Every finding on record at Des Moines County Health Department

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 1/20/26 through 1/22/26 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 1/20/26 through 1/22/26 and the home health agency was found to be operating out of compliance with the following standard level regulatory requirements. The agency reported a census of 7 patients at the time of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician 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 2 of 7 sampled patients. (Patients #2 and #6) 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 Plan of Care – CMS #485 and Physician/ Practitioners Orders, dated February 2025, if the agency provides fewer visits than the physician/ practitioner orders, it has altered the plan of care and the physician/ practitioner must be notified. The agency must maintain documentation in the clinical record indicating that the physician/ practitioner was notified and is aware of the missed visit. During an interview on 1/8/26 at 10:37 AM, Administrator reported communication with physicians is documented in an electronic physician notification, printed out and faxed to the physician. 1. Patient #6 had a start of care date of 11/7/24 and a discharge date of 12/31/25. Clinical record review revealed: a. Plan of Care, dated 11/2/25 to 12/31/25, included primary diagnosis of end-stage renal disease and physician orders for skilled nursing and home health aide services. b. Home health aide documentation, dated 11/20/25, identified the patient refused services. c. Interim physician order, dated 11/20/25, included documentation of a missed home health aide visit on 11/20/25, a handwritten signature and dated 1/21/26. During an interview on 1/22/26 at 9:00 AM, Staff B, Clinical Manager, reported she was unable to locate an interim physician order for the missed visit on 11/20/25, Staff C, RN (registered nurse) wrote an order and faxed to physician office on 1/21/26. 2. Patient #2 had a start of care date of 3/5/25. Clinical record review revealed: a. Plan of Care, dated 11/1/25 to 12/30/25, included primary diagnosis of chronic obstructive pulmonary disease and physician orders for skilled nursing and home health aide services 2 times a week. b. Home health aide documentation, dated 12/26/25, identified the patient refused services. c. Interim physician order, dated 12/23/25, included documentation of a missed home health aide visit on 12/23/25, a handwritten signature and dated 1/21/26. During an interview on 1/22/26 at 9:00 AM, Staff B, Clinical Manager, reported she was unable to locate an interim physician order for the missed visit on 12/23/25, Staff C, RN wrote an order and faxed to physician office on 1/21/26. The above findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to obtain physician orders for resumption of care services for 2 of 2 sampled patients (Patients #1 and #5) with resumption of care assessments. Failure to ensure staff obtain physician orders for all services and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care – CMS #485 and Physician/ Practitioners Orders, dated February 2025, drugs, services and treatments are administered by staff as ordered by physician/ practitioner. Verbal orders are put in writing, signed, timed and dated with the date of receipt by skilled nurse responsible for furnishing or supervising ordered services. All clinical services are implemented only in accordance with a Plan of Care established by a physician/ practitioner’s written order. 1. Patient #1 had a start of care date of 4/27/17. Clinical record review revealed: a. Plan of Care, dated 9/12/25 to 11/10/25, included primary diagnosis of major depressive disorder and physician orders for skilled nurse and home health aide services. b. Resumption of care assessment, dated 9/16/25, completed. c. Interim physician order, dated 9/16/25, for resumption of home care services identified a handwritten signature, dated 1/22/26. During an interview on 1/22/26 at 11:00 AM, Staff B, Clinical Manager, reported she was unable to find the resumption of care order for 9/16/25. The agency failed to obtain interim physician order for resumption of care at the time resumption of care assessment was completed. 2. Patient #5 had a start of care date of 3/16/17. Clinical record review revealed: a. Plan of Care, dated 9/30/25 to 11/28/25, included primary diagnosis of neuroleptic induced parkinsonism and physician orders for skilled nurse and home health aide services. b. Resumption of care assessment, dated 11/6/25, completed. c. Interim physician order, dated 11/6/25, for resumption of home care services identified a handwritten signature, dated 1/21/26. During an interview on 1/22/26 at 9:00 AM, Staff B, Clinical Manager, reported she was unable to find the resumption of care order for 11/6/25. The agency failed to obtain interim physician order for resumption of care at the time resumption of care assessment was completed. The above findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.

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 patient 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 4 of 5 sampled patients receiving home health aide services that required aide supervision (Patients #1, #2, #3 and #5). 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 agency policy titled, Home Health Aide Supervision, dated February 2024, hoe health aide supervision must ensure that aides furnish care in a safe and effective manner, including but not limited to, the following elements: following the patient’s plan of care, maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies and procedures, reporting changes in the patient’s condition, and honoring patient rights. During an interview on 1/21/26 at 3:00 PM, Staff B, Clinical Manager, reported some aide supervision may be handwritten on a nurses note document verses the visit note document but voiced understanding of what elements were missing. 1. Patient #1 had a start of care date of 4/27/17. Clinical record review revealed: a. Plan of Care, dated 11/11/25 to 1/9/26, included primary diagnosis of major depressive disorder and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit notes, dated 11/25/25, 12/2/25, 12/9/25, 12/23/25, 12/30/25 and 1/13/26, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. 2. Patient #2 had a start of care date of 3/5/25. Clinical record review revealed: a. Plan of Care, dated 11/1/25 to 12/30/25 and 12/31/25 to 2/28/26, included primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit notes, dated 11/26/25, 12/3/25, 12/10/25, 12/22/25, 12/31/25 and 1/14/26, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. 3. Patient #3 had a start of care date of 2/9/23. Clinical record review revealed: a. Plan of Care, dated 11/25/25 to 1/23/26, included primary diagnosis of Type 2 Diabetes Mellitus without complications and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit note, dated 12/22/25, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. 4. Patient #5 had a start of care date of 3/16/17. Clinical record review revealed: a. Plan of Care, dated 11/29/25 to 1/27/26, included primary diagnosis of neuroleptic induced parkinsonism and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit notes, dated 12/3/25, 12/17/25, 12/31/25 and 1/14/26, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. The above findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.

The Department of Inspections and Appeals conducted a recertification survey, dated 1/9/23 to 1/11/23, and found the agency to be operating in substantial compliance with the Emergency Preparedness Condition of Participation.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 1/9/23 to 1/11/23. The survey identified the following standard level deficient practices. The agency reported a census of 8 patients at the time 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 clinical record review, agency policy review and staff interview, the agency failed to ensure accurate completion of all pertinent components 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 an update to the comprehensive assessment at the resumption of care (Patient #6). 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: Review of the policy, titled Initial Assessments/Comprehensive Assessments, dated 2/2022, identified the agency's comprehensive assessment includes the use of Outcome and Assessment Information Set (OASIS) and agency nursing staff must conduct a an assessment within 48 hours of a patient's return home (from an inpatient hospitalization) or physician-ordered start of care date. The OASIS items collected include data items related to the inpatient facility admission or discharge. On 1/10/22 at approximately 8:30 AM, during an interview, the Clinical Manager identified Patient #6 as the only patient to have an update to the comprehensive assessment at the time of resumption of care, dated 9/12/22, in the last 6 months. Patient #6, a patient receiving home health services through Medicaid a required the completed of a OASIS as part of the comprehensive assessment, had a start of care date of 3/30/22 and discharged from agency services on 10/21/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/28/22 to 9/25/22, included orders for skilled nursing and home health aide services. b. A transfer OASIS, dated 9/8/22, included documentation the patient had been transferred and admitted to a local hospital on 9/8/22. c. The clinical record included documentation of an update to the comprehensive assessment, dated 9/12/22. The update to the comprehensive assessment identified the assessment as an "other assessment" and agency staff completed the OASIS data set questions identified with an update to the comprehensive assessment at the time of recertification. Agency staff failed to complete the required correct OASIS data set for an update to the comprehensive assessment at the resumption of care. The assessment failed to identify when the patient discharged from the hospital and when the agency received the referral to resume agency services. The clinical record lacked documentation which identified when the patient discharged from the hospital and when the agency received notification of the patient's discharge. On 1/10/23 at 11:00 AM, during an interview, the surveyor informed the Clinical Manager of the incorrect OASIS being done for the resumption of care. The Clinical Manager did not think they had another type they could do at first, but then agreed they should have done a the start of care (SOC)/resumption of care (ROC) OASIS. The clinical record lacked information on the hospitalization including date of discharge and when the agency became aware of the patient’s discharge. On 1/10/23 at 2:02 PM, during an interview, the Clinical Manager reported the agency contacted the hospital where the patient had received inpatient services and found out the patient discharged from the hospital on 9/9/22. The Clinical Manager reported the agency requested a copy of the hospital’s discharge report. Agency staff failed to complete the update to the comprehensive assessment at the time of resumption of care within 48 hours of the patient's discharge from an inpatient hospitalization. The Administrator and Clinical Manager received the above findings

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, and patient interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all medication, supplies and equipment used by the patient to meet their needs for 4 of 7 sampled patients (Patients #1, #2, #3 and #4). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 3. Patient #3 had a start of care date of 1/7/22. Review of the clinical record revealed the following: The POC, dated 1/2/23 to 3/2/23, included an order for skilled nursing services to assess the patient and set up medications one time every other week. The POC had medication orders which included orders for Zinc 50 milligrams (mg) 1 tablet every day, Oxycodone 5 mg tablets 1 tab every 6 hours as needed for pain and Polyethylene Glycol (Miralax) 17 grams every day. On 1/10/23 at 1:00 PM, during a home visit observation, the surveyor observed Staff C, Registered Nurse (RN), assessed the patient and set up the patient’s medications. Staff C, RN, set up the patient medications per the POC with the following exception: Zinc 30 mg by mouth 1 tablet daily. The POC included an order for Zinc 50 mg 1 tablet daily. Staff C, RN, commented they were setting up 30 mg instead of the 50 mg tablets. The surveyor observed a Pro Air inhaler, 90 mcg, a bottle of Acetaminophen 500 mg tablets, open, but mostly full. The surveyor was unable to find the bottle of Oxycodone 5 mg tablets and a bottle of Miralax. In an interview, during the same home visit observation, Staff C, RN, reported the Zinc bottle with 30 mg tablets started out with 100 tablets and had approximately 20 left in the bottle after Staff C, RN, just set up 14 days of the medication. Staff C, RN, reported they had been setting up 30 mg tablets instead of 50 mg tablets for at least a couple weeks. The patient reported using the Pro Air inhaler for years. The patient reported being unable to take the Miralax and last had it more than a year ago. The patient reported not having the Oxycodone and does not remember ever taking the medication. The patient reported buying the Acetaminophen 500 mg 3 weeks ago and took it for a migraine. They reported it was not very effective. The POC failed to include current orders for medications. On 1/11/23 at 9:41 AM, during an interview, Staff C, RN, reported they had contacted the patient’s physician on 11/18/22 in regards to the Zinc change in dose from 50 mg a day to 30 mg daily, and received a verbal order 11/21/22 verifying the dose change was okay. Staff C, RN, reported the order had been sent for physician signature on 12/15/22. 4. Patient #4, a pediatric patient, had a start of care date of 10/30/17. Review of the clinical record revealed the following: The POCs, dated 10/4/22 to 12/2/22 and 12/3/22 to 1/31/23, included an order for skilled nursing services and the following incomplete medication orders: a. Albuterol Sulfate inhalation as needed breathing treatment. The order failed to identify the medication was delivered via a nebulizer and failed to identify a frequency (for example, daily or 4 times per day). b. Acetaminophen pediatric rectal suppository as needed every 4 hours for pain. The order failed to identify a dosage amount. c. Keppra 300 mg twice per day, Vitamin B6 80 mg daily, Nexium 5 mg bid and Miralax 17 grams in 8 ounces of water all lacked a route of administration of the medication. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. Findings include: According to agency policy, titled Plan of Care - CMS #485 and Physician/Practitioner Orders, dated February 2022, each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must include the types of services, supplies and equipment required; and all medications and treatments. 1. Patient #1 had a start of care date of 4/27/17. The Plan of Care, dated 11/27/22 to 1/25/23, included hydroxyzine, ayr saline nasal spray, hydrocortisone, saline nasal spray, chlorahexadine gluconate, biofreeze and memo max pro, as medications the patient was taking. a. During a home visit observation, on 1/10/23 at 9:05 AM, with Staff C, registered nurse, the surveyor asked the patient about as needed medications and the patient was able to report if they continued to take the medication. The patient reported they no longer took hydroxyzine, ayr saline nasal spray, hydrocortisone, saline nasal spray, chlorahexadine gluconate, biofreeze and memo max pro, and had not for approximately 2 months. The Plan of Care failed to be updated with the removal of medications the patient no longer utilized. The Plan of Care failed to identify a correct list of medications used by the patient. 2. Patient #2 had a start of care date of 10/20/22. The Plans of Care, dated 10/20/22 to 12/18/22 and 12/19/22 to 2/16/23, included blood glucose monitor, sharps container, wheeled walker with seat, pill planner, incontinent brief, pulse oximeter, toilet riser, and shower chair, as medical equipment used by the patient. a. During a home visit observation, on 1/10/23 at 10:10 AM, with Staff C, registered nurse, the surveyor observed the patient use a reacher to obtain the blood glucose monitor from a shelf in the living room, grab bars and a handheld shower in the bathroom, and dressing supplies used for wound care. The patient reported using the handheld shower and grab bars in the bathroom to bathe themself, Staff C used the wound care supplies to complete wound care. The patient reported not having a pulse oximeter in the home. Clinical record review revealed: b. Skilled nursing visit notes, dated 12/28/22 and 1/4/23, included documentation of wounds and wound care provided. The plan of care, dated 12/19/22 to 2/16/23, failed to include wound care orders. The Plan of Care failed to include reacher, grab bars, handheld shower, and dressing supplies as medical equipment used by the patient and wound care orders. The Plan of Care failed to identify accurate medical equipment used by the patient and current wound care orders.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, agency policy review and staff interview, the agency failed to update the Plan of Care with healthcare practitioner orders obtained during a 60 day certification period for 5 of 7 sampled patients (Patients #2, #3, #4, #6 and #7). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 4. Patient #2 had a start of care date of 10/20/22. The Plans of Care, dated 10/20/22 to 12/18/22 and 12/19/22 to 2/16/23, included the diagnosis of Type 2 diabetes and orders for skilled nursing services. a. The clinical record included interim physician order for wound care to right foot fifth toe, dated 11/16/22. During an interview on 1/11/23 at 10:30 AM, Staff C, registered nurse, confirmed interim physician order, dated 11/16/22, was not added to the plan of care, dated 10/20/22 to 12/18/22. The clinical record lacked documentation of a Plan of Care update for the certification period, dated 10/20/22 to 12/18/22, which included the interim physician order for wound care to right foot fifth toe. 5. Patient #7 had a start of care date of 8/30/11 and a discharge date of 9/27/22. The Plan of Care, dated 7/3/22 to 8/31/22, included diagnosis of essential hypertension and orders for skilled nurse and home health aide services. a. The clinical record included interim physician order for an additional skilled nurse visit, dated 7/13/22. The clinical record lacked documentation of a Plan of Care update for the certification period, dated 7/3/22 to 8/31/22, which included the interim physician order for an additional skilled nurse visit. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey. Review of the agency policy, titled Plan of Care (POC)- CMS #485 and Physician/Practitioners Orders, dated 2/2022, revealed agency staff provide services under a plan of care established by a physician. Staff must record all patient orders in the POC. Agency staff will revise the POC to reflect any orders received during the 60 day certification period so that all staff are working from a current POC. On 1/9/23 at 9:15 AM, during an interview, the Clinical Manager reported agency nursing staff were required to update the POC with interim physician orders. Staff write the orders received during the certification period on the back of the current POC. 1. Patient #3 had a start of care date of 1/7/22. Review of the clinical record revealed the following: a. The POCs, dated 11/3/22 to 1/1/23 and 1/2/23 to 3/2/23, included an order for skilled nursing services and orders for medications. The POCs included an order for Zinc 50 milligrams (mg) 1 tablet by mouth daily. b. The clinical record included documentation of a verbal request to the physician from the nurse, dated 11/18/22, to change the patient's Zinc dose to 30 mg 1 tablet by mouth daily. The physician responded on 11/21/22 that this dose change was okay. The clinical record lacked documentation of an updated POC, for the certification period of 11/3/22 to 1/1/23 with an interim physician order (IPO) change for the dose of Zinc and the current POC continued to have the order for Zinc 50 mg daily. On 1/10/23 at 1:00 PM, during a home visit observation, the surveyor observed Staff C, RN, set up the patient's medications including Zinc 30 mg 1 tablet daily. On 1/11/23 at 9:41 AM, during an interview, Staff C, Registered Nurse (RN), reported they had contacted the patient’s physician on 11/18/22 in regards to the Zinc change in dose from 50 mg a day to 30 mg daily, and received a verbal order 11/21/22 verifying the dose change was okay. Staff C, RN, reported the order had been sent for physician signature on 12/15/22. 2. Patient #4, a pediatric patient, had a start of care date of 10/30/17. Review of the clinical record revealed the following: a. The POC, dated 12/3/22 to 1/31/23, included an order for skilled nursing services and orders for medications. b. An IPO, dated 12/7/22, included the following medication orders: Dexamethasone 2 mg tabs, 1 tab twice per day for 5 days, Cefdinir 125 mg/ 5 milliliters (ml) suspension, take 6 ml every 12 hours for 10 days. c. The clinical record lacked documentation of an updated POC, for the certification period of 12/3/22 to 1/31/23 with the medication changes from the IPO, dated 12/7/22. 3. Patient #6 had a start of care date of 3/30/22 and discharged from agency services on 10/21/22. Review of the clinical record revealed the following: a. The POC, dated 7/28/22 to 9/25/22, included an order for skilled nursing services and orders for medications. b. An IPO, dated 8/16/22, included an order for Metolazone 5 mg 1 tab every day for 5 days by mouth and take with extra Potassium 20 mg. c. An IPO, dated 9/1/22, included an order or Cipro 500 mg every 12 hours for 5 days. d. An IPO, dated 9/12/22, included orders for an as needed nursing visit after the patient's discharge from the hospital, discontinue Amlodipine 5 mg by mouth daily and discontinue Lorazepam 0.5 mg by mouth twice per day as needed for panic attacks. e. The clinical record lacked documentation of an updated POC, for the certification period of 7/28/22 to 9/25/22 with the medication changes from the IPO,s dated 8/16, 9/1 and 9/12/22.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency staff failed to provide medications and treatments only as ordered by the healthcare practitioner for 3 of 7 sampled patients (Patients #2, #3 and #6). Failure to ensure staff obtain/follow healthcare practitioner orders for administration of medications and treatments placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 3. Patient #2 had a start of care date of 10/20/22. Clinical record review revealed: a. The Plan of Care, dated 10/20/22 to 12/18/22, included orders for skilled nurse services for assessment, vital sign monitoring, blood glucose monitoring, medication set-up in medication planner, medication compliance monitoring, assess for falls each visit, depression, anxiety level, safety at home, homebound status and pain. i. Skilled nurse visit note, dated 12/7/22, included documentation of two wounds on the right foot and wound care completed. ii. Skilled nurse visit note, dated 12/14/22, included documentation of one wound on right foot third toe and one wound on right foot great toe. b. The Plan of Care, dated 12/19/22 to 2/16/23, included orders for skilled nurse services for vital sign monitoring, head to toe assessment, blood glucose monitoring, medication set-up, and medication compliance monitoring. i. Skilled nurse visit note, dated 12/28/22, included documentation of three wounds on the right foot, one wound on the left foot and wound care provided. ii. Skilled nurse visit note, dated 1/4/23, included documentation of three wounds on the right foot and one wound on the left foot. During an interview on 1/11/23 at 10:30 AM, Staff C, registered nurse, reported reviewing the patient clinical record for interim physician orders for wound care and was unable to find any interim physician orders after 11/16/22. Staff C confirmed wound care orders were not included on the plan of care, dated 12/19/22 to 2/16/23. The clinical record lacked documentation of interim physician orders for wound care orders for the above stated wounds. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey. Review of the agency policy, titled Plan of Care (POC)- CMS #485 and Physician/Practitioners Orders, dated 2/2022, revealed agency staff provide services under a plan of care established by a physician. Agency staff implement the POC and provide services and treatments only as ordered. Agency staff promptly notify the physician to any changes that suggest a need to alter the POC. 1. Patient #3 had a start of care date of 1/7/22. Review of the clinical record revealed the following: a. The POC, dated 11/3/22 to 1/3/23, included an order for skilled nursing services one time every other week and for the nurse to set up the patient's medications. b. The skilled nursing visit, dated 12/15/22, included documentation the nurse assessed the patient's medication compliance, but lacked documentation the nurse set up the patient's medications per the POC. 2. Patient #6 had a start of care date of 3/30/22 and discharged from agency services on 10/21/22. Review of the clinical record revealed the following: The POCs, dated 7/28/22 to 9/25/22 and 9/26/22 to 11/24/22, included an order for skilled nursing services one time every other week, an order for the nurse to set up the patient's medications and an order for the nurse to give the patient a monthly B-12 injection. a. The skilled nursing visits, dated 8/9, 8/15, 8/23, 9/6, 9/12 and 9/21/22, lacked documentation the nurse set up the patient's medications. b. A skilled nursing visit, dated 8/9/22, included documentation the nurse gave the patient their monthly B-12 injection. 1) A skilled nursing visit, dated 8/23/22, included documentation the nurse planned on seeing the patient on 9/6/22 and administering the B-12 injection at that visit. 2) A skilled nursing visit, dated 9/6/22, lacked documentation the nurse gave the patient a B-12 injection per the POC. 3) The clinical record lacked documentation the patient received a B-12 injection prior to 10/4/22. Agency nursing staff failed to administer a B-12 injection in the month of September per the POC orders. On 1/11/23 at 12:23, during an interview, the Clinical Manager reported the inability to find any further information on the missed B-12 injection.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the patients clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 1 of 1 sampled patients with wounds (Patient # 2). Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's policy, titled Wound Policy and Procedure, dated May 2017, identified if a patient is currently undergoing wound treatment, weekly assessments and documentation will be performed. Wound assessment should take into account dimensions: length, width and depth. During an interview on 1/9/23 at 9:15 AM, Staff B, Clinical Manager, reported wounds should be measured weekly and include length, width and depth. Patient# 2 had a start of care date of 10/20/22. Clinical record review revealed: Plans of Care, dated 10/20/22 to 12/18/22 and 12/19/22 to 216/23, included orders for skilled nursing services weekly. a. The update to the comprehensive assessment completed at recertification, dated 12/14/22, included documentation of wound on right foot third toe measured 0.7 cm (centimeters) by 0.3 cm and wound on right foot great toe measured 1.5 cm by 0.5 cm. b. Skilled nurse visit note, dated 12/28/22, included documentation of wound #1 on right foot measured 1.5 cm by 0.7 cm, wound #2 on right foot measured 0.5 cm by 0.4 cm, wound #3 on right foot measured 1.0 cm by 0.8 cm, and wound #4 on left foot measured 0.4 cm by 0.3 cm. Depth for all wounds were marked with a slash in the box. During an interview on 1/11/23 at approximately 10:00 AM, Staff C, Registered Nurse, reported all wounds were open and superficial in depth. The clinical record failed to include wound measurements that included length, width and depth for all wounds identified. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey.