Every finding on record at County of Webster

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 2/9/26 through 2/11/26 and the home health agency was found to be operating out of compliance with the following standard requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 2/9/26 through 2/11/26. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a current census of 25 patients.

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 for 1 of 6 sampled patients with admissions since last survey (Patient #3). Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: The agency policy, Initial and Comprehensive Assessment Policy, dated Feb. 2026, a Registered Nurse must conduct the initial assessment visit to determine the immediate care and support needs of the client. They must also determine eligibility for the Medicare Home Health benefit and homebound status. The initial assessment must be held within 48 hours of referral or within 48 hours of the clients' return home or on the physician ordered start of care date. Patient #3 had a start of care date of 9/26/25 and received services from the agency. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/26/25 to 11/24/25, identified the patient had a start of care dated of 9/26/25 and had a diagnosis of Chronic Obstructive Pulmonary Disease. The POC included orders for Home health aide services and skilled nurse services for home care aide supervision. b. The initial referral, dated 9/22/25, to the agency per telephone call, for home health aide services but did not identify a specific start of care date. c. The clinical record lacked documentation of any skilled nursing visit prior to 9/26/24 and lacked documentation of any case communication notes or notes in the electronic medical record (EMR) explaining the delay of the start of care. d. The clinical record lacked documentation of any follow up with the referring physician to report the delay in start of care. The clinical record lacked documentation of any physician's order to delay the home health services greater than 48 hours. The patient was not admitted to service until 4 days after receiving the referral. In an interview on 5/15/24 at 11:00 AM, the Clinical Manager reported the agency does not have a physician order to allow for the admission greater than 48 hours after the referral. The agency failed to initiate home health services within 48 hours of receiving the referral. The above findings reviewed with the Administrator and Home Health Aide Coordinator

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency staff interviews, clinical record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 1 of 3 sampled patients with home observation visits (Patient #3). 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 Plan of Care Policy and Procedure, dated Feb. 2026, a review of all medications the client is currently using to identify any potential advers effects, and drug reactions, including ineffective drug therapy, side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. During an interview on 2/11/26 at 11:10 AM, the Administrator/Clinical Manager stated the skilled nurse expeted to complete the Drug Regimen Review at the time of each comprehensive assessment including recertivication of home health services. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed: a. Plans of Care, dated 11/25/25 to 1/23/25 and 1/24/26 to 3/24/26, included primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for home health aide services, skilled nurse services for comprehensive assessments and home health aide supervision. The POC included orders for Morphine 15 milligrams (mg) every 6 hours as needed for pain. b. Recertification comprehensive assessment, dated 1/20/26, included documentation of drug regimen review completed. c. During an observation home health visit on 2/10/26 at 10:30 AM with Staff E, Home Care Aide (HCA), the patient stated he/she currently took Hydorocodone/Acetaminophen 10 mg /325 mg every 6 hours as needed for pain. He/She also stated no longer had an order for morphine. The patient identified the change in pain medication occured greater than 2 months ago. The registered nurse failed to complete an accurate drug regimen review at the time of the recertification comprehensive assessment as regulated. The findings were reviewed with the Administrator/Clinical Manager and Home Care Aide Coordinator.

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 observation visits, patient interview, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care (POC), including all medical supplies/equipment, all medications, and treatments used by the patient for 2 of 3 sampled patients with observation home visits (Patients #2 and #3). Failure to maintain complete and accurate POCs with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Plan of Care Policy and Procedure, Dated Feb. 2026, the required content of the plan of care must include: diagnosis, measureable treatment goals, services required, frequency and duration of visits, specific interventions, medication profile and reconciliation, safety measures, rehabilitation potential, functional limitations, nutritional requirements, activities permitted, patinet/caregiver education needs, emergency preparedness plan and discharge planning. 1.Patient #2 had a start of care date of 1/21/26. Clinical record review revealed: a. The Plan of Care (POC), dated 1/26/26 to 3/26/26, identified the patient had a primary diagnosis of Schizoaffective disorder and included physician orders for medical supplies/equipment used by the patient including: 4 wheeled walker, medicatin planners, cane, glasses, pill cutter, lockbox, lift chair and electric chair. b. During a home observation visit on 2/10/26 at 9:00 AM with Staff D, Registered Nurse (RN), the surveyor identified the patient had a surgical shoe on the left foot. The patient stated the surgical shoe was worn at all times due to an open wound on the left foot caused by a callous. The agency failed to include all medical supplies/equipment on the patient's POC, including a surgical shoe. 2. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed: a. The POCs, dated 11/25/25 to 1/23/26 and 1/24/26 to 3/24/26, identified the patient had a primary diagnosis of Chronic obstructive pulmonary disease and included physician orders for medical supplies/equipment used by the patient including: cane, 4 wheeled walker with seat, pill cutter, electric scooter, lift chair, glasses, dentures, grab bars, pill cutter and shower chair. b. During a home observation visit on 2/10/26 at 10:30 AM with Staff E, Home Care Aide (HCA), the surveyor identified Staff E assisted the patient with a shower and utilized a hand health shower head. The patient also noted to use an oxygen concentrator and portable oxygen. The agency failed to include all medical supplies/equipment on the patient's POC, including a hand health shower, oxygen concentrator and portable oxygen. The findings reviewed with the Administrator and Home Health Aide Coordinator.

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 clinical record review, policy review and agency staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 3 sampled patients receiving home health aide services (Patients #1, #3 & #7). The agency reported 5 patients received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician 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 policy, titled Plan of Care, dated Feb. 2026, Home Health Aide Services must be included in the plan of care, based on nursing and therapy assessment. The Home Health Aide supervised and documented at least every 14 days when receiving skilled nursing services and tasks must be specific and measurable. During an interview on 2/11/26 at 11:10 AM, The Administrator/Clinical Manager stated the aide documentation completed on an electronic application that does not allow for tasks to be separated. 1.Patient #1 had a start of care date of 12/4/2020. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/8/25 to 1/6/26 and 1/7/26 to 3/7/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 1/7/26, identified the following home health aide tasks: assist with shower, assist to shampoo hair and lotion to skin each visit. c. Aide visit notes, dated 1/27/26, 1/30/26, 2/3/26 and 2/6/26, completed by Staff E, Home Care Aide (HCA), included documentation personal care tasks completed (grouped together). The notes failed to identify which tasks were actually completed and if any were not. The agency failed to document on the individual home health aide task to identify each task completed. 2. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed the following: a. The POC, dated 11/25/25 to 1/23/26 and 1/24/26 to 3/24/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 1/24/26, identified the following home health aide tasks: assist with shower, assist to shampoo hair and lotion to skin each visit. c. Aide visit notes, dated 1/27, 1/30/26, 2/3/26 and 2/5/26, completed by Staff E, HCA, included documentation personal care tasks completed (grouped together). The notes failed to identify which tasks were actually completed and if any were not. The agency failed to document on the individual home health aide task to identify each task completed. 3. Patient #7 had a start of care date of 5/27/25 and discharge date of 7/3/25. Clinical record review revealed the following: a. The POC, dated 5/7/25 to 7/3/25, included primary diagnosis of Diabetes Mellitus and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 5/7/25, identified the following home health aide tasks: apply baza antifungal cream under abdominal and breast folds, assist with shower, assist to shampoo hair, assist dressing and lotion to skin each visit. c. Aide visit notes, dated 5/25/25, 6/1/25 and 6/2/25, completed by Staff E, HCA, included documentation personal care tasks completed (grouped together). The notes failed to identify which tasks were actually completed and if any were not. The agency failed to document on the individual home health aide task to identify each task completed. The above stated findings were reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights for 1 of 3 patient receiving home health aide services (Patient #3). Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. Findings include: According to the policy, titled Plan of Care, dated Feb. 2026, Home Health Aide Services must be included in the plan of care, based on nursing and therapy assessment. The Home Health Aide supervised and documented at least every 14 days when receiving skilled nursing services and tasks must be specific and measurable. In an interview on 2/11/26 at 11:10 AM, the Administrator/Clinical Manager stated the Registered Nurse completes the Home Health Aide supervision evry 14 days and tries to complete weekly to be in compliance. 1.Patient #1 had a start of care date of 12/4/2020. Clinical record revealed the following: a. The Plans of Care dated 11/8/25 to 1/6/26 and 1/7/26 to 3/7/26 included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 12/23/25, 1/2/26, 1/9/26, 1/16/26, 1/23/26, 1/28/26 and 2/6/26, Staff C, Registered Nurse, documented home health aide supervision completed and the aide reported changes in the patient's condition. The agency failed to supervise home health aide services to include all required supervisory elements. The above findings reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.

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 observations, agency staff interviews, record review and policy review, the agency failed to send a transfer summary 2 business days of becoming aware of transfer and discharge summary other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 1 patient's discharged from the agency and transferred to another facility. (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 undated policy, titled Discharge and Transfer Summary Policy and Procedure, dated Feb. 2026, discharge/transfer summaries completed with 48 hours of transfer/discharge. Discharge/Transfer summaries must be submitted to the receiving facility, provider, and/or agency with successful transmission to receiving entity. During an interview on 2/11/26 at 11:10 AM the Administrator/Clinical Manager stated the agency did not send a transfer summary or discharge summary to the receiving agency for patient #7. Patient #7 had a start of care date of 5/27/25 and discharge date of 7/3/25. Clinical record review revealed the following: a. The plan of care, dated 5/27/24 to 7/25/25, identified the patient had a diagnosis of Diabetes Mellitus and included orders for skilled nursing services. b. The comprehensive assessment at discharge, dated 7/3/25, identified the patient discharge from the agency and transfered to another specific home health agency. c. The discharge summary, dated 7/3/25, included the patient discharged from the agency due to admission to another specific agency. The discharge summary sent to the physician. The documentation failed to include a copy of the discharge summary sent to the receiving home health agency. The agency failed to send a copy of the discharge summary to the receiving home health agency. The agency failed to complete the transfer summary and send to the receiving facility within 2 business days of knowledge of the transfer or 5 business days following discharge. The above findings reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.

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: According to the policy, titled Policy for Electronic Signature/Authentication, dated Feb. 2026, routine or on-call visits will need to be completed and e-signed within 72 hours of the assessment with expectations to be completed within 24 hours. During an interview on 2/11/26 at the Home Care Aide Coordinator stated the agency Aides only document in the State application for billing. The record does not incclude the staff electronic signature. 1.Patient #1 had a start of care date of 12/4/2020. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/8/25 to 1/6/26 and 1/7/26 to 3/7/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The home health aide visit notes, dated 1/27, 1/30/26, 2/3 and 2/6/26, completed by Staff E, Home Care Aide (HCA), failed to include Staff E's electronic signature to include the discipline. The agency failed to staff electronic signature and discipline. 2. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed the following: a. The POC, dated 11/25/25 to 1/23/26 and 1/24/26 to 3/24/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The home health aide visit notes, dated 1/27, 1/30/26, 2/3 and 2/5/26, completed by Staff E, HCA, failed to include Staff E's electronic signature to include the discipline. The agency failed to include staff electronic signature and discipline. 3. Patient #7 had a start of care date of 5/27/25 and discharge date of 7/3/25. Clinical record review revealed the following: a. The POC, dated 5/7/25 to 7/3/25, included primary diagnosis of Diabetes Mellitus and physician orders for skilled nurse and home health aide services. b. The home health aide visit notes, dated 5/25/25, 6/1 and 6/2/25, completed by Staff E, HCA, failed to include Staff E's electronic signature to include the discipline. The agency failed to include staff electronic signature and discipline. The above stated findings were reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.

The Department of Inspections and Appeals conducted a recertification survey, dated 2/6/23 to 2/8/23, and found the agency to be operating in substantial compliance with regulations found under the Emergency Preparedness Condition of Participation.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 2/6/23 to 2/8/23. The survey identified the following standard level deficient practices. The agency reported a census of 48 patients at the time of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure completion of an update to comprehensive at the time of discharge within 2 calendar days of identification of the need to discharge a patient for 1 of 1 sampled patients requiring a discharge comprehensive assessment (Patients #7). Failure to accurately and thoroughly complete an update to the comprehensive assessment at the time of discharge in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the undated agency policy titled Comprehensive Assessment Policy, the comprehensive assessment just be updated and revised including the administration of the OASIS as frequently as the client's condition warrants due to major decline or improvement in the client's health status but not less frequent than the last 5 days of every 60 days beginning with the start of care date unless there is a beneficiary elected transfer, significant change in condition or discharge and return to the same agency during the 60 day episode. Patient #7, a pediatric patient, had a start of care date of 11/29/22 and a discharge date of 1/11/23. The Plan of Care, dated 11/29/22 to 1/27/23, included orders for skilled nursing services. The agency billed private insurance for the patient's home care services and the patient a pediatric patient; thereby, not requiring the collection of OASIS data as part of the comprehensive assessments. A discharge summary, dated, 1/13/23, completed by the nurse identified the patient's goals met and a copy sent to the physician on 1/13/23. During an interview on 2/7/23 at 4:00 PM the Administrator stated the nurse did not complete a comprehensive assessment at the time of discharge. The clinical record failed to include a comprehensive assessment completed by the nurse at discharge as required by regulation and agency policy. The surveyor reviewed the above stated findings with the Administrator, and Staff B, Office Manager. The agency provided no additional information prior to the end of the survey. Review of the agency policy, titled Skilled nursing services policy, dated 2/2019, identified agency skilled nursing staff are responsible for the assessment and regular reassessment of the nursing needs of the patient throughout the course of care. The skilled nurses are responsible for preparation of progress notes, medication profiles, discharge summaries, and other documentation as indicated.

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, agency policy review, home visit observation, patient and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 2 of 3 sampled patients (Patients #1 and #3) with a home visit observation. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive medications and/or treatments according to assessed needs and physician orders. Findings include: Patient #1 had a start of care date of 12/12/22. Review of the clinical record revealed the following: The POCs, dated 12/12/22 to 1/11/23 and 1/12/23 to 3/12/23, included orders for skilled nursing services, medications and identified the patient used the following medical equipment and supplies: On 2/7/23 at 8:30 AM, during a home visit observation, Staff D, RN, set up the patient’s medications and completed a routine visit assessment on the patient per the POC. The RN sanitized her hands, gloved and set up the patient’s medications. The surveyor identified a bottle of eye drops labeled Dorzolamide Hydrochloride and Timolol Maleate ophthalmic solution (to alleviate high eye pressure). During an interview with the patient's spouse during the same home visit they stated the eye drop ordered as 1 drop in the right eye daily and have been used since the start of home health services. During the home visit the surveyor identified the patient had the following equipment: glucometer, urinal, scale, pill cutter, incontinence products and toilet riser. During an interview with the patient's spouse during the same home visit they identified the patient utilized the equipment since the beginning of services. The POCs failed to identify the use of a glucometer, urinal, scale, pill cutter, incontinence products and toilet riser and failed to include an order for the Dorzolamide Hydrochloride and Timolol Maleate ophthalmic solution eye drops. The surveyor reviewed the above stated findings with the Administrator, and Staff B, Office Manager. The agency provided no additional information prior to the end of the survey. Review of the agency policy, titled Skilled Nursing Services Policy, dated 2/2019, identified agency staff would provide services in accordance with a physician ordered Plan of Care (POC) and shall include assistance to the physician in the development and renewal of the POC. Patient #3 had a start of care date of 11/9/22. Review of the clinical record revealed the following: The POCs, dated 11/9/22 to 1/7/23 and 1/8/23 to 3/8/23, included orders for skilled nursing services, medications and identified the patient used the following medical equipment and supplies: cane, shower chair, hand-held shower, grab bars, medication planner, scale and automatic blood pressure machine. The POCs included an order for Cetirizine 10 milligrams (mg) tabs, take one-half of a tablet every day in the morning. On 2/7/23 at 8:42 AM, during a home visit observation, Staff C, Registered Nurse (RN), set up the patient’s medications and completed a routine visit assessment on the patient per the POC. The RN sanitized her hands, gloved and set up the patient’s medications. Staff C, RN, used a pill cutter to cut Cetirizine 10 milligrams (mg) tabs in half and set the tabs up every day for a week in the morning slot of the medication box. After setting up the patient’s medications, Staff C, RN, asked the patient if the patient had any medication questions. The Patient grabbed a prescription labeled-box off the patient’s counter which was located where the patient kept all of the rest of the patient’s medications. The label identified the medication in the box was Spiriva Respimat Inhaler 2.5 mg and instructed the patient to inhale 2 puffs one time per day every day with a medication fill date of 11/22/22. The patient reported to the nurse the patient had difficulty getting the medication dispenser to work correctly, and the patient explained the patient had not been able to use the medication because of this. The RN provided the patient with education on the use of the medication. In an interview during the same home visit observation, Staff C, RN, reported they had been using the patient’s pill cutter to cut the Cetirizine tabs as the pharmacy sent the pills whole in 10 mg tablets. The patient reported having the Spiriva inhaler for a couple months, but had not been able to use it. The POCs failed to identify the use of a pill cutter and the current POC failed to include an order for the Spiriva inhaler.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 1 of 4 sampled patients receiving home health aide services (Patients #4). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: Review of the agency policy, titled Home Care Aide Supervisory Visit Policy Every 56 to 60 Days, dated 7/2019, identified the home health aide will document direct hands-on services provided to the patient as instructed by the registered nurse (RN) following the client’s plan of care (POC). The RN and the home health aide will meet monthly to review each client’s POC, make appropriate changes and document this in the patient's clinical record. On 2/7/23 at 8:15 AM, during an interview, the Administrator reported the admit nurse creates the home health aide care plan. If the patient requests for the home health aide to complete an unassigned task, the home health aide should contact the nurse to obtain approval prior to completing the task. Patient #4 had a start of care date 12/4/2020. Review of the clinical record revealed the following: a. The POCs, dated 9/25/22 to 11/23/22, 11/24/22 to 1/22/23 and 1/23/23 to 3/23/23, included orders for skilled nursing services one time per week and home health aide services 2 times per week. The POC included instructions to the home health aide to complete the following tasks: assist with shower, shampoo and applying lotion to the skin every visit and partial bath as requested by the patient. b. The home health aide visit notes, dated 12/1, 12/5, 12/8, 12/12, 12/15, 12/19, 12/27 and 12/29/22, 1/3, 1/5, 1/9, 1/12, 1/19, 1/23, 1/26, 1/30, 2/2 and 2/6/23, included documentation the home health aide completed the assigned tasks of shower, shampoo and applying lotion to the skin. c. The update to the comprehensive assessment completed at the time of recertification by Staff D, RN, dated 1/18/23, identified the patient did not need any assistance with lower body dressing, was able to dress the upper body without assistance if someone laid the clothing out or handed it to the patient and needed assistance with personal grooming. On 2/7/23 at 1:45 PM, during an interview, Staff E, Home Health Aide, reported they help the patient with taking a shower, shampooing and washing the body. The patient undresses independently. Staff E, Home Health Aide, reported they help with applying deodorant and lotion, they assist the patient with lower body dressing and putting the patient’s shoes on and they comb the patient’s hair. They also help with putting the patient’s shirt on due to the patient’s shoulder pain. The patient can put the patient’s shirt on by themselves, but Staff E, Home Health Aide, assists the patient because of the patient’s increased pain with shoulder movement. Staff E explained they have been providing assistance with dressing the patient since the patient started to receive home health aide services. On 2/7/23 at 2:27 PM, during a phone interview, Staff D, RN, reported the home health aide mostly helped the patient with upper body dressing due to right shoulder pain. Staff D reported the patient was scheduled to have right shoulder surgery next week. Staff D explained the patient could do the lower body dressing mostly without help and just needed help with putting shoes on due to difficulty bending over. Staff D, RN was aware the home health aide had been assisting the patient with combing hair and dressing since the patient started to receive home health aide services. Staff D, RN explained she missed putting this on the home health aide assignment. The home health aide assignment failed to included the specific tasks of dressing assist and hair combing the patient required assistance with in order to meet the patient's needs. The above stated findings were reviewed with the Administrator, and Staff B, Office Manager. The agency provided no additional 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 clinical record review, policy review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care 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 #8). Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. According to the policy titled, Skilled Nursing Services policy, dated 02/2019, the registered nurse shall perform supervision and teaching of other nursing service personnel such as home health aides. During an interview on 2/7/23 at 3:15 PM the Administrator reported the home health aides document using a phone, one click documents the assigned task was completed. If the task is not marked as completed it does not appear on the aide visit note and appears to be not addressed. The aides must click twice on a task to document it as refused or declined. 1. Patient #2 had a start of care date of 8/6/19. Clinical record review revealed: a. The Plans of Care, dated 11/18/22 to 1/16/23 and 1/17/23 to 3/17/23, included physician orders for skilled nursing visits once a week and home health aide visits three times a week. b. The home health aide assignment, dated 7/15/22, directed the aides to assist the patient with applying deodorant per patient request, applying skin barrier protectant as requested by patient, assist patient with dressing per patient request, assist with a shower, assist with perineal care as requested by patient, assist with shampoo hair as requested, assist with skin care – apply lotion per patient request, and provide fall precautions. c. Home health aide visit note, dated 12/28/22, lacked documentation the aide assisted with or patient refused the tasks of applying deodorant, assist with dressing per patient request, a shower, shampoo hair as requested and perineal care as requested by patient. d. Home health aide visit note, dated 1/11/23, lacked documentation the aide assisted with or patient refused a shower, perineal care as requested by patient, shampoo hair as requested, and provide fall precautions. e. Home health aide visit note, dated 2/2/23, lacked documentation the aide assisted with or patient refused the tasks of a shower, perineal care as requested by patient, shampoo hair as requested, and provided fall precautions. f. Home health aide visit note, dated 12/6/22, lacked documentation the aide assisted with or patient refused the tasks of fall precautions, shampoo hair as requested and perineal care as requested by patient. g. Home health aide visit note, dated 12/12/22, lacked documentation the aide assisted with or patient refused the tasks to assist with dressing per patient request, fall precautions and perineal care as requested by patient. h. Home health aide visit note, dated 1/20/23, lacked documentation the aide assisted with or patient refused the tasks of fall precautions, perineal care as requested by patient, and shampoo hair as requested. i. Home health aide visit note, dated 1/23/23, lacked documentation the aide assisted with or patient refused the tasks of shower, perineal care as requested by patient and shampoo hair as requested. j. Home health aide visit note, dated 12/11/22, 12/14/22, 12/16/22, 12/20/22, 1/6/23 and 1/13/23, lacked documentation the aide assisted with or patient refused the tasks of perineal care as requested by patient and provided fall precautions. k. Home health aide visit note, dated 12/21/22 and 1/16/23, lacked documentation the aide assisted with or patient refused the tasks of perineal care as requested by patient, and shampoo hair as requested. l. Home health aide visit note, dated 1/10/23, 1/30/23, lacked documentation the aide assisted with or patient refused the tasks of shower and perineal care as requested by patient. m. Home health aide visit note, dated 1/17/23, 1/25/23, 1/27/23, and 1/31/23, lacked documentation the aide assisted with or patient refused the task of perineal care as requested by patient. 2. Patient #8 had a start of care date of 6/3/21. Clinical record review revealed: Plans of Care, dated 10/22/22 to 12/20/22 and 12/21/22 to 2/18/23, included physician orders for skilled nurse services once every 60 days and home health aide services. a. The home health aide assignment, dated 8/18/22, directed the aides to apply ready wraps, assist patient with dressing, partial/sponge bath per patient request, shower, and skin care – lotion to skin. b. Home health aide visit note, dated 12/5/22, 12/9/22, 12/19/22, 12/28/22, 1/3/23, 1/6/23, 1/9/23, 1/13/23, 1/17/23, 1/20/23, 1/24/23, 1/27/23, 1/31/23 and 2/3/23, lacked documentation the aide assisted with or patient refused the task of shower. c. Home health aide visit note, dated 12/16/22, lacked documentation the aide assisted with or patient refused the task of shower and skin care – lotion to skin. e. Home health aide visit note, dated 12/13/22, lacked documentation the aide assisted with or patient refused the tasks of shower, apply ready wraps, and assisted patient with dressing. The above stated findings were reviewed with the Administrator, and Staff B, Office Manager. The agency provided no additional information prior to the end of the survey.