2022. The Plan of Care lacked an order for the patient's use of Flunisolide taken by the patient. b. During the same home visit observation with agency Clinical Manager, the nurse performed medication set up in a med dispenser and reviewed all meds taken by the patient. The surveyor located a bottle of Sumatriptan 50 milligrams (mg) to be taken daily as needed for migraines and the patient reported use of the medication for about a month. The Plan of Care lacked an order for Sumatriptan 50 mg as needed for migraines. c. The Plan of Care, dated 10/3/22 to 12/1/22, included orders for Vitamin D3 1000 units daily. The Client Medication Report, dated 11/7/22, included orders for Vitamin D3 1000 units daily. During the same home visit observation with agency Clinical Manager, the nurse performed medication set up in a med dispenser and reviewed all meds taken by the patient. The surveyor identified the bottle used to fill the medication dispenser was Vitamin D3 10,0000 units. The Clinical Manager reported the current bottle was opened last week and the nurse did not notice the different dosage. The Plan of Care lacked an order for Vitamin D3 10,0000 units used by the patient. 2. Patient #2 had a start of care date of 11/16/18 and received skilled nursing services and home care aide services. Clinical record review, home visit observation and accompanying interviews revealed the following: Ta. he Plans of Care, dated 6/28/22 to 8/26/22, 8/27/22 to 10/25/22 and 10/26/22 to 12/24/22, identified the following equipment and supplies were needed to meet the patient's needs: cane, grab bar, bath chair, Continuous Positive Pressure Airway Device (CPAP) machine, lympha press pants, life chair, ted hose, med cassette, and exercise machine. During home visit observation on 11/8/22 at 10:40 AM, with Staff C, Registered Nurse (RN), the surveyor observed the nurse assess the patient's weight and obtained the weight with a scale under chair next to kitchen countertop. Patient reported has had the scale for more than more than a year, probably about 2 years. During the same home visit observation with Staff C, Registered Nurse (RN), the surveyor observed a hand held shower in the patient's bathroom. The patient reported it has been in the bathroom since the patient moved in and the aides have been helping the patient with a shower since 2018. During the same home visit observation with Staff C, Registered Nurse (RN), the surveyor observed a donut cushion on a chair in the kitchen. The patient uses this when sitting in kitchen and reported having the cushion for 3 years. During the same home visit observation with Staff C, Registered Nurse (RN), the surveyor observed the nurse performing skin assessment and skin care and while the patient was laying in a bed in bedroom. The surveyor observed the patient’s use of a wedge pillow used to keep the head of bed elevated and patient reported using the wedge pillow for at least 1 year. The Plans of Care lacked identification of the scale, hand held shower, cushion, and wedge pillow as equipment used to meet the patient's needs. 3. Patient #3 had a start of care date of 10/27/22 and received physical therapy services. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 10/28/22 to 12/26/22, included orders for Docusate sodium/Senna 50 mg/8.6 mg twice daily as needed for constipation. The Client Medication Report, dated 11/7/22, included orders for Docusate sodium/Senna 50 mg/8.6 mg twice daily as needed for constipation. During a home visit observation on 11/8/22 at 4:12 PM, with Staff J, Physical Therapy Assistant (PTA), the surveyor reviewed the patient's medications with the caregiver who sets up the medications. The caregiver reported the patient does not have the Docusate sodium/Senna in the home and does not take the medication. The Plan of Care incorrectly identified the patient's use of Docusate Sodium/Senna. b. The Plan of Care, dated 10/28/22 to 12/26/22, included orders for Tylenol 325 mg every 6 hours as needed for pain. The Client Medication Report, dated 11/7/22, included orders for Tylenol 325 mg every 6 hours as needed for pain. During the same home visit observation with Staff J, Physical Therapy Assistant (PTA), the surveyor reviewed the patient's medications with the caregiver who sets up the medications. The surveyor observed a bottle of 500 mg Tylenol and the patient's caregiver reported patient has only had that dosage since returning home from the hospital. The Plan of Care lacked an order for the dosage of Tylenol taken by the patient. c. The Plan of Care, dated 10/28/22 to 12/26/22, identified the following equipment and supplies were needed to meet the patient's needs: walker, med planner, ted hose, and blood pressure cuff. During the same home visit observation with Staff J, Physical Therapy Assistant (PTA), the surveyor reviewed the equipment used to meet the patient's needs. The patient reported wears incontinence pads at all times and reported use of the pads for several years. During the same home visit observation on 11/8/22 at 4:12 PM, with Staff J, Physical Therapy Assistant (PTA), the surveyor reviewed the equipment used to meet the patient's needs. The surveyor observed the patient had a stool riser with grab bars in the patient's bathroom. The caregiver reported the patient has used the equipment since having a heart attack in July. The Plans of Care lacked identification of a stool riser with grab bars as equipment and incontinence supplies used to meet the patient's needs. The findings were reviewed with agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 2 of 3 sampled patients with new verbal/interim orders. (Patients #1, and #4) 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 Plan of Treatment/Care-485, dated last revised 9/16/15, an individualized Plan of Treatment/485 signed by a physician shall be receiving nursing, therapy, social worker, or home health aide services. Verbal orders shall be obtained from the patient's physician for changes in the Plan of Treatment. Interview on 11/7/22 at 12:07 PM with the Clinical Manager reported interim physician orders are added to the Plan of Care if needed. 1. Patient #1 had a start of care date of 11/9/15. Clinical record review revealed: a. The Plan of Care, dated 6/5/22 to 8/3/22, included the following interim physician orders: 1) a verbal order dated 6/21/22, to start Trulance 3 milligrams (mg) po daily per GI dr for constipation. 2) a verbal order, dated 7/5 ordered to discontinue Trulance and start Lubiprostone. 3) a verbal order, dated 7/13/22, to change Fluphenazine to 20 mg po daily. The clinical record lacked Plan of Care updates for the time period 6/5/22 to 8/3/22. b. The Plan of Care, dated 10/3/22 to 12/1/22, included the following interim physician orders: 1) a verbal order, dated 10/4/22 ordered to start Topamax 50 mg at bedtime. 2) a verbal order, dated 10/11/22 discontinued Milk Of Magnesia, Docusate Sodium with Senna, and Linzess. The clinical record lacked Plan of Care updates for the time period 10/3/22 to 12/1/22. 2. Patient #4 had a start of care date of 2/9/21. Clinical record review revealed: a. The Plan of Care, dated 6/4/22 to 8/2/22, included the following interim physician orders: 1) a verbal order dated 6/26/22, to resume services after hospitalization and start Ciprofloxacin 500 mg PO twice daily for 4 days, start Nitrofurantoin 100 mg nightly for prophylaxis from 7/9-7/11/22,) take Fluconazole 200 mg tablet for 14 days and then take the remaining 3 pills daily for the 3 days leading up scheduled procedure. 2) a verbal order, dated 7/13/22 ordered to change Oxybutnin to 5 mg 1 tab every 6 hrs as needed for bladder spasms and start Oxycodone 5 mg 1 tab every 4 hrs as needed pain. The clinical record lacked Plan of Care updates for the time period 6/4/22 to 8/2/22. b. The Plan of Care, dated 8/3/22 to 10/1/22, included a verbal order dated 9/21/22, to cleanse the nephrostomy drainage bag weekly with 1 part vinegar and 3 parts water solution and rinse well. The clinical record lacked Plan of Care updates for the time period 8/3/22 to 10/1/22. Interview on 11/8/22 at 1:45 PM with agency Clinical Manager reported they are aware of needing to update the POC and Staff C, Registered Nurse showed surveyor how it should be done. The Clinical Manager stated the agency has been working with a home health consultant and identified it was an issue, but they have not yet implemented changes. Staff C, RN has been doing updates, but not all staff are. The agency failed to ensure the Plan of Care was updated to include all patient care orders. The above findings were reviewed with the agency Administrator and Clinical Manager. Staff provided no additional information prior to the end of the survey.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on agency staff interview, home visit observation, and admission packet review, the agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address). The agency failed to provide this information for 7 of 7 sampled patients (Patients #1 , #2, #3, #4, #5, #6, and #7). Failure to provide the contact information for the agency's clinical manager left the patients without the needed information to contact the agency clinical manager for any concerns about their services. Findings include: Review of the agency's admission packet identified forms that lacked the agency clinical manager's name, telephone number and/or email address. Interview on 11/8/22 at 8:00 AM with the agency Administrator reported the agency's hired home health consultants brought to the agency’s attention the Administrator and Clinical Manager’s name and contact information is not in the admission packet and they plan to get that fixed in the future. The agency provided no further information prior to the end of the survey.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency: 1) failed to ensure home health aides were competency tested for all assigned tasks beyond the basic skills (G768); and 2) failed to ensure all home health aides provided care as ordered in the plan of care (G800). The cumulative systemic practices resulted in the failure to ensure all home health services of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's current patients.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review and staff interview, the agency failed to ensure the home health aides successfully completed competencies in all home health aide skills that exceed basic skills, which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 2 of 2 sampled home health aides (Staff H and I). Failure to ensure home health aides were competent in any assigned skill which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: According to the Policy and Procedure titled Home Health Aide Competency Evaluation, dated as last reviewed 9/15/15, Home Care Aides providing home health aide services must be certified and/or demonstrate competency prior to assignment to patient call....A Home Care Aide will not be permitted to provide Home Health Aide services until evidence of adequate training and/or competency has been determined by their supervisor....Any other task the agency chooses to have the Home Care Aide perform must have evidence of the aides orientation to and competency in the delegated tasks....Documentation of individual Home Health Aide training shall be maintained in the Home Care Aide's personnel file. Interview on 11/10/22 at 10:30 AM the Administrator reported the agency had identified the need to provide competency testing and had a list of skills needed to be checked off for Staff H and Staff I, but had not yet completed the competency evaluations for skills beyond the basic skills that were assigned. 1. Patient #2 had a start of care date of 11/16/18. The home health aide care plan directed the aide to apply neosporin, nystatin powder, Atractain lotion (medicated ointments and creams), shave the patient, apply support stockings, weigh the patient, and measure the patient's legs. The clinical record identified Staff I provided care to Patient #2. Staff I, HHA, had a hire date of 5/26/22. Staff I's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for applying medicated ointments and creams, shaving the patient, applying support stockings, weighing the patient, and measuring the patient's legs prior to providing care for Patient #2. 2. Patient #4 had a start of care date of 2/9/21. The home health aide care plan directed the aide to change the nephrostomy tube dressing. The clinical record identified Staff H provided care to Patient #4. Staff H, HHA, had a hire date of 4/20/22. Staff H's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for the nephrostomy dressing change prior to providing care for Patient #4. The above findings were reviewed with the Administrator. The agency provided no further information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients 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 2 of 4 sampled patients receiving home health aide services (Patients #2 and #4). The agency reported 21 patients currently received care provided by a home health aide at the time of the survey. 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. Findings include: According to agency policy, titled Home Health Aide Services, date of last revision 9/16/15,.... the aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising nurse. Interview on 11/7/22 at 12:07 PM with the agency Clinical manager reported the nurses complete the initial aide care plan and review the aide care plan every 60 days with recertification. If an aide can’t complete an assigned task, they document refused and notify the the nurse and the nurse will send an order if the patient did not receive the assigned task. For unassigned task, the aide is to notify the nurse to get approval if trained or not, may approve. 1. Patient #2 had a start of care date of 11/16/18 The Plans of Care, dated 8/27/22 to 10/25/22 and 10/26/22 to 12/24/22, included physician orders for skilled nursing services weekly and home health aide services 3 times per week to assist with personal cares. Clinical record review revealed: a. The Aide Care Plans for the months of September included direction to the aide to assist with shower, shampoo, dressing/undressing and skin care. b. Home health aide visit notes, dated 9/9/22 and 9/12/22, 9/21/22, 9/26/22, documented the aide apply nystatin powder. The notes lacked documentation of an order for the aide to complete the task of application of nystatin powder. c. Home health aide visit note, dated 9/12/22, included documentation the aide applied compression socks. The notes lacked documentation of an order for the aide to complete the task of application of compression socks. 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. 2. Patient #4 had a start of care date of 2/9/21 The Plans of Care, dated 8/3/22 to 10/1/22 and 10/2/22 to 11/30/22, included physician orders for skilled nursing services every 60 days and home health aide services 3 times per week to assist with personal cares. Clinical record review revealed: a. The Aide Care Plans for the month of September included direction to the aide to assist with shower, shampoo, dressing/undressing and skin care. b. Home health aide visit notes, dated 10/3, 10/5, 10/10, 10/12, 10/14, 10/17, 10/21, 10/24, 10/26, 10/28 and 10/31, and 11/2/22, included documentation the aide did provide skin care. The notes lacked documentation of a reason why the aide did not complete the assigned task. c. Home health aide visit note, dated 11/2/22, included documentation the aide did not assist with dressing/undressing. The notes lacked documentation of a reason why the aide did not complete the assigned task. 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 and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on agency policy review, review of additional applicable documents, and agency staff interview, the agency failed to do the following: disclose ownership and management information (G850), including the change of management at the time of change, (G852), and the name and address of each person who is an officer, a director, an agent, or a managing employee of the agency(G856). The cumulative systemic practices resulted in the failure to ensure all home health services of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's current patients.

Disclosure of ownership and management info. CFR(s): 484.100(a) Standard: Disclosure of ownership and management information. The HHA must comply with the requirements of part 420 subpart C, of this chapter. This STANDARD is not met as evidenced by: Based on related document review and agency staff interview, the agency failed to comply with the requirements of disclosure of ownership and management. Failure to to comply with the requirements of disclosure of ownership and management, placed agency patients at risk of not receiving adequate care and/or inappropriate care. Findings include: Review of agency governing body minutes revealed the following: a. The governing body minutes, dated 1/12/22, documented the Administrator submitted a resignation, effective January 26, 2022. b. The governing body minutes, dated 3/23/22, documented a nurse had not been compensated for stepping into the Interim Administrator role. c. The governing body minutes, dated 4/20/22, documented the Interim Administrator was appointed. The Interim stepped into the role of Interim Administrator on 1/26/22. The state agency was notified of the appointment of the Interim Administrator. d. The governing body minutes, dated 4/27/22, documented an offer was made to the Administrator for the position. e. The governing body minutes, dated 5/25/22, documented the Interim Administrator has given up the position with the start of the new Administrator, effective 5/23/22. f. The governing body minutes, dated 6/15/22, documented the Administrator reported to the governing body updates regarding the agency. g. The governing body minutes, dated 7/20/22, documented the Administrator reported to the board the CMS form 855A needs submitted to name the new Administrator and the Department and Inspections and Appeals audit is expected between now and the end of the year, but could occur as soon as the new Administrator is named. h. The governing body minutes, dated 8/17/22, documented the Administrator gave a report and the agency was working with a home health consultant on a mock audit to prepare for the Department of Inspections and Appeals site visit. i. The governing body minutes, dated 9/21/22, documented the Administrator gave a report regarding the agency and working with a home health consultant. Chart review identified areas of improvement and the nurses are working together to update documentation. The agency was preparing to resume admissions. j. The governing body minutes, dated 10/19/22, documented the Administrator gave a report regarding the agency and continued working with a home health consultant. The mock survey was completed and a triage of the most important items was underway. The Home Health Administrator was appointed, a Pro Tem Administrator of the Financial Administrator was appointed, and appointment of a Supervising Nurse (The Clinical Manager). The governing body and Administrator were both aware of the need to submit CMS form 855A beginning in July 2022. The agency failed to comply with the requirements of disclosure of management. .

Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: This STANDARD is not met as evidenced by: Based on related document review and agency staff interview, the agency failed to disclose to the state survey agency at the time of the agency's change in management. Failure to disclose to the state survey agency at the time of the agency's change in management placed agency patients at risk of not receiving adequate care and/or inappropriate care. Findings include: See G850. The governing body and Administrator were both aware of the need to submit CMS form 255A beginning in July 2022. The agency failed to submit the paperwork at the time of change in management.

Officer, a director, agent, managing employee CFR(s): 484.100(a)(2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. This ELEMENT is not met as evidenced by: Based on related document review and agency staff interview, the agency failed to disclose to the state survey agency the name and address of each person who is an officer, a director, an agent, or a managing employee of the agency. Failure to disclose to the state survey agency at the time of the agency's change in management placed agency patients at risk of not receiving adequate care and/or inappropriate care. Findings include: See G850. The governing body and Administrator were both aware of the need to submit CMS form 255A beginning in July 2022. The agency failed to submit the paperwork to share the name and address of the managing employee of the agency. See G850. The governing body and Administrator were both aware of the need to submit CMS form 855A beginning in July 2022. The agency failed to submit the paperwork to share the name and address of the managing employee (the Administrator).

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on agency staff interview and review of governing body meeting minutes, the agency failed to do the following: 1) ensure the governing body assumed authority and responsibility for the agency's overall management and operation and the provision of all home health services (G942), 2) ensure the Administrator was responsible for all day to day operations of the agency (G948), and 3) ensured the Administrator assured the development of policies (G952). The system practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the the agency's patients.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on agency policy review and review of the agency's governing body meeting minutes, the governing body failed to ensure authority and responsiblity for the overall management and operation of the agency and provision of all home health services resulting in the governing body not assuring all policies were updated by the Administrator. Failure of the governing body to ensure authority and responsiblity for the overall management and operation of the agency and provision of all home health services placed agency patients at risk for inadequate and unsafe care. Findings include: According to agency policy, titled Iowa County Board of Health Rules and Regulations, last reviewed 3/18/15, ...the board will delegate the Administrator the authority and responsibility for the provision of home care services in accordance with state and federal regulations...The board shall adopt and periodically review and approve administrative and personnel policies, patient care policies and procedures...... Review of the governing body meeting minutes, dated 5/25/22, documented the Interim Administrator stopped performing duties with the start of the new Administrator, hired on 5/23/22. Review of the governing body meeting minutes, dated 6/15/22, documented the Administrator reported to the board the need for the agency's policies and procedures manual to be updated. The board motioned to have the Administrator review, update, and revise the policies and procedures and bring them to the board for approval. Interview on 11/8/22 at 10:30 AM with the Administrator reported, the Policy manual had sticky notes on pages needed revised. All policies were dated as last reviewed on 3/18/15 The Administrator reported knowledge of the policies needing updates, but has not been a priority with other issues they have discovered. The goal was to get a percentage of the policies updated by the January board meeting. The governing body was aware on 6/15//22 of the agency needing to update policies. The governing body failed to ensure authority and responsibility for the overall management and operation of the agency and provision of all home health services.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on agency policy review and review of the agency's governing body meeting minutes, the governing body failed to ensure the Administrator was responsible for all day to day operations of the agency including updating the policies. Failure of the governing body to ensure he Administrator was responsible for all day to day operations of the agency including updating the policies placed agency patients at risk for inadequate and unsafe care. Findings include: See G942. The governing body was aware on 6/15/22 of the agency needing to update policies. The governing body failed to ensure the Administrator was responsible for all day to day operations of the agency including updating the policies.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on agency policy review and review of the agency's governing body meeting minutes, the governing body failed to ensure the Administrator assured development of policies. Failure of the governing body to ensure the Administrator assured development of policies placed agency patients at risk for inadequate and unsafe care. Findings include: See G942. The governing body was aware on 6/1522 of the agency needing to update policies. The governing body failed to ensure the Administrator assured development of policies.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 3 of 3 sampled patients with transfers/ discharges (Patients #4, #6, and #7). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: Agency policy review revealed the agency did not have a policy for transfers and discharges. 1. Patient #4 had a start of care date of 2/9/21. a. A skilled nurse visit note, dated 6/10/22, documented the nurse received a phone call from aide stating client was not feeling well since Wednesday evening and started running a temp last night. It was 102 but came down to 98.9 with Tylenol. The aide also reported green drainage at nephrostomy insertion site with an odor and some blood. The nurse advised the aide to have the patient be seen immediately due to previous infections. The patient agreed to be seen and had a bag packed just in case. The visit note documentation date was 6/13/22. b. A skilled nurse visit note, dated 6/13/22, documented the nurse received a phone call from the patient notifying the nurse the patient was hospitalized and the nurse stated patient's services would be placed on hold. c. A transfer assessment was completed by the nurse on 6/13/22, documented the patient was transferred to an inpatient facility and the patient not discharged from agency. d. An interim physician's order, dated 6/13/22, ordered to transfer the patient to inpatient hospital and the agency will resume services when the patient returns home. Interview with Staff C, Registered Nurse (RN) on 11/9/22 at 3:13 PM, reported the nurse was aware a complete assessment based on when patient was last seen should have been completed and a transfer summary should have been sent to the hospital, including a medication list. This was discovered by the agency from their home health consultants and the nurse changed transfer process since then. The Staff C reported only a transfer order was sent to the physician and no transfer summary was sent to the physician or the facility. The home health consultants have educated them on this. The agency failed to provide the hospital and physician with a complete transfer summary. 2. Patient #6 had a start of care date of 6/21/22 and discharged from the agency on 7/1/22. a. A skilled nurse visit note, dated 6/27/22, documented the nurse was contacted by a hospital social worker to inform the patient was admitted to the hospital for a pulmonary embolism (blood clot in the lung) on 6/25/22. b. A transfer assessment was completed by the nurse on 6/27/22, documented the patient was transferred to an inpatient facility and the patient not discharged from agency. c. An interim physician's order, dated 6/27/22, documented the patient was transferred to the hospital for a pulmonary embolism. d. A discharge assessment was completed on 7/1/22 due to the patient needing a higher level of care. The agency failed to provide the hospital and physician with a complete transfer summary. 3. Patient #7 had a start of care date of 7/26/22 and discharged from the agency on 8/18/22. a. A transfer assessment, dated 8/16/22, was completed by the nurse on 8/18/22, and documented the patient was discharged and remained in the community with formal assistive services. b. An interim physician's order, dated 8/16/22, ordered to discharge the patient from physical therapy and home health aide services through the agency due to the patient meeting desired goals. The agency failed to provide the physician with a complete discharge summary within 5 business days of discharge. On 11/14/22 at 10:00 AM, the surveyor informed agency Administrator the surveyor would like to give findings for charts reviewed. The Administrator stated the administrator believed there wouldn't be any surprises of what the findings would be and the Administrator could follow along with the report the home health consultants provided to the agency during the mock survey done in late September. The Administrator reported having notes of what needs to be done, but the agency has not implemented or made the recommended changes due to needing to prioritize what needed to be done. Priority was to start OASIS submissions and doing recovery claims of billing that was not done since the fall of 2020. Agency staff provided no additional details prior to the end of the survey.