Every finding on record at Crawford County Home Health Hospice & Public Health

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing completed on 4/1/24 through 4/3/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections Appeals and Licensing conducted a Recertification Survey from 4/124 through 4/324. 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 census of 26 current patients.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 2 of 4 sampled patients, who had an admission between 11/8/23 through 4/1/24. (Patients #1 and # 4). The agency reported a current census of 26 patients. Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: 1. Patient #1 had a start of care of date of 11/8/2023. The Plan of Care, dated 11/8/23 to 1/6/24, included physician orders for skilled nursing and home health aide services. The Financial data form, dated 11/8/23 included a financial responsibility section which identified the agency planned to bill services through medicaid, but failed to identify the amount the patient would be responsible to pay. During an interview on 4/1/24 at 3:15 PM, Staff B, Clinical Manager verified Patient #1 should have "Zero for the amount the patient would owe". The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey. Findings include: 2. Patient #4 had a start of care of date of 1/15/24. The Plan of Care, dated 1/16/24 through 3/16/24, included physician orders for skilled nursing and physical therapy services. The Financial data form, dated 11/8/23 included a financial responsibility section which identified the agency planned to bill services through Medicare, but failed to identify the amount the patient would be responsible to pay. During an interview on 4/1/24 at 3:15 PM, Staff B, Clinical Manager verified Patient #4 should have "Zero for the amount the patient would owe".

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, agency staff interview, and home visit observation, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 2 of 2 sampled patients with home visit observations completed that included medication set up. (Patient #2 and #3) Failure to communicate the patients status with the physician placed the agency at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: 1. Patient #2 had a start of care date of 5-22-19. a. The Plan of Care (POC) dated 2/25/24 through 4/24/24, included orders for all medications the patient was to be taking, and included orders for the nurse to set up the medications each week in the medication planner. b. During a home observation visit on 4-1-24 at 1pm, the surveyor observed Staff C, Registered Nurse, (RN) set up medications in a medication planner for the following week. The RN observed and commented that the patient missed one night of taking all of his bedtime medications. c. Review of the clinical record revealed the following: the RN documented the missed medications, however failed to notify the physician that the patient had missed taking his medications and the details of the medications missed. 2. Patient # 3 had a start of care dated 10/9/23, The Plan of Care (POC) dated 2/6/24 through 4/5/24, included orders for all medications the patient was to be taking, and included orders for the nurse to set up the medications each week in the medication planner. Review of the clinical record revealed the following: On 3/4/24, the RN documented Patient # 3 missed Wednesday medications, however failed to notify the physician that the patient had missed taking his medications and the details of the medications missed. During staff interview on 4-3-24 at 8:15 am, the RN and the Clinical Manager both stated they were not aware they needed to alert the physician when a patient failed to take medications as set up by the RN. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to communicate, and involve the physician and the patient, in plans for discharge from the agency prior to the patients discharge in 1 of 3 sampled patients discharged. (Patient #7) Failure to communicate and involve the patient and the physician in the discharge planning process prior to the patients discharge, placed the patient at risk for not receiving needed care and services after discharge from the agency. Findings Include: 1. Patient #7 had a start of care date of 9/18/2023 and a discharge date of 9/28/2023. The Plan of Care (POC) dated 9/18/23 through 11/16/23, included orders for skilled nursing, physical therapy, and home health aide services. Review of the clinical record revealed the following: a. POC included orders for patient to wear a back brace except when lying down, with restrictions including no bending or twisting, and no sitting for excess of 30 minutes at a time. b. Skilled nurse visit note dated 9/21/23, Patient declined the physical therapy initial evaluation. Skilled nurse documented the physical therapy initial visit was cancelled per the patients request. The clinical record lacked physician notification of the patients refusal of physical therapy services. Clinical record lacked documentation the patient or physician was included in any discharge planning discussion before the nursing visit dated 9/28/23, where the discharge assessment was completed and the physician order for discharge was received on 9/29/23. During an interview with the Administrator and the Clinical Manager on 4/3/24 at 9:15 am, the clinical manager stated the patient basically kicked the agency out of the home stating the patient didn't need services. The clinical record lacked documentation of this discussion between the patient and the agency staff. The agency failed to notify and involve the patient and the physician in discharge planning prior to the discharge date of 9/28/23. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to coordinate care provided by all disciplines, and integrate services, to assure patient needs are being met for 1 of 1 patients sampled with contracted therapy services. (Patient #4) Failure to coordinate care provided by all disciplines and to integrate services, puts the patients at risk for inappropriate treatments or unmet home health care needs. Findings include: 1. Patient #4 had a start of care date of 1/16/24. Review of the clinical record revealed the following: a. Physical Therapy Assistant (PTA) documented on 2/1/24, patient's spouse was concerned about a pink area on the top of the patient's left foot. PTA documents the spouse to continue to monitor the pressure area on the top of the patient's left foot and discussion with the spouse to find alternate footwear that would not cause any pressure to that area, and indicated to spouse, may have to try laced up tennis shoes. The documentation lacked notification the PTA had communicated with the RN or supervisor of possible pressure area on the foot. b. The PTA documentation on 2/5/24, indicated that the pressure area on the top of patients left foot was improved and that the patient was wearing different shoes that were of a looser fit. The documentation lacked notification or coordination with the RN or a supervisor. c. The RN documentation from the visit on 2/7/24, lacked any assessment of the left foot or pressure area and indicated no skin issues noted, or discussed with the patient or spouse. d. During an interview on 4-3-24 at 9:20 am, the RN indicated she was not aware of a possible pressure area on patients foot and that she had not been notified by therapy of any skin issues. RN indicated that the coordination of care is expected to happen in weekly phone conversations for patients care needs, but that most of the conversations are centered around to increase, decrease or discontinue services and not the specific of the care itself. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and agency staff interview, the agency failed to ensure skilled professional staff involved in the patient's plan of care completed an ongoing interdisciplinary wound assessment as required by agency policy and expectation for 1 of 1 sampled patients with wounds (Patient #3). Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. Findings include: According to the agency policy, titled Wound Assessment and Photography, dated 6/2020, wounds will be measured weekly and more often if wound deterioration is noticed. Do depth measurement first. Complete measurement with length and width. During interview on 4/1/24 at 2:00 PM, Staff B, Clinical Manager, reported wound measurements should be completed weekly. The measurements include depth, length and width of the wound. The wound measurements would be documented in the clinical record under assessment. Patient #1 had a start of care date of 11/8/23. Clinical record review revealed: Plan of Care, dated 3/7/24-5/5/24 included physician orders for skilled nursing 3 times a week that included wound care to left great toe. Interview during home visit with Staff C, Clinical Manager, reported wounds are usually measured at the first visit of the week Skilled nursing visit notes, dated 3/11/24 and 3/13/24, documentation did not include a length, width and depth of the wound. No wound measurements were completed for the week of 3/10/24. The agency nurse failed to follow their agency policy and measure wounds weekly. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to ensure documentation included electronic staff signature and credentials for 1 of 3 sampled patients with orders for Physical Therapy. (Patient #5) Failure to maintain appropriately authenticated electronic signatures risked patients receiving services from inappropriate staff. Findings include: 1. Patient #5 had a start of care date of 2/17/2020. Clinical record review revealed the following: The initial Physical Therapy Evaluation dated 3/28/24, lacked both an electronic signature and credentials. Agency staff failed to appropriately authenticate the clinical record documents The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.

The recertification survey, conducted 4/26/2021 through 4/28/2021, found the agency operating in substantial compliance with the regulatory requirements of the Establishment of Emergency Preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 4/26/21 through 4/28/21 . 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 found the agency operating out of compliance with multiple standard level regulatory requirements for Home Health Conditions of Participation.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and staff interview the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 4 of 6 sampled patients (Patients #3, #4, #6, and #7). At the time of the survey, the agency reported a current census of 40 patients. Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: Agency policy, titled Policy on Determining Fee for Service, dated 5/22/08, identified the agency will have a financial sheet completed upon admission. A client does have a right to not release any financial information and still receive services, however, it will be made known to the client that the client will be required to pay full fee for all services received, if not eligible for third party payment. The following information will need to be filled in below the financial data fields and fields should not be left blank but should be filled in with "N/A" or "0". Interview on 4/27/21 at 3:15, with the Clinical Manager revealed the agency reports the cost with insurance and their individual responsibility if there is a difference. The patient is notified if the insurance is not going to pay, what amount the patient may be billed. 1. Patient #3 had a start of care date of 3/18/19. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 3/18/19, included documentation the agency planned to bill Medicaid HMO/managed care plan for agency services. b. The Financial Data form included a handwritten signature by the patient and agency staff, dated 3/18/19. The form identified the agency's full fee amount for the services the patient was receiving, the amount the patient agreed to pay in the event the patient is not eligible for third party payment and identified what services the agency planned to provide and bill the responsible party and how much the agency planned to bill the responsible party for services the agency planned to bill the Medicaid HMO/managed care organization, but left the amount the patient would be responsible for under the Medicaid section blank. 2. Patient #4 had a start of care date of 4/5/21. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 4/5/21, included documentation the agency planned to bill Medicare for agency services. b. The Financial Data form included a handwritten signature by the patient and agency staff, dated 4/5/21. The form identified the agency's full fee amount for the services the patient was receiving, the amount the patient agreed to pay in the event the patient is not eligible for third party payment and identified what services the agency planned to provide and bill the responsible party and how much the agency planned to bill the responsible party for services the agency planned to bill Medicare, however, the agency checked all three boxes, making it unclear which fees applied to the patient. 3. Patient #6 had a start of care date of 1/15/21 and was discharged from the agency on 3/8/21. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 1/15/21, included documentation the agency planned to bill a Medicare HMO/managed care/Advantage Plan for agency services. b. The Financial Data form included a handwritten signature by the patient and agency staff, dated 1/15/21. The form identified the agency's full fee amount for the services the patient was receiving and the amount the patient agreed to pay in the event the patient is not eligible for third party payment, however failed to identify the agency planned to bill a Medicare HMO/managed care/Advantage Plan and identify the cost the patient would be responsible for. The agency checked the boxes for agency full fee and the patient agreed to pay the amount in the event the patient was not eligible for 3rd party payment, making it unclear which fees applied to the patient. 4. Patient #7 had a start of care date of 2/12/2020 and was discharged from the agency on 4/9/2020. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 2/12/2020, included documentation the agency planned to bill Medicare for agency services. b. The Financial Data form included a handwritten signature by the patient's representative and agency staff, dated 12/25/19. The form was completed when the patient was first admitted to the agency. The agency failed to complete a new form when the patient was readmitted to the agency. The form on file, identified Medicare was to be billed for the services the patient was receiving at that time, but failed to include physical therapy fee amounts, which the patient was receiving at the time of the 2/12/2020 admission. The above findings for Patients #3, #4, #6, and #7 were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency patients and/or patient representative received proper written notice, in advance of a service being furnished, if the agency believes the service may be non-covered for 2 of 3 patients with private insurance (Patients #1 and #8). At the time of the survey, the agency reported a current census of 40 patients. Failure to ensure agency patients and/or patient representative received proper written notice, in advance of a service being furnished, if the agency believes the service may be non-covered, placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: Agency policy, titled Policy on Determining Fee for Service, dated 5/22/08, identified the agency will have a financial sheet completed upon admission. A client does have a right to not release any financial information and still receive services, however, it will be made known to the client that the client will be required to pay full fee for all services received, if not eligible for third party payment. The following information will need to be filled in below the financial data fields and fields should not be left blank but should be filled in with "N/A" or "0". Interview on 4/27/21 at 3:15, with the Clinical Manager revealed the agency reports the cost with insurance and their individual responsibility if there is a difference. The patient is notified if the insurance is not going to pay, what amount the patient may be billed. 1. Patient #1 had a start of care date of 4/15/21. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 4/15/21, included documentation of a non-OASIS admission, which is performed for patients who do not have insurance that is Federally-funded or a Federal aide program. b. The Financial Data form included a handwritten signature by the patient and agency staff, dated 4/15/21. The form identified the agency's full fee amount for the services the patient was receiving, the amount the patient agreed to pay in the event the patient is not eligible for third party payment and identified the patient had private insurance, and checked all three boxes, agency full fee, insurance, and the patient agreement to pay full fee if not eligible for 3rd party payment, making it unclear to the patient's what the patient's cost will be. 2. Patient #8 had a start of care date of 2/23/21. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 2/23/21, included documentation of a non-OASIS admission, which is performed for patients who do not have insurance that is Federally-funded or a Federal aide program. b. The Financial Data form included a handwritten signature by the patient and agency staff, dated 2/23/21. The form identified the agency's full fee amount for the services the patient was receiving, the amount the patient agreed to pay in the event the patient is not eligible for third party payment and identified the patient had private insurance, and checked all three boxes, agency full fee, insurance, and the patient agreement to pay full fee if not eligible for 3rd party payment, making it unclear to the patient's what the patient's cost will be. The above findings for Patients #1 and #8 were reviewed with the agency Administrator, Public Health Administrator, and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment within the allowed time frames for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7 and #8 ). The agency reported a census of 40 patients at the time of the survey. Failure to ensure medications were reviewed at the time of each comprehensive assessment, using a current and accurate list of medications taken by the patient at the time of the assessment, increased the potential for unidentified medication interactions, patient non-compliance, ineffective medication therapy and side effect risks to the patient. Findings include: According to the agency policy, titled Drug Regimen Review, dated 1/25/21, a Drug Regimen Review (DRR) is to include medication reconciliation, identification of potential or actual clinically significant medication issues, and medication intervention as needed will be completed by the nurse for all home health clients at certain time points. The DRR should occur at the beginning of a care episode: Start of Care/Resumption of Care, at Recertification, Discharge, and with any other comprehensive assessment or any time significant medication issues are identified throughout the care episode. At those time points, the nurse will review and reconcile medications in order to assure the client is taking only the medications/dosages ordered by his/her physician. Medication orders are entered into the electronic medical record (EMR). The nurse will document in the EMR information related to medication allergies, nonadherence to medication regimen to include medications not in the home and/or medications taking incorrectly, knowledge deficit (client and/or caregivers), teaching/other follow up provided, adverse reactions noted, ineffective drug therapy, significant side effects, drug interactions, duplicate medications, medication omissions, dosing errors, and nonadherence to medication regimen. During interview on 4/26/21 at 11:10 AM, the Clinical Manager revealed the DRR is completed by the nurses and is to be completed at start of care, f/u assessments, with significant change in condition assessments, resumption of care assessments, and at discharge. 1. Patient #1 had a start of care date of 4/15/21. Clinical record review revealed: a. The initial Plan of Care dated 4/15/21 to 6/13/21, included orders for acetaminophen and ibuprofen for pain. b. The initial comprehensive assessment completed at start of care, dated 4/15/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for pain. c. The update to the comprehensive assessment completed for resumption of care dated 4/21/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for pain. 2. Patient #2 had a start of care date of 3/2/21. Clinical record review revealed: a. The initial Plan of Care dated 3/2/21 to 4/30/21, included orders for pioglitazone and glipizide for diabetes and doxazosin, hydrochlorothiazide-losartan, and metoprolol for blood pressure. b. The initial comprehensive assessment completed at start of care, dated 3/2/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "yes". The DRR identified under list problems identified the patient takes multiple medications for pain. The DRR failed to identify the duplicate medications used by the patient for diabetes and blood pressure. 3. Patient #3 had a start of care date of 3/18/19. Clinical record review revealed: a. The initial Plan of Care dated 3/18/19 to 5/16/19, included orders for vitamin b12 and vitamin D3 as supplements, Tradjenta, Lantus insulin, and glipizide for diabetes, and colace and miralax for constipation. b. The initial comprehensive assessment completed at start of care, dated 3/18/19, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for supplements, diabetes and constipation. c. The updates to Plan of Care dated 11/7/2020 to 1/5/21, 1/6/21 to 3/6/21, and 3/7/21 to 5/5/21, included orders for vitamin b12 and vitamin D3 as supplements, Tradjenta, Lantus insulin, and glipizide for diabetes, and naproxen, tramadol, and acetaminophen for pain. d. The updates to the comprehensive assessment for recertification, dated 11/3/2020, 1/4/21, and 3/2/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for supplements, diabetes and pain. 4. Patient #4 had a start of care date of 4/5/21. Clinical record review revealed: a. The initial Plan of Care dated 4/5/21 to 6/3/21, included orders for acetaminophen and acetaminophen/hydrocodone for pain, bisacodyl suppository, fleet enema, milk of magnesia, polyethylene glycol for bowels, and lantus and novolog insulin for diabetes. b. The initial comprehensive assessment completed at start of care, dated 4/5/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for pain, bowels, and diabetes. 5. Patient #5 had a start of care date of 4/2/21. Clinical record review revealed: a. The initial Plan of Care dated 4/2/21 to 5/31/21, included orders for spironolactone and lisinopril for blood pressure. b. The initial comprehensive assessment completed at start of care, dated 4/2/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "yes", but only identified multiple diabetic medications. The DRR failed to identify the duplicate medications used by the patient for blood pressure. 6. Patient #6 had a start of care date of 1/15/21 and was discharged from the agency on 3/8/21. Clinical record review revealed: a. The initial Plan of Care dated 1/15/21 to 3/15/21, included orders for glipizide and pioglitazone for diabetes and tramadol and acetaminophen for pain. b. The initial comprehensive assessment completed at start of care, dated 1/15/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for diabetes and pain. c. The update to the comprehensive assessment completed at discharge, dated 3/8/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for diabetes and pain. 7. Patient #7 had a start of care date of 2/12/2020 and was discharged from the agency on 4/9/2020. Clinical record review revealed: a. The initial Plan of Care dated 2/12/2020 to 4/11/2020, included orders for losartan and metoprolol for blood pressure. b. The initial comprehensive assessment completed at start of care, dated 2/12/2020, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "yes". The DRR failed to identify the duplicate medications used by the patient for blood pressure. c. The update to the comprehensive assessment completed at discharge, dated 4/9/2020, lacked documentation of completion of a drug regimen review. 8. Patient #8 had a start of care date of 2/23/21. Clinical record review revealed: a. The initial Plan of Care dated 2/23/21 to 4/23/21, included orders for acetaminophen and acetaminophen-hydrocodone for pain and multiple vitamins, vitamin D3 and vitamin B12 as vitamins. b. The initial comprehensive assessment completed at start of care, dated 2/23/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "no". The DRR failed to identify the duplicate medications used by the patient for pain and vitamins. c. The update to the Plan of Care for recertification, dated 4/24/21 to 6/22/21, included orders for acetaminophen and acetaminophen-hydrocodone for pain and multiple vitamins, vitamin D3 and vitamin B12 as vitamins. d. The update to the comprehensive assessment completed at discharge, dated 4/20/21, documented completion of a drug regimen review, however, answered the question "have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified" as "yes". The DRR failed to identify the duplicate medications used by the patient for pain and vitamins. The above findings for Patients #1, #2, #3, #4, #5, #6, #7, #8 were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 1 of 2 sampled patients requiring a recertification assessment (Patient #3). The agency reported a census of 40 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments 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 agency policy, titled OASIS/Comprehensive Assessment completion policy, dated 4/21, an update of the comprehensive assessment for recertification will be completed every other month from start of care (comprehensive assessment to be done within day 56 through day 60 of the certification period). Patient #3 had a start of care date of 3/18/19. Clinical record review revealed: a. The Plans of Care, dated 11/7/2020 to 1/5/21 and 1/6/21 to 3/6/2021, included physician orders for skilled nursing and home health aide services. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 11/3/2020 (day 57 of the certification period) but was not completed until 11/20/2020, 14 days into the new certification period. The certification period ended on 11/6/2020. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. c. The update to the comprehensive assessment at the time of recertification, dated as initiated on 1/4/21 (day 59 of the certification period) but was not completed until 1/15/21, 10 days into the new certification period. The certification period ended on 1/5/21. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. he above findings were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #1). The agency provided services to 40 patients at the time of the survey and performed 5 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment 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 agency policy, titled OASIS/Comprehensive Assessment completion policy, dated 4/21, an update of the comprehensive assessment for resumption of care will be completed within 48 hours of the client's return home from a hospital admit of 24 hours or more for reasons other than diagnostic tests. Patient #1 had a start of care date of 4/15/21. Clinical record review revealed: a. The transfer assessment, dated 4/19/21, documented the patient was hospitalized for urinary issues. b. The update to the comprehensive assessment at the time of resumption of care, dated 4/21/21, documented the patient was discharged from the hospital on 4/20/21. The nurse initiated the update to the assessment on 4/21/21 but did not complete the assessment until 4/26/21, 6 days after the patient's return home from the inpatient stay. The assessment was completed 4 days late as required by regulation and the agency's own policy. The above stated findings were reviewed with the Administrator and Clinical Manager. 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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 7 of 8 sampled patients (Patients #2, #3, #4, #5, #6, #7 and #8). The agency reported a census of 40 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the agency policy, titled Policy for Home Health Plan of Care, dated revised 2021, the plan of care must be discipline specific for all treatments and services. 1. Patient #2 had a start of care date of 3/2/21. Clinical record review revealed: a. The Plan of Care, dated 3/2/21 to 4/30/21, included physician orders for home health aide visits one time per week for one week and then two times per weekly for eight weeks; three times weekly for three weeks; twice weekly for two weeks; then three times weekly for three weeks and orders for physical therapy to evaluate and treat the patient. b. Home health aide visit notes, dated 3/11/21, documented one home health aide visit was made during the week of 3/7/21. c. Home health aide visit notes, dated 3/23/21, documented one home health aide visit was made during the week of 3/21/21. The physician ordered 2 home health aide visits to occur during both weeks. The clinical record lacked documentation of why the visits were not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in home health aide visit frequency. d. The physical therapy visit note, dated 3/9/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 3/9/21 to 4/9/21. The plan included a frequency of 2 visits per week for four weeks. e. Physical therapy visit notes, dated 4/4/21, documented only one physical therapy visit was made during the week of 4/4/21. The physician ordered 2 physical therapy visits to occur during the week. The clinical record lacked documentation of why the visits were not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in physical therapy visit frequency. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. 2. Patient #3 had a start of care date of 3/18/19. Clinical record review revealed: a. The Plan of Care, dated 1/6/21 to 3/6/21, included physician orders for home health aide visits three times per week for eight weeks beginning during the week of 1/10/2021. b. Home health aide visit notes, dated 3/3/21 and 3/5/21, documented two home health aide visit was made during the week 2/28/21. The physician ordered 2 home health aide visits to occur during this week. The clinical record lacked documentation of why the visit was not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in home health aide visit frequency. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. 3. Patient #4 had a start of care date of 4/5/21. Clinical record review revealed: a. The Plan of Care, dated 4/5/21 to 6/3/21, included physician orders for physical therapy to two times per week the week of 4/5/21 and then two times per week for seven weeks effective 4/11/21. b. The physical therapy visit note, dated 4/7/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 4/5/21 to 6/3/21 The plan included a frequency of 2 visits per week for four weeks. The note documented only one physical therapy visit was made during the week of 4/5/21. c. Physical therapy visit notes, dated 4/16/21, documented only one physical therapy visit was made during the week of 4/11/21. The notes documented only one physical therapy visit was made the weeks of 4/5/21 and 4/11/21. The physician ordered 2 physical therapy visits to occur during the week. The clinical record lacked documentation of why the visits were not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in physical therapy visit frequency. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. 4. Patient #5 had a start of care date of 4/2/21. Clinical record review revealed: a. The Plan of Care, dated 4/2/21 to 5/31/21, included physician orders for skilled nursing services for assessments, teaching, medication monitoring, and wound care. The Plan of Care included vital signs reporting parameters. b. The skilled nurse visit note, dated 4/6/21, lacked documentation of assessment of the patient's pulse, respirations, blood pressure, and oxygen saturation. c. The skilled nurse visit note, dated 4/9/21, lacked documentation of assessment of the patient's temperature, pulse, respirations, blood pressure, and oxygen saturation. d. The skilled nurse visit note, dated 4/23/21, lacked documentation of assessment of the patient's temperature. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. 5. Patient #6 had a start of care date of 1/15/21 and was discharged from the agency on 3/8/21. Clinical record review revealed: a. The Plan of Care, dated 1/15/21 to 3/15/21, included physician orders for skilled nursing services for assessments, teaching, wound care and colostomy teaching. The Plan of Care included vital signs reporting parameters. b. The skilled nurse visit note, dated 2/18/21, lacked documentation of assessment of the patient's temperature, pulse, respirations, blood pressure, and oxygen saturation. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. 6. Patient #7 had a start of care date of 2/12/2020 and was discharged from the agency on 4/9/2020. Clinical record review revealed: a. The Plan of Care, dated 2/12/2020 to 4/11/2020, included physician orders for skilled nursing services for assessments and teaching of glucose monitoring by the patient. b. The skilled nurse visit notes, dated 2/19, 2/27, 3/5, 3/11, and 3/24, lacked documentation of assessment of the patient's glucose monitoring. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. c. The Plan of Care, dated 2/12/2020 to 4/11/2020, included physician orders for home health aide visits two times per week for nine weeks. d. Home health aide visit notes, dated 2/27/2020, documented one home health aide visit was made during the week of 2/23/2020. e. Home health aide visit notes, dated 3/5/2020, documented one home health aide visit was made during the week of 3/1/2020. f. Home health aide visit notes, dated 3/30/2020, documented one home health aide visit was made during the week of 3/29/2020. g. The clinical record lacked documentation of home health aide visits the week of was made during the week of 4/9/2020. The physician ordered 2 home health aide visits to occur during every week. The clinical record lacked documentation of why the visits were not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in home health aide visit frequency. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. 7. Patient #8 had a start of care date of 2/23/21. Clinical record review revealed: a. The Plan of Care, dated 2/23/21 to 4/23/21, included physician orders for home health aide visits two times per week for nine weeks. b. Home health aide visit notes, dated 3/19/21, documented one home health aide visit was made during the week of 3/14/21. The physician ordered 2 home health aide visits to occur during the week of 3/14/21. The clinical record lacked documentation of why the visit was not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in home health aide visit frequency. The documentation lacked evidence of providing treatments as ordered by the doctor or notification to approve modifications from the original Plan of Care. The above stated findings for Patients #2, #3, #4, #5, #6, #7, and #8 were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and patient interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and physician approved staff interventions for 2 of 3 sampled patients with surveyor home visit observation(Patients #2 and #3). The agency reported a current census of 40 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy, titled Policy for Home Health Plan of Care and dated as revised in 2021, the individualized plan of care must include the following: all pertinent diagnoses, the patient's mental, psychosocial and cognitive status, the types of services, supplies and equipment required, the frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, all medications and treatments used by the patient, safety measures to protect against injury, a description of the patient's risk for emergency hospitalization and hospital readmission, discharge planning, patient-specific interventions and education and measurable outcomes and goals and information related to advance directives. 1. Patient #2 had a start of care date of 3/2/2021. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The physical therapy evaluation, dated 3/9/2021, documented the patient used a heating pad to relieve back pain. b. The physical therapy routine visit note, dated 3/16/2021, documented the patient continued using the heating pad to relieve back pain. c. On 4/27/2021 at 11:15 AM, the surveyor accompanied Staff E, Physical Therapy Assistant, to Patient #2's home. During the home visit, the patient explained pain levels and means of pain relief, including pharmacological and non-pharmacological. Patient interview during the home visit revealed Patient #2 used Tramadol for shoulder and elbow pain relief and used a heating pad to relieve back pain. d. The Plan of Care, dated 3/2/2021 to 4/30/2021, lacked inclusion of the heating pad used by the patient for pain relief. 2. Patient #3 had a start of care date of 3/18/2019. Clinical record review revealed the following: a. The Plan of Care, dated 3/7/2021 to 5/5/2021, included physician orders for home health aide assistance 3 times weekly to assist the patient with showering; shampooing; dressing and undressing; and application of lotion to the patient's back, arms and legs. The surveyor accompanied Staff F, Registered Nurse (RN), to Patient #3's home. During the home visit, patient interview revealed the home health aide had been applying a medicated cream underneath the breast area when reddened. The Plan of Care as stated above included physician orders for the use of Nystatin Cream under the breasts when reddened to treat fungal/yeast infection; however, lacked physician orders or direction for the aide to apply the powder as an extension of nursing services. The Plan lacked inclusion of the intervention. b. During the same home visit, patient interview revealed Patient #3 used a grab bar attached to the lower shower to assist with sitting and standing from the built in tub bench. Patient #3 reporting he/she used the grab bar when bathing. The Plan of Care, dated 3/7/2021 to 5/5/2021, lacked inclusion of the grab bar as equipment used to meet the needs of the patient. The above stated findings were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 5 of 5 sampled patients with new verbal/interim orders. (Patients #1, #2, #3, #4 and #6) The agency reported a current census of 40 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to agency policy, titled Policy for Home Health Plan of Care, revised 2020, new orders that arise, or changes or discontinuations to orders that occur are reflected in addendum or interim orders that are written in the Electronic Medical Record (EMR) and sent to the provider for signature. These orders will flow on the EMR to the Clinical Update, in order to have a working care plan. 1. Patient #1 had a start of care date of 4/15/21. Clinical record review revealed: a. The Plan of Care, dated 4/15/21 to 6/13/21, included physician orders for physical therapy to evaluate and treat the patient and instructed to see the physical therapy plan of care. b. The physical therapy visit note, dated 4/22/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 4/22/21 to 5/13/21. The plan included a frequency of weekly visits for three weeks and included physical therapy goals for the patient. c. A Clinical Update to the Plan of Care, dated 4/26/21, lacked documentation of updating the Plan of Care to include the changed physical therapy plan of care frequency and goals. 2. Patient #2 had a start of care date of 3/2/21. Clinical record review revealed: a. The Plan of Care, dated 3/2/21 to 4/30/21, included physician orders for physical therapy to evaluate and treat the patient. b. The physical therapy visit note, dated 3/9/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 3/9/21 to 4/9/21. The plan included a frequency of 2 visits per week for four weeks and included physical therapy goals for the patient. c. An interim physician's order, dated 3/11/21, included orders for physical therapy effective 3/11/21 for 1 visit per week for one week, and effective 3/14/21, two visits per week for three weeks and included see Physical Therapy Plan of Care. d. A Clinical Update to the Plan of Care, dated 4/6/21, lacked documentation of updating the Plan of Care to include the changed physical therapy plan of care frequency and goals. 3. Patient #3 had a start of care date of 3/18/19. Clinical record review revealed: a. An interim physician's order, dated 2/23/21, to collect a urinalysis due to increased confusion and weakness and instructed take the urine specimen to the hospital laboratory. b. An interim physician's order, dated 3/5/21, for Ceftin 500 milligrams (mg) twice a day for 10 days for patient's urinary tract infection. c. An interim physician's order, dated 3/16/21, for Colace 100 mg , 2 caps daily for constipation. The Plans of Care, dated 1/6/21 to 3/6/21 and 3/7/21 to 5/5/21, failed to include an update with the changes of the added orders. 4. Patient #4 had a start of care date of 4/5/21. Clinical record review revealed: a. The Plan of Care, dated 4/5/21 to 6/3/21, included physician orders for physical therapy to two times per week the week of 4/5/21 and then two times per week for seven weeks effective 4/11/21 and orders for occupational therapy to evaluate and treat. The Plan of Care lacked documentation of physical therapy goals and included documentation to see physical therapy Plan of Care. b. The physical therapy visit note, dated 4/7/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 4/5/21 to 6/3/21. The plan included a frequency of 2 visits per week for four weeks and included physical therapy goals for the patient. c. The occupational therapy visit note, dated 4/20/21, included the initial evaluation completed by the occupational therapist and orders for the occupational therapy plan of care for the period of 4/5/21 to 6/3/21. The plan included a frequency of 1 visits per week for one week and then two times per week for two weeks and included occupational therapy goals for the patient. d. An interim physician's order, dated 4/20/21, included orders for occupational therapy effective 4/20/21 for 1 visit per week for one week, and effective 4/25/21, two visits per week for one week and included see Occupational Therapy Plan of Care. e. A Clinical Update to the Plan of Care, dated 4/23/21, lacked documentation of updating the Plan of Care to include the changed occupational therapy plan of care frequency and goals. The Plans of Care, dated 4/5/21 to 6/3/21, failed to include an update with the changes of the added orders for physical and occupational therapy. 5. Patient #6 had a start of care date of 1/15/21 and was discharged from the agency on 3/8/21. Clinical record review revealed: a. An interim physician's order, dated 1/25/21, to perform a complete blood count laboratory draw to check the patient's hemoglobin and hematocrit. b. An interim physician's order, dated 2/19/21, to change skilled nursing visits to weekly for four weeks with 3 as needed visits effective 2/21/21. The Plan of Care, dated 1/15/21 to 3/15/21, failed to include an update with the changes of the added orders. The agency failed to ensure the Plan of Care was updated to include all patient care orders. The above stated findings for Patients #1, #2, #3, #4 and #6 were reviewed with the agency Administrator, Public Health Administrator, and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on agency staff interview, home visit observation and admission packet review, the agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address). The agency failed to provide this information for 3 of 3 sampled patients with a home visit observation (Patients #1, #2 and #3). The agency reported a census of 40 patients at the time of the survey. Failure to provide the contact information for the agency's clinical manager left the patients without the needed information to contact the agency clinical manager for any concerns about their services. Findings include: Review of the agency's admission packet revealed a form that included the following: "Call___________________ if you have clinical concerns or questions, we want to know. Please call your Clinical Manager ________________ at: 712-263-3303." A stamped insert of the name, address and main telephone number of the agency was added to the first blank line. The second blank line awaiting the name of the Clinical Manager was left blank. The form lacked the identification of the agency clinical manager's name or email address. 1. Patient #1 had a start of care date of 4/15/21. On 4/27/21 at 9:00 AM, the surveyor accompanied Staff D, Registered Nurse (RN), to Patient #1's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. Review of the admission folder, which included all paper work given to the patient by the agency, revealed a copy of the above stated form used by the agency to present the Clinical Manager's name, telephone and/or email contact information to the patient. The line on form used to place the Clinical Manager's name was left blank. None of the other documents in the folder included identification of who the Clinical Manager was or contact information. 2. Patient #2 had a start of care date of 3/2/21. On 4/27/21 at 11:15 AM, the surveyor accompanied Staff E, Physical Therapy Assistant, to Patient #2's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. Review of the admission folder, which included all paper work given to the patient by the agency, revealed a copy of the above stated form used by the agency to present the Clinical Manager's name, telephone and/or email contact information to the patient. The line on form used to place the Clinical Manager's name was left blank. None of the other documents in the folder included identification of who the Clinical Manager was or contact information. 3. Patient #3 had a start of care date of 3/18/19. On 4/27/21 at 2:00 PM, the surveyor accompanied Staff F, RN, to Patient #3's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. Review of the admission folder, which included all paper work given to the patient by the agency, revealed a copy of the above stated form used by the agency to present the Clinical Manager's name, telephone and/or email contact information to the patient. The line on form used to place the Clinical Manager's name was filled in with Staff G, an RN working only as needed (PRN) for the agency. None of the other documents in the folder included identification of who the Clinical Manager was or contact information. The above stated findings were reviewed with the Administrator and the Clinical Manager. During agency staff interview on 4/27/2021 at 3:45 PM, the Administrator and Clinical Manager both agreed the form identified above was the correct form the agency used to notify patients of the name and contact information of the Clinical Manager. The form was initiated just prior to the hiring of the current Clinical Manager, therefore the section was left blank. The agency never added the Clinical Manager's name to the form permanently, requiring admitting nurses to handwrite in the Clinical Manager's name. The agency provided no additional information prior to the end of the survey.

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 clinical record review and agency staff interview, the agency failed to send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 2 sampled patients with a discharges (Patient #7). The agency reported discharging 39 patients in the past 6 months. 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: Patient #7 had a start of care date of 2/12/2020 and was discharged from the agency on 4/9/2020. Clinical record review revealed: a. The Plan of Care, dated 2/12/2020 to 4/11/2020, documented the patient's diagnoses as aftercare following a left below the knee amputation. b. The discharge assessment, dated 4/9/2020, documented the patient was discharged from the agency on 4/9/2020. c. The discharge summary, dated 4/9/2020, did not include any notification to indicate when the summary was sent to the physician. There was a stamp the signed discharge summary was received by the agency on 05/12/2020 Interview with the Clinical Manager on 4/28/21 at 12:55 PM revealed no documentation was found to indicate when the discharge summary was sent to the physician. The above findings were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on patient clinical record review and agency staff interview, the agency failed to ensure agency staff properly authenticated all clinical entry notes and/or completed within the agency's expected timeframe for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, and #8) receiving home health services. The agency reported 40 patients received home health aide services at the time of the survey. Failure to ensure all clinical record documentation was dated, timed and signed with staff title and/or completed within the agency's expected timeframe, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: Interview on 4/26/21 at 11:10 AM with the Administrator and Clinical Manager revealed agency staff are to complete all documentation within 24 hours from when the visit is completed. 1. Patient #1 had a start of care date of 4/15/21. Clinical record review revealed: a. The physical therapy visit note for initial evaluation, dated 4/22/2020, included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time of when the note was completed. b. The skilled nurse visit note, dated 4/16/21 included an electronic signature and date of completion of 4/19/21, 2 days late according to agency expectation. 2. Patient #2 had a start of care date of 3/2/21. Clinical record review revealed: a. The physical therapy visit note for initial evaluation, dated 3/9/21 included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time when the note was completed. b. The physical therapy visit notes, dated 3/11, 3/16, 3/18, 3/22, 3/25, and 3/30, 4/2, 4/8, 4/13, and 4/16/21 included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time of when the note was completed. 3. Patient #3 had a start of care date of 3/18/19. Clinical record review revealed: a. The home health aide visit note, dated 4/7/21 included an electronic signature and date of completion of 4/12/21, 4 days late according to agency expectation. b. The skilled nurse visit note, dated 4/13/21 included an electronic signature and date of completion of 4/15/21, 1 day late according to agency expectation. 4. Patient #4 had a start of care date of 4/5/21. Clinical record review revealed: a. The physical therapy visit note for initial evaluation, dated 4/07/2020, included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time when the note was completed. b. The physical therapy visit notes, dated 4/16, 4/19, and 4/22/21 included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time when the note was completed. c. a. The occupational therapy visit note for initial evaluation, dated 4/20/2020, included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time when the note was completed. 5. Patient #5 had a start of care date of 4/2/21. Clinical record review revealed: a. The home health aide visit note, dated 4/2/21 included an electronic signature and date of completion of 4/7/21, 4 days late according to agency expectation. b. The home health aide visit note, dated 4/5/21 included an electronic signature and date of completion of 4/7/21, 1 day late according to agency expectation. c. The skilled nurse visit note, dated 4/6/21 included an electronic signature and date of completion of 4/12/21, 5 days late according to agency expectation. d. The skilled nurse visit note, dated 4/9/21 included an electronic signature and date of completion of 4/14/21, 4 days late according to agency expectation. 6. Patient #6 had a start of care date of 1/15/21 and was discharged from the agency on 3/8/21. Clinical record review revealed: a. The skilled nurse visit note, dated 1/17/21 included an electronic signature and date of completion of 1/27/21, 9 days late according to agency expectation. b. The skilled nurse visit note, dated 1/19/21 included an electronic signature and date of completion of 1/27/21, 7 days late according to agency expectation. c. The skilled nurse visit note, dated 1/20/21 included an electronic signature and date of completion of 1/27/21, 6 days late according to agency expectation. d. The skilled nurse visit note, dated 1/25/21 included an electronic signature and date of completion of 2/2/21, 7 days late according to agency expectation. e. The skilled nurse visit note, dated 1/27/21 included an electronic signature and date of completion of 2/4/21, 7 days late according to agency expectation. f. The skilled nurse visit note, dated 1/29/21 included an electronic signature and date of completion of 2/2/21, 3 days late according to agency expectation. 7. Patient #7 had a start of care date of 2/12/2020 and was discharged from the agency on 4/9/2020. Clinical record review revealed: a. The physical therapy visit note for initial evaluation, dated 2/13/2020 included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time when the note was completed. b. The physical therapy visit notes, dated 2/18, 2/21, 2/25, 2/28, 3/3, 3/6, 3/9, 3/11, 3/17, 3/19, 3/23, 3/27 and 3/31/2020, included documentation of a signature of completion and title of the therapist, however included a time in and out of the visit, not the date and time of when the note was completed. 8. Patient #8 had a start of care date of 2/23/21. Clinical record review revealed: a. The home health aide visit note, dated 2/23/21 included an electronic signature and date of completion of 2/26/21, 2 days late according to agency expectation. b. The home health aide visit note, dated 4/6/21 included an electronic signature and date of completion of 4/12/21, 5 days late according to agency expectation. The Administrator and Clinical Manager received the above findings for Patients #1, #2, #3, #4, #5, #6, #7, and #8. Agency staff provided no further information prior to the end of the survey.