Every finding on record at County of Pocahontas

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing completed on 9/23/24 through 9/25/24 and the home health agency was found to be operating out of compliance with the following standard level requirements of the Establishment of Emergency Preparedness.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on agency staff interview, agency policy review and review of emergency preparedness testing documentation, the agency failed to ensure participation an emergency preparedness exercises annually. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: According to the agency policy, titled Emergency Preparedness, dated 12/14/23, on the years when community wide drills do not occur, a table top drill can be conducted. The purpose of the drills is to determine the effectiveness and efficiency of the current policy and processes in place. A post drill analysis of results and an action plan will be used to identify and mitigate any gaps. Emergency preparedness training documentation included an emergency preparedness tabletop exercise, dated 8/27/24. The agency lacked any documentation of any additional training exercise in 2022 or 2023. During an interview on 9/24/24 at 4:15 PM, the Administrator reported that the agency did not participate in an additional exercise in 2022 or 2023. The findings were reviewed with the Administrator, Clinical Manager, Staff C, Registered Nurse (RN), Staff D, RN and Staff G, RN.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 9/23/24 through 9/25/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 30 patients at the time of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home visit observations, patient interviews, clinical record reviews and agency policy reviews, 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 5 of 7 sampled patients (Patients #1, #2, #3, #6 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 4. Patient #1 had a start of care date of 5/9/24. Clinical record review revealed the following: a. The POCs, dated 7/8/24 to 9/5/24 and 9/6/24 to 11/14/24, included the following DME used by the patient: 20 Fr Foley catheter, 4 x 4 gauze, ABD pads, Foley kit, alcohol prep pads, alternating pressure relief mattress, Aquacel AG, Band aids, bed rails, betadine swabs, catheter insertion kit, catheter irrigation solution, catheter irrigation et, catheter irrigation kit, catheter leg strap, ceiling Hoyer lift, cervical collar, chest & back brace, chin/neck support brace, chux, drainage bag, edema wear, enema supplies, fingernail clippers, fingernail file, Foley catheters, glasses, grabber, handheld shower head, handicap van, heating pad, heel lift boots, kerlix, KY jelly, leg drainage bad, manual wheelchair, mattress overlay, medication boxes, mepilex with border, mepilex without border, mesh stocking sleeves, non-sterile gloves, OTC lotions, powders & creams, pill cutter, power wheelchair, Q-tips, ROHO cushion, shower chair with commode, skin prep, tape, toenail clippers, trapeze, wheelchair ramp, wound cleanser. c. During a home visit observation on 9/23/24 at 1:00 PM, with Staff G, RN, the surveyor identified the patient utilized a lifeline. d. During an interview at the same observation home visit the patient stated he/she used a warm pack for many years The POC failed to include the DME lifeline. 5. Patient #7 had a start of care date of 8/5/24 and discharged on 9/19/24. Clinical record review revealed the following: a. The POC, dated 8/5/24 to 10/3/24, included the following DME used by the patient: 4-wheeled walker, band aids, fingernail clippers, fingernail file, glasses, grab bar, handheld shower head, mepilex, nebulizer, oxygen concentration, oxygen tank, oxygen-nasal cannula, pulse oximeter. c. The skilled nurse note, dated 8/19/24, identified the patient utilized a lifeline. The POC failed to include the DME lifeline. The above items shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff G, RN. According to the agency policy titled Plan of Care, dated 5/14/24, the plan of care is established and authorized in writing by the physician/allowed practitioner based on evaluation of the client's immediate and long-term needs. The plan of care includes but is not limited to all pertinent diagnoses, frequency of visits, types of services and equipment required, medications and treatments and any safety measures to protect against injury. 1.Patient #2 had a start of care date of 5/10/23. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24 included the following durable medical equipment (DME) used by the patient: Alcohol pads, bath bench, bathroom scale, dentures, diabetic supplies, fingernail file, glasses, glucometer, grab bars, handheld shower, incontinent supplies, medication boxes and toenail/fingernail clippers. b. The Comprehensive Assessment, dated 8/27/24, completed by Staff B, Registered Nurse (RN), identified the patient has a platform lift in his garage that he uses. c. During a home visit observation on 9/24/24 at 1:30 PM, with Staff C, RN, the surveyor identified the platform lift in the garage. During this same visit, an interview with the patient's daughter revealed the patient does use the lift to avoid having to carry groceries up the steps into the house. The POC failed to include the DME platform lift. 2.Patient #3 had a start of care date of 1/5/24. Clinical record review revealed the following: a. The POC, dated 9/1/24 to 10/30/24 included the following medications: Aspirin 81 milligrams (mg) 1 tablet every morning, acetaminophen 325 mg 1-2 tablets every 6-8 hours, arformoterol tartrate 15 micrograms (mcg)/2 milliliters (ml) inhalation twice per day morning and night, albuterol sulfate 108 (90 base) mcg/act inhalation 1-2 puffs every 4-6 hours as needed, alendronate sodium 70mg 1 tablet every 7 days, budesonide 0.5mg/2ml inhalation 1 vial twice per day (AM and PM), Cholecalciferol 25 mcg take 2 tablets every morning, clopidogrel bisulfate 75mg 1 tablet every morning, diclofenac sodium 1% external small amount 4 times per day (AM, Noon, PM, HS), Losartan Potassium 50mg 1 tablet every morning, omeprazole 40mg 1 capsule every morning, nystatin 100000 unit/gram external small amount twice per day as needed for rash, multiple vitamin 1 tablet every morning, ipratropium-albuterol 0.5-2.5 (3) mg/3ml inhalation 3ml four times per day, bumetanide 2mg 1 tablet daily every morning, amlodipine besylate 5mg 1 tablet daily in the morning, and prednisone 10 mg 1 tablet daily as needed for shortness of breath. b. During a home visit observation on 9/24/24 at 10:00 AM with Staff D, RN, an interview with the patient revealed the patient is taking Acetaminophen 500mg 1-2 tablets as needed. The surveyor observed the patient's omeprazole was last refilled on 5/31/24 and the dose is 40mg with instructions to take 1 tablet by mouth twice a day. An interview with the patient identified the patient is taking the medication per the instructions on the bottle. The POC failed to include correct medications taken by the patient. 3.Patient #6 had a start of care date of 4/26/24 and a discharge date of 5/8/24. Clinical record review revealed the following: a. The POC, dated 4/26/24 to 6/24/24, included the following DME used by the patient: 2-wheeled walker, alcohol prep pads, bath bench, bathroom scale, compression stockings, diabetic supplies, edema wear, glasses and grab bars. b. The initial assessment, completed by Staff C, RN, identified patient is utilizing medication cassettes. The POC failed to identify all DME/supplies used by the patient.

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 observation, clinical record reviews, staff and patient interviews and policy reviews, the agency failed to administer treatments and services only as ordered by the physician for 2 of 3 sampled patients with home visits (Patients #1 and #2). Failure to ensure staff obtain physician orders for all treatments being utilized placed patients at risk for inconsistent care/treatment and possible harm. Findings include: 2.Patient #2 had a start of care date of 5/10/23. Clinical record review revealed: a. The POCs, dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24, documented the patient had physician orders for medications and treatments. b. The comprehensive assessment, dated 8/27/24, completed by Staff B, RN, identified the patient was utilizing a cream to treat a hemorrhoid. The clinical record lacked a physician order for cream to treat a hemorrhoid. The above findings were reviewed with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN, and Staff G, RN. According to agency policy, titled Plan of Care Policy, dated 5/14/24, the plan of care consist of medications which include prescription, over the counter, and herbal. Indicate if self-administered or administered by the agency. 1. Patient #1 had a start of care date of 5/9/24. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 7/8/24 to 9/5/24 and 9/6/24 to 11/4/24, documented the patient had physician orders for medications and treatments. b. During an observational visit with Staff G, Registered Nurse (RN) the patient noted to use a warm pack to his/her neck. c,. During an interview at the same observational visit the patient stated he/she used the warm pack to the neck area for pain and had for The clinical record lacked physician orders for warm packs for patient use.

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 review of employee personnel files and staff interview, the hospice failed to ensure 3 of 4 sampled home health aides (Staff E, Staff J and Staff K) satisfactorily demonstrated competency on the written skills examination prior to the home health aide providing service to patients. The home health agency employed 5 home health aides at the time of the survey. Failure to ensure home health aides have successfully completed a competency evaluation program increased the risk for patients to receive inadequate or inappropriate care. Findings include: On 9/25/24 at 9:30 AM during an interview, the Administrator revealed she was unaware a Registered Nurse (RN) needed to sign off on the home health aide written competency test acknowledging the test was administered and reviewed by the RN. 1.Staff E, Home Health Aide, had a hire date of 4/20/23. Staff D's personnel filed lacked documentation a RN had administered and reviewed the written competency test, dated 4/27/23. 2. Staff J, Home Health Aide, had a hire date of 9/14/22. Staff J's personnel file lacked documentation a RN had administered and reviewed the written competency test, dated 9/15/22. 3. Staff K, Home Health Aide, had a hire date of 4/20/23. Staff K's personnel file lacked documentation a RN had administered and reviewed the written competency test, dated 4/23/23. The above findings were reviewed with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN, and Staff G, RN.

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 interviews, clinical record reviews and agency policy reviews, the agency failed to ensure home health aides provided care to patients only as ordered by a 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 #5). Failure to ensure 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 plan of care increased the risk that the patient's personal care needs were not adequately met. Findings include: 2.Patient #2 had a start of care date of 5/10/23. Clinical record review revealed the following: a. The POCs, dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24, included physician orders for skilled nursing services twice monthly and home health aide visits twice weekly to assist with personal cares. b. The home health aide care plans, dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24, identified the following interventions: shower, may offer sponge bath if client refuses. Document in comments which patient had. c. Home health aide visit notes, dated 7/23/24, 7/25/24, 7/30/24, 8/2/24, 8/9/24, 8/12/24, 8/16/24, 8/20/24, 8/22/24, 8/26/24, 8/30/24, 9/3/24, 9/5/24 and 9/9/24, identified Staff E, Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. d. Home health aide visit note, dated 8/6/24, identified Staff F, LPN/Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. The home health aide failed to provide services ordered by the physician and included in the patient's POC. The above findings were reviewed with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN, and Staff G, RN. According to the agency policy titled Home Health Aide Services Policy, dated 3/12/24, a Registered Nurse (RN) develops the plan of care with input from the client or client's family. The assignment and duties of the home health aide will include written client care instructions prepared by the RN and in collaboration with the client, family, representative and/or caregiver. Assigned duties/tasks will be listed on the aide plan of care. The aide will be assigned to the client with consideration of the needs and geographic locations. During an interview on 9/23/24 at 10:17 AM, the Clinical Manager, identified when he aide is unable to complete an assigned task, they will call and report to the RN and write a narrative note they the reason or if they declined the service. 1. Patient #5 had a start of care date of 1/23/24. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 7/21/24 to 9/18/24 and 9/19/24 to 11/17/24, included physician orders for skilled nursing services twice monthly and home health aide visits twice weekly to assist with personal cares. b. The home health aide care plan, dated 7/22/24, identified the following interventions: shower, sponge bath per request of client. Specify shower or sponge bath. c. Home health aide visit notes, dated 7/22, 7/29, 8/23, 9/9 and 9/12/24, identified Staff F, LPN/Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. d. Home health aide visit notes dated 8/28/24, Staff K, Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. The home health aide failed to provide services ordered by the physician and included in the patient's POC.

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 1 of 2 sampled patients with transfers/ discharges (Patient #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: According to the agency policy titled, Client Transfer, dated 5/23/18, a transfer summary shall be completed by the Registered Nurse. The original transfer summary form shall be sent to the new provider or facility, and a copy shall be retained for the client's chart. The transfer summary must be completed within 2 working days. During an interview on 9/25/24 at 10:30 AM Staff C, Registered Nurse (RN) stated the transfer summary had only been sent to the primary care physician and not sent to the admitting facility. Patient #7 had a start of care date of 8/5/24 and discharged from the agency on 9/19/24. Clinical record review revealed: a. The comprehensive assessment at the time of hospital transfer, dated 8/8/24 by Staff D, RN, documented the patient transferred to the hospital. b. A home health transfer summary completed by Staff D, RN , dated 8/8/24, included identification the patient transferred to the hospital and the summary sent to the primary care physician. The agency failed to send the transfer summary to the receiving hospital. The above findings shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff G, RN.

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 agency interviews, clinical record reviews and agency policy reviews, the home health agency failed to ensure all clinical documentation was completed and appropriately authenticated in a timely manner for 2 of 7 sampled patients (Patients #1 and #4). Failure to ensure all clinical record documentation was completed in a timely manner increased the risk of ineffective communication between staff members providing services to its patients. Findings include: 2. Patient #1 had a start of care date of 5/9/24. Clinical record review revealed the following: a. The skilled nurse visit notes, dated 9/9/24 and 9/11/24, signed completed by Staff D, RN on 9/24/24 (8 days late per agency policy). b. The skilled nurse visit note, dated 9/11/24, signed completed by Staff D, RN on 9/24/24 (6 days late per agency policy). The agency clinical record failed to include timely documentation. The findings were reviewed with the Administrator, Clinical Manager, Staff C, Registered Nurse (RN), Staff D, RN and Staff G, RN. According to the agency policy titled Clinical Record, dated 5/14/24, clinical notes are timed visit notes and are completed within seven days of all services rendered. During an interview on 9/24/24 at 10:17 AM, the Clinical Manager reported routine visit documentation is to be completed within 5 days if possible. 1.Patient #4 had a start of care date of 2/2/24. Clinical record review revealed the following: a. The skilled nurse visit note, dated 8/27/24, signed completed by Staff D, Registered Nurse (RN) on 9/5/24 (2 days late per policy). b. The skilled nurse visit note, dated 9/10/24, signed completed by Staff B, RN on 9/25/24 (8 days late per policy). The agency clinical record failed to include timely documentation.

The recertification survey, conducted from 10/25/21 through 10/27/21, identified the agency to be operating in substantial compliance in the area of emergency preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 10/25/21 through 10/27/21 . The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey, conducted 10/25/21 through 10/27/21, found the agency operating out of compliance with the following standard level regulatory requirements.

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 review of the agency's patient admission packet, agency policy review and staff interview, agency staff failed to ensure patients and their representatives received information on the agency's transfer and discharge policies. The agency reported a census of 27 patients at the time of the survey. The agency reported a total of 21 patients discharged and 3 patients transferred to an inpatient hospital from 5/25/21 to present. Failure to ensure agency staff provided patients and their representatives (if any) with information on the agency's transfer and discharge policies increased the risk of patient's not understanding their rights in regards to discharging and transferring from agency services. Findings include: Review of the agency's policy, titled Transfer and Discharge Criteria, dated 11/13/18, revealed discharge planning would involve consultation and notification of the physician and patient/family prior to discharge. If the patient protests discharge, the formal appeals process should be followed. The policy listed the criteria for discharge including when goals of the medical and nursing care plan have been achieved, the patient transfers to a hospital or extended care facility, the patient dies, the patient requires a higher level of care and the agency can no longer meet the patient's needs, the patient/family request termination of services, the physician requests the discontinuation of services, lack of cooperation, verbal, physical or sexual abuse by the patient or family and the abuse impedes nursing care, lack of physician orders, the patient is able to receive services through outpatient services, lack of payment for services and service needs change and another agency meets the needs of the patient better. Review of the agency's patient admission packet revealed a document, titled Patient Bill of Rights, dated 9/14/2020. The document identified the patient had the right to be involved in care planning from admission to discharge, and to be informed in a reasonable amount of time of anticipated termination and/or transfer of service. On 10/27/21, further review of the agency's patient admission packet revealed a lack of information on the agency's policies for transfer and discharge. On 10/27/21 at 12:21 PM, during an interview, the surveyor informed the Administrator of the inability to find any information in the agency's admission packet which informed patients and their representatives about the agency's transfer and discharge policies. On 10/27/21 at 12:27 PM, during an interview, the Administrator reported the patient admission packet did not have any information on the agency's transfer and discharge policy. She explained at one time the admission packet included a copy of the agency's transfer summary form. The nurse would explain this form to the patient. The patient admission packet no longer contained this information. Agency staff provided no further information prior to the end of the survey.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff completed a transfer summary and sent the transfer summary to the receiving facility for 1 of 3 sampled patients (Patient #6) reviewed requiring the completion of a transfer summary. The agency reported a census of 27 patients at the time of the survey. Failure to complete and send a transfer summary to the receiving facility placed agency patients at risk for not ensuring the safe and effective transition of patient care. Findings include: Review of the agency's policy, titled Transfer and Discharge Criteria, dated 11/13/2018, identified the registered nurse (RN) must complete and send the transfer summary to the receiving facility or provider within 2 business days of a planned transfer or within 2 business of days of becoming aware of an unplanned transfer. Patient #6 had a start of care date of 6/26/21 and discharged from agency services on 8/24/21. Review of the clinical record revealed the following: a. The Plan of Care, dated 6/26/21 to 8/24/21, identified the patient had a diagnosis of bladder cancer and included physician orders for skilled nursing and home health aide services. b. An interim physician order, dated 7/25/21, included an order to hold skilled nursing and home health aide services due to the patient being admitted to the hospital. c. An updated to the comprehensive assessment completed at the time of resumption of care, dated 8/3/21, included documentation which identified the patient discharged from the hospital on 8/2/21. The assessment also identified the agency billed the patient's agency services to Medicare. d. The clinical record lacked documentation of a transfer OASIS (Outcome and Assessment Information Set) assessment, a transfer summary and lacked documentation any information had been sent to the hospital within 2 business days of the patient's transfer. On 10/27/21 at 1:44 PM, during an interview, the Administrator confirmed the patient's registered nurse had not completed or sent a transfer summary to the hospital. The Administrator received the above findings and agency staff provided no further information prior to the end 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 clinical record review, agency policy review and staff interview, the agency failed to notify the physician of changes in visit frequency ordered on the Plan of Care for 2 of 7 sampled patients (Patients #2 and #4). The agency reported a current census of 27 patients at the time of the survey. Failure to follow the Plan of Care or notify the physician of the need to alter the Plan placed agency patients at risk to not receive safe, individualized and consistent care designed to meet each patient's health care needs. 2. Patient #2 had a start of care date of 9/19/16. The POC, dated 8/24/21 to 10/22/21 included orders for skilled nursing services 2 times per month and home health aide services 3 times per week. On 10/26/21, review of the clinical record revealed the following: During the week of 9/5/21 through 9/11/21, 2 home health aide visits, dated 9/7/21 and 9/10/21. During an interview 10/26/21 at 2:38 PM, Staff B, registered nurse, (RN) reported that the visit had been missed due to it being a holiday week. Staff B, stated, “I forgot to notify the physician.” Agency staff failed to notify the patient's physician and obtain an order to cancel the aide service. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey. Findings include: According to the agency policy titled Care Planning, Coordination of Services, and Quality Care Conditions of Participation, dated 11/7/2018, each client must receive the home health services that are written in an individualized plan of care that identifies client specific goals and outcomes and which are reviewed periodically and signed by a physician of medicine, osteopathy or podiatry acting within their scope of state license, certification or registration. 1. Patient #4 had a start of care date of 5/17/14. The POC, dated 8/8/21 to 10/6/21 and 10/6/21 to 12/5/21, included orders for skilled nursing services 1 time per week and home health aide services 3 times per week. On 10/26/21, review of the clinical record revealed the following: During the week of 9/5/21 through 9/11/21, 2 home health aide visits, dated 9/8/21 and 9/10/21. During an interview 10/27/21 at 12:30 PM, the Administrator reported an inability to find a physician order to cancel the one home health aide visit for the week of 9/5/2021.. Agency staff failed to notify the patient's physician and obtain an order to cancel the aide service

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, patient and family member interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 3 of 7 sampled patients (Patients #4, #5 and #6)). The agency reported a current census of 27 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 3. Patient #6 had a start of care date of 6/26/21 and discharged from agency services on 8/24/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 6/26/21 to 8/24/21, identified the patient had a diagnosis of bladder cancer and included physician orders for skilled nursing and home health aide services. The POC identified the patient had chosen to be a "DNR". The POC did not identify any further advanced directives. b. Review of a Cardiopulmonary (CPR)/DNR Order Declaration Form, dated with the patient's and nurse's signature on 6/26/21, identified the patient had chosen to receive CPR in the event the patient stopped breathing or the patient's heart stopped beating. c. Review of an agency form with consent to treat, dated with the patient's and nurse's signature on 6/26/21, identified the patient reported having a Power of Attorney (POA) for Healthcare decisions and a living will. The form identified the POA as the patient's spouse and included documentation which identified the patient provided a copy of the patient's living will to agency staff. The POC failed to identify advanced directives chosen by the patient. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey. Findings include: According to the undated agency policy titled Advance Directives Policy the agency recognizes that all persons have the fundamental right to make decisions about their own medical treatment including the right to accept or refuse medical treatment. According to the agency policy titled Care Planning, Coordination of Services and Quality Care Conditions of Participation, dated 11/7/2018, the individual plan must include all medication and treatments and information related to any advance directives. 1. Patient #4 had a start of care date of 5/17/14. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/7/21 to 12/5/21, identified the patient had a diagnosis of low back pain and included physician orders for skilled nursing and home health aide services. The POC identified the patient had chosen to be a do no resuscitate (DNR). The POC did not identify any further advanced directives. Review of a Cardiopulmonary (CPR)/DNR Order Declaration Form, dated with the patient's and nurse's signature on 11/25/19, identified the patient had chosen to receive CPR in the event the patient stopped breathing or the patient's heart stopped beating. Review of the undated Face Sheet revealed the patient wished to be full code status. The POC failed to identify correct advanced directives chosen by the patient. On 10/27/21 at 1:50 PM, during an interview, Staff B, RN (Registered Nurse) stated the patient had decided to change his/her status to DNR. She further stated the patient signed the form but she could not locate it. b. The POC dated, 10/7/21 to 12/5/21, included a physicians order for pantoprazole 1 tablet every morning orally. The medication list, dated 10/5/21, included a physicians order for pantoprazole 1 tablet every morning orally. During an observation home visit on 10/26/21 at 8:50 AM with Staff B, RN, the surveyor observed the nurse fill the patient's medication planner for 1 week of medications. The medication pantoprazole filled on 9/27/21identified the dose of 40 milligrams. The agency failed to include complete medication orders on the POC. 2. Patient #5 had a start of care date of 9/8/20. Review of the clinical record revealed the following: a. The POC, dated 9/3/21 to 11/1/21, identified the patient had a diagnosis of myeloproliferative disease and included physician orders for skilled nursing services. The POC identified the patient had chosen to be CPR if need arises". The POC did not identify any further advanced directives. b. Review of a Cardiopulmonary (CPR)/DNR Order Declaration Form, dated with the patient's and nurse's signature on 11/25/19, identified the patient had chosen to receive DNR in the event the patient stopped breathing or the patient's heart stopped beating. c. Review of the undated Face Sheet revealed the patient wished to be DNR. The POC failed to identify correct advanced directives chosen by the patient.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical record review, agency staff interview and agency policy review, the agency clinician's failed to assess, including wound measurements, each wound at least weekly as identified by agency policy for 2 of 4 sampled patients with wounds. The agency reported a current census of 27 patients at the time of the survey. Failure to document assessment of wounds, including measurements, may result in unidentified worsening of the wounds or unidentified need to alter wound treatment. Findings include: According to the agency policy, titled Wound Care Policy and dated 11/26/18, the clinician's shall assess and document any wound that is visible even if the agency was not responsible for dressing changes. The location and condition of the wound, including appearance, color, odor, and estimated drainage amount, description of the surrounding skin and staging of the wound must be documented on every visit. Wound measurements, including the length of the wound, width of the wound and the depth of the wound must be documented in centimeters (cm) at least weekly. Wound graphs will be drawn weekly. Staging the wound using the following descriptions: Including, Stage 2: Partial-thickness skin loss, involving epidermis and/or dermis; this may present clinically as on abrasion, blister, or shallow crater. Update the plan of care with changes to wound care. 1. Patient #2 had a start of care date of 9/19/16 a. The Recertification Comprehensive Assessment, dated 8/20/21 and the Resumption of Care Comprehensive Assessment, dated 8/30/21, lacked documentation of wound measurements. b. The skilled nursing visit note dated 9/7/21 documented the right shin wound as healed. Included on the same visit note was a photo of the right shin wound dated 9/7/21 at 12:00 PM and labeled; wound location: right shin. c. The skilled nursing visit notes, dated 9/21/21 and 10/5/21 lacked weekly documentation of wound measurements. The clinical record lacked weekly wound measurements. 2. Patient #3 had a start of care date of 7/03/19. a. The skilled nursing note dated 10/7/21 includes documentation of a burn to the patient’s right hand ring finger on the finger pad. The patient reports it occurred while he/she was cooking. A blister formed and the patient was allowing his/her body to take care of it. Skilled nurse and home health aide will monitor. The same note failed to document wound measurements. b. The skilled nursing notes dated, 10/15, 10/20 and 10/22/21 lacked documentation of wound measurements. c. The Plans of Care, (POC), dated 8/21/21 and 10/15/21 included physician orders for neomycin-bacitracin-polymycin, (triple antibiotic) external apply small amount as needed to affected areas. d. The 60 day progress note dated 10/15/21 included documentation that the patient continues with the burn to his/her right ring finger. He/she reported the blister had popped and it was now a scab. He/she has been using triple antibiotic ointment and covering it with a band aid as needed. e. In an interview on 10/26/21 at 2:38 PM, Staff C, registered nurse, (RN), identified the physician was not notified by the RN that the patient had a burn to his/her right hand ring finger because the patient gets this type of injury often and cares for the burn himself/herself. Patient has prn order for triple antibiotic to apply as needed. The agency provided no additional information prior to the end of the survey.