Every finding on record at Emedicial Group of Iofwa No.2 LLC

As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City location, the Iowa Department of Inspections, Appeals & Licensing conducted a complaint survey for complaint #2666917-C from 12/15/25 to 12/17/25. The complaint survey identified the following: Condition of Participation 42 CFR 484.60 Care Planning, coordination of services and quality of care, was investigated and no condition level deficiency was identified and one standard level deficiency was identified (G574) and Condition of Participation 42 CFR 484.110 Clinical records, was investigated and no condition level deficiency was identified and one standard level deficiency was identified (G1012). The agency reported a census of 100 patients at the time of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a home observation visit, patient interview, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all medical supplies/equipment used by the patient for 3 of 5 sampled patients (Patients #1, #2 and #5). Failure to maintain complete and accurate Plans of Care placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs. Findings include: According to the agency policy titled Plan of Care, revised in February 2022, the plan of care is based upon relevant assessment findings. The content of the patient's plan of care includes, but is not limited to: diagnoses, medications, medical supplies/equipment, safety measures and functional limitations. 1.Patient #1 had a start of care date of 11/16/23. Clinical record review revealed: a. The Plan of Care (POC), dated 11/5/25 to 1/3/26, identified the patient had diagnosis of sepsis and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: cane, rails/grab bars, shower/tub equipment, walker, wheelchair and nursing supplies. b. The skilled nurse visit note, dated 12/3/25, completed by Staff C, Registered Nurse (RN), identified the patient was using a heating pad and got burned. c. During a home observation visit on 12/15/25 at 12:05 PM with Staff C, RN, the patient stated he/she plans to continue to use the heating device (rice bag) as needed for pain relief; however, will not heat it up as long in the microwave. The agency failed to include all medical supplies/equipment on the patient's POC, including the heating device (rice bag). 2. Patient #2 had a start of care date of 10/17/25. Clinical record review revealed: a. The POC, dated 10/17/25 to 12/15/25, identified the patient had a diagnosis of pressure ulcer of sacral region and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: commode, lift, wheelchair, incontinence supplies, wound care supplies and nursing supplies. b. The physical therapist visit note, dated 10/17/25, completed by Staff I, Physical Therapist, identified the patient uses a handheld shower head. The agency failed to include all medical supplies/equipment on the patient's POC, including a handheld shower head. 3. Patient #5 had a start of care date of 10/29/25. Clinical record review revealed: a. The POC, dated 10/29/25 to 12/27/25, identified the patient had a diagnosis of age related osteoporosis and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: walker. b. The skilled nurse start of care comprehensive assessment visit, dated 10/29/25, completed by Staff D, RN, identified the patient utilized a lifeline and also identified the patient had incontinence. c. The skilled nurse visit note, dated 12/3/25, completed by Staff E, Licensed Practical Nurse (LPN), identified the patient checks his/her blood sugars. The agency failed to include all medical supplies/equipment on the patient's POC, including lifeline, incontinence supplies and diabetic supplies. The above findings were reviewed with the Administrator, Director of Nursing and Regional Clinical Director.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to provide complete wound assessments on a weekly basis per agency policy for 2 of 3 sampled patients with wounds (Patient #2 and #3). Failure to accurately and thoroughly complete wound assessments put patients at an increased risk of unidentified condition changes. Findings include: According to the agency's clinical procedure for wound care and assessment, wound assessments and measurements are to be documented weekly. During an interview on 12/16/25 at 10:03 AM, Staff A, Administrator stated wounds are measured weekly and documented in the patient's electronic medical record. Wound measurements include length, width and depth in centimeters. 1.Patient #2 had a start of care date of 10/17/25. Clinical record review revealed: a. The Plan of Care (POC), dated 10/17/25 to 12/15/25, identified the patient had a diagnosis of pressure ulcers of sacral region (fives wounds) and included physician orders for skilled nursing services two times a week for one week and then three times a week for three weeks. b. The skilled nurse visit notes, dated 10/22/25 and 10/24/25, completed by Staff G, Registered Nurse (RN), failed to include documentation of an assessment including measurements for the following wounds: 1) Stage II pressure ulcer to right superior sacral 2) Stage II pressure ulcer to medial right upper buttock 3) Stage II pressure ulcer to distal right lower buttock 4) Stage II pressure ulcer to left superior sacral 5) Stage II pressure ulcer to distal left lower buttock The agency nurse failed to obtain complete wound assessments and measurements per agency policy. 2. Patient #3 had a start of care date of 11/25/25. Clinical record review revealed: a. The POC, dated 11/25/25 to 1/23/26, identified the patient had a diagnosis of encounter for surgical aftercare following surgery on the circulatory system and included physician orders for skilled nursing services to perform and teach wound care. b. The skilled nurse start of care visit note, completed by Staff B, Director of Nursing, included documentation of an assessment including measurements of the wound to the medial sternal, inferior surgical incision that had a small opening. c. The skilled nurse visit note, dated 12/8/25, completed by Staff G, RN, failed to include documentation of an assessment including measurements of the wound to the medial sternal, inferior surgical incision that had a small opening. The agency nurse failed to obtain a complete wound assessment and measurements per agency policy. The above findings were reviewed with the Administrator, Director of Nursing and Regional Clinical Director.

As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City location, the Department of Inspections, Appeals & Licensing conducted a complaint survey for complaint #110995-C from 12/09/24 to 12/12/24. The complaint survey identified the following: Condition of Participation 42 CFR 484.55 Comprehensive Assessment of Patient was investigated, 1 Condition level deficiency was identified (G510) and 1 standard level deficiency was identified (G528), Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care was investigated, 1 Condition level deficiency was identified (G570) and 2 standard level deficiencies were identified. (G574, G580) and Condition of Participation 42 CFR 484.50 Patient’s Rights, was investigated and no condition level deficiency was identified. The agency reported a census of 144 patients at the time of the survey.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on provider and agency staff interviews, clinical record review and agency policy review, the agency failed to ensure comprehensive assessments included the patient's current health, psychosocial, functional, and cognitive status. The cumulative effects of these systemic practices resulted in placing patients at risk of not receiving safe, individualized and consistent care designed to meet each patients health needs.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on agency staff interview, clinical record review, and agency policy review, the agency failed to ensure accurate and thorough completion of all pertinent components of each comprehensive assessment for 4 of 5 sampled patients with wounds (Patients #1, #2, #4 and #5). Failure to accurately and thoroughly complete comprehensive assessments to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. 2. Patient #1 had a start of care date of 10/26/24 and received skilled nurse services 2 times a week. a. The POC, dated 10/26/24 to 12/24/24, included orders for the skilled nurse to instruct care to incision site located on the right lower abdomen. b. The comprehensive skilled nurse visit at start of care, dated 10/26/24, included measurement of a surgical wound on the right lower abdomen of 3.5 (cm) length by 0.1 cm width by 0 cm depth. c. The skilled nurse notes, dated 10/28/24 and 10/31/24, Staff C, Registered Nurse (RN) revealed the patient had a surgical wound to the right lower abdomen. The notes failed to include wound measurements. d. The skilled nurse notes, dated 11/2/24, Staff J, RN revealed the patient had a surgical wound to the right lower abdomen. The notes failed to include wound measurements. The agency nurse failed to include weekly measurement of the patient's surgical wound. 3. Patient #2 had a start of care date of 10/24/24 and received skilled nurse services 3 times a week. a. The POC, dated 10/24/24 to 12/22/24, included orders for the skilled nurse to perform/teach wound care to the pressure ulcer to the coccyx, left heel, right 2nd toenail and left pinky (5th) toenail. b. The comprehensive skilled nurse visit at start of care, dated 10/24/24, Staff A, Administrator, included the following measurements: 1) left heel, unstaged ulcer, 1 cm length by 1 cm width by 0.2 cm depth. 2) right lower buttock stage 2 (partial thickness skin loss with a red or pink wound bed, or an open or closed blister) pressure ulcer 1.5 cm length by 1.5 cm width by 0.2 cm depth. 3) left 5th toe diabetic ulcer, 0.7 length by 0.7 cm width by 0.3 cm depth. 4) right 2nd toe diabetic ulcer, 2 cm length by 2 cm width by 0.3 cm depth. c. The skilled nurse note, dated 10/28/24, Staff H, RN revealed the patient had wounds to the left heel, right lower buttock, left 5th toe and right 2nd toe. The note failed to include wound measurements and identified measurements not due. d. The skilled nurse notes, dated 10/30/24 and 11/1/24, Staff I, Licensed Practical Nurse (LPN) revealed the patient had a surgical wound to the left heel, right lower buttock, left 5th toe and right 2nd toe. The note failed to include wound measurements and identified measurements not due. The agency nurse failed to include weekly measurement of the patient's wounds. 4. Patient #5 had a start of care date of 11/23/24 and received skilled nurse services 3 times a week. a. The POC, dated 11/23/24 to 1/21/25, included orders for the skilled nurse to perform/teach wound care to the stage 3 (full thickness skin loss with visible subcutaneous fat, but no exposed bone, tendon or muscle) pressure ulcer to the sacrum. b. The comprehensive skilled nurse visit at start of care, dated 10/24/24, Staff H, RN, included measurements for the stage 3 coccyx (sacrum) pressure ulcer 1 cm length by 1 cm width by 0.5 cm depth. c. The skilled nurse note, dated 11/25/24, Staff D, RN revealed the patient had a stage 3 pressure ulcer to the coccyx. The note failed to include wound assessment or measurements and identified staff awaiting orders. d. The skilled nurse notes, dated 11/27/24 and 11/29/24, Staff F, RN revealed the patient had a stage 3 pressure ulcer to the coccyx. The note failed to include wound measurements and identified measurements not due. The agency nurse failed to include weekly measurements of the patient's wounds. The above findings reviewed with the Administrator. The agency policy titled Patient Assessment and Reassessment, dated 4/2023, patients who are accepted for skilled service by the agency will receive a comprehensive assessment that will identify the medical, nursing, rehab and social needs of the patient. Relevant assessment findings will be communicated to the physician to aide in the development of the plan of care. Additional assessments or reassessments will be conducted as frequently as the patient condition warrants. During an interview on 12/11/24 at 9:30 AM, the Administrator reported the agency did not have a policy specific for wound care assessments and measurements, but that the staff follow physician orders, or in the absence of a physician order, staff would follow best practice with wound assessments and wound documentation. The Administrator could not specify what best practice expectations would include at the time of the interview. During an interview on 12/10/24 at 10:40 AM, Primary Care Physician reported Patient #4, had been hospitalized prior to the admission of home care with a serious wound infection in his coccyx needing Intravenous (IV) antibiotics. The primary physician reported her professional opinion was the patient needed a much higher level of care in a facility that could provide 24 hour care. The wife refused this and the patient was discharged to home following the hospital stay on 9/13/24 with home health care. The primary physician reported that the clinic did receive a call from the home care agency nurse caring for this patient on 10/7/24, with an update the patient had developed three new wounds, and had received orders from the wound clinic on how to treat these wounds. The physician did indicate she signed an order for wound treatments the agency indicated the Advanced Registered Nurse Practitioner (ARNP), had faxed to the agency. The physician indicated the specifics of the wounds were not given to her and that she had not been aware prior to the nurses call that the mobile wound clinic had been in the home assessing patients wounds on a weekly basis. She indicated the clinic had not received any specific documentation from the mobile wound clinic practitioner or the agency and that she could not attest to the exact condition of the patient, as there was not a way to transport the patient to the clinic for assessment. The primary physician did report she had given the agency an order for a foley catheter on 10/21/24 in an attempt to keep the patient dry and facilitate wound healing in his coccyx. During an interview on 12/10/24, at 10:25 AM, Staff F, Registered Nurse (RN) reported completing the initial comprehensive assessment on 9/14/24 for Patient #4 admission to home care. Staff F reported the wound to the patients coccyx was large and significant and that a considerable amount of time was spent providing education to the spouse on the importance of keeping the patient as dry as possible and turning with repositioning every two hours. Staff F reported the only wound noted and observed was the pressure ulcer on patients coccyx and completed a wound assessment including measurements in her documentation of that coccyx wound. During an interview on 12/10/24 at 11:46 AM, Staff D, RN, reported the Patient #4 was a complicated case and acknowledged role as patients primary nurse. Staff D reported patient had a severe pressure ulcer on his coccyx that was being assessed, measured and treated, 3 times per week by agency nurses following admission. Staff D reported mobile wound care became involved at the end of September and the ARNP with the mobile wound care service began to make a weekly visit on Mondays to the patient's home for evaluation of the wound and provide orders for treatment of the wound. Staff D reported three new wounds developed 10/7/24 on patients lower left leg, on the end of the stump on the right leg, and on the scrotum. Staff D confirmed she reported those new wounds to the primary caregiver. Staff D reported had also requested a foley catheter 10/21/24 to assist with wound healing because the patient's spouse had difficulty keeping the patient turned and changed on a consistent schedule. During an interview on 12/12/24 at 3:35 PM, ARNP from the mobile wound care service reported she first assessed Patient #4's wounds on 9/30/24. The ARNP reported the coccyx wound was quite serious and with all of Patient #4 comorbidities, felt the patient was on a definite downward trajectory. The ARNP reported her documentation of Patient #4's onset date for all wounds of 6/1/24 was based off of the spouse knowledge of the wound origins. 1.Patient #4 had a start of care date of 9/14/24 and a discharge date of 10/25/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/14/24 to 11/12/24, included physicians orders for skilled nursing services 3 times per week to assess all body systems, to identify changes requiring medical attention, to intervene to prevent complications, and wound care orders for the stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer to the coccyx. b. The initial comprehensive assessment, dated 9/14/24, completed by Staff F, RN, identified the stage 4 pressure ulcer on the coccyx with wound description and measurements of 9 centimeters length by 11 centimeters width by 2.5 centimeters depth (CM). No additional wounds were identified or assessed. c. Skilled nursing visit notes, dated 9/18/24 and 9/20/24, Staff E, RN, included assessment of the pressure ulcer on the coccyx. No additional wounds were identified or assessed. d. Skilled nursing visit notes, dated 9/23/24, 9/25/24 and 9/27/24, Staff D, RN, included assessment of the pressure ulcer on the coccyx. No additional wounds were identified or assessed. e. The initial wound evaluation, dated 9/30/24, by the ARNP with the mobile wound clinic, identified the following wounds: assessment and measurements for the stage 4 ulcer on the coccyx and further divided into measurements of the left section measuring 4.1 CM length by 4.5 CM width by 2.3 CM depth, with additional undermining of 2.4 CM, the right side measuring 4.9 CM length by 5.5 CM width by 3.7 CM depth with additional undermining of 3.8 CM. An unstageable pressure ulcer to the right heel was identified and measured 4.5 CM length by 5.5 CM width and no measurable depth as the wound was covered with eschar (necrotic dead tissue usually black or brown) and 2 stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) ulcers to the scrotum, one on the front measuring 1 CM length by 1.5 CM width by 0.1 CM depth, and the second one on the back measuring 2.1 CM width by 1.9 CM length by 0.1 CM depth. f. The skilled nurse visit note, dated 10/2/24, Staff D, RN, included assessment of only the stage 4 pressure ulcer on the coccyx. The skilled nursing visit note failed to identify or assess the pressure areas on the left heel and the scrotum. g. The skilled nurses visit note, dated 10/9/24, Staff D, RN, included assessment and measurements for the stage 4 pressure ulcer on the coccyx, 1 of the 2 pressure ulcers on the scrotum, and documentation onset of new wounds to the mid area of the left leg and the bottom of the right leg stump where an amputation had previously been done. The skilled nursing note failed to identify or assess the second pressure ulcer to the scrotum and the unstageable pressure ulcer to the left heel. h. The skilled nurses note, dated 10/11/24, Staff E, RN, included assessment and measurements for the stage 4 pressure ulcer on the coccyx, 1 of the 2 pressure ulcers on the scrotum, wound to the mid area of the left leg and the bottom of the right leg stump. The skilled nursing note failed to identify or assess the second pressure ulcer to the scrotum and the unstageable pressure ulcer to the left heel. i. The Skilled nurses notes, dated 10/16/24, 10/18/24, and 10/25, Staff D, RN, included assessment for the stage 4 pressure ulcer on the coccyx, 1 of the 2 pressure ulcers on the scrotum, the wound to the mid area of the left leg and the bottom of the right leg stump. The skilled nursing note failed to identify or assess the second pressure ulcer to the scrotum and the unstageable pressure ulcer to the left heel. j. The hospital discharge records, dated 9/12/24, noted the left heel to have dry gangrene and brown/purple color changes at the time of discharge. The agency failed to identify and assess pressure ulcers to the scrotum and the right heel.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency: 1) failed to include all required components of the Plan of Care (G574); and 2) failed to provide medications, treatments and services only as ordered by a physician (G580). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 144 patients.

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 observation, clinical record, agency policy and patient interview, the agency failed to include all required components of the Plan of Care (POC) for 1 of 1 sampled patients with observational home visit (Patient #1). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. Findings include: Patient #1 had a start of care date of 10/26/24 and received skilled nursing services. According to the agency policy, titled Plan of Care, dated February 2022, the contents of the patient's POC may include, but are not limited to prescribed and over-the-counter medications. a. The POC, dated 10/26/24 to 12/24/24, included orders for medications the patient currently required. b. During a home observation visit on 12/10/24 at 10:30 AM with Staff C, Registered Nurse (RN), the patient identified he/she had the prescription medication Omeprazole 40 milligrams daily by mouth. c. During the same home visit, the patient stated the medication was prescribed prior to the start of home health services. The agency failed to include all medications on the patient's POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services as ordered by the physician for 3 of 5 sampled patients with wounds (Patients #2, #4 and #5). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 2. Patient #2 had a start of care date of 10/24/24. The clinical record revealed the following: a. The POC, dated 10/24/24 to 12/22/24, included orders for the skilled nurse to perform/teach wound care to the pressure ulcer to the coccyx, left heel, right 2nd toenail and left pinky (5th) toenail as follows: 1) Pressure ulcer to coccyx, cleanse with saline, pat dry. Cover with mepilex using clean technique. Wound care to be performed 3 times a week by skilled nurse. May discontinue when wound is healed. 2) Diabetic ulcer wounds to 2nd toenail bed and toe, left pinky toenail bed and left heal, cleanse with soap and water and or irrigate with normal saline. Paint toes with betadine, cover toes with bandaids and heel with mepilex boarder using clean technique. Wound care to be performed by skilled nurse 3 times a week. May discontinue when wound is healed. b. The comprehensive skilled nurse visit note on admission, dated 10/24/24, included documentation Staff A, Administrator, completed wound care to the 2nd toenail bed and toe, left pinky toenail bed, left heel and buttock per physician's orders. c. The skilled nurse visit note, dated 10/28/24, included documentation Staff H, RN, wound care to the patient's 2nd toenail bed and toe, left pinky toenail and buttock completed per physician's order. The wound care to the left heel not provided due to "not ordered this visit". The skilled nurse failed to complete all wound care as ordered by the physician. 3. Patient #5 had a start of care date of 11/23/24. The clinical record revealed the following: a. The POC, dated 11/23/24 to 1/21/25, included orders for the skilled nurse to perform/teach wound care to the pressure ulcer to the sacrum as follows: irrigate with normal saline or generic wound cleanser, pack with calcium alginate AG(silver). Dressing using cotton tip applicator. Cover and secure with border silicone bordered foam dressing. Change Monday, Wednesday and Friday and as needed using clean technique. Wound care to be performed by skilled nurse. May discontinue when wound is healed. b. The comprehensive skilled nurse visit note on admission, dated 11/23/24, included documentation Staff H, RN, completed wound care to the coccyx (sacrum) per physician's orders. c. The skilled nurse visit note, dated 11/25/24, included documentation Staff D, RN, wound care to the sacrum not provided due to "waiting on orders". The skilled nurse failed to complete wound care as ordered by the physician. The above findings reviewed with the Administrator. The agency policy titled Plan of Care, dated 2/2022, requires the agency to develop and implement an individualized Plan of Care (POC) for each patient the agency serves. The clinical services are implemented in accordance with the POC and established by a providers written orders. The content of the POC includes clinical problems, and specific orders, including procedures, modalities, interventions and treatments for each discipline. During an interview on 12/11/24, at 10:00 AM, the Administrator acknowledged the agency received updated orders from the Advanced Registered Nurse Practitioner (ARNP), on 10/1/24 with the mobile wound care unit, and could not explain why the wound care orders were not updated to the POC until 10/7/24. 1.Patient #4 had a start of care date of 9/14/24 and a discharge date of 10/25/24. Clinical record review revealed the following. a. The POC, dated 9/14/24 to 11/12/24, included physician orders for wound care to the pressure ulcer on patient 's coccyx as follows: irrigation of the coccyx wound using normal saline, pack the wound with betadine (drying/antibacterial agent) soaked gauze and to cover with a foam sacral dressing to be completed daily, three times per week by the agency nurse and caregiver the other days. b. Physician orders, dated and faxed by the ARNP with mobile wound care to the agency on 9/30/24, included new wound care orders as follows: cleanse the sacral wound with wound cleanser and apply hydrofera blue foam (antibacterial dressing that absorbs drainage and controls bacteria) into the wound and cover with a sacral foam dressing. The left heel included orders to cleanse with wound cleanser, apply betadine with a swab, and apply a protective boot over the heel. Cleanse the scrotum wounds with wound cleanser and apply a thick layer of calmoseptine to both wounds. c. Skilled Nurse visit notes, dated 10/2/24 and 10/4/24, Staff D, RN included documentation of wound care completed to the coccyx as follows: irrigated with saline, packed wound with betadine soaked gauze and covered with foam dressing which was not the current physician order. The note lacked documentation of wound care completed for the scrotum, and left heel. Staff D failed to complete wound care per physicians orders. The agency failed to perform wound care as ordered by the physician.

The #96007-C complaint investigation, conducted by the Department of Inspections and Appeals from 2/28/23 through 3/8/23, resulted in substantiation of the complaint allegations and found the agency operating out of compliance with related standard level deficiencies under the Condition of Participation 42 CFR 484.60 Care Planning, Coordination and Quality of Care (See G0572 and G580). The survey also found the agency operating in compliance with the Condition of Participation 42 CFR 484.50 Patient Rights and with no related deficiencies related to the complaint. The agency reported a current census of 127 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 as ordered on the Plan for Care for 3 of 4 sampled patients (Patients #1, #2, and #3). 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 agency policy titled, Plan of Care, dated 2/2022, the agency will develop and implement an individualized Plan of Care (POC) for each patient admitted to the agency. Clinical services are implemented in accordance with a POC established by a physician's written orders when required by state/federal regulation....The contents of the Plan of Care may include, but are not limited to...specific orders, including procedures, modalities, interventions and treatments for each discipline. Interview with the Administrator on 3/8/23 at 8:39 AM reported if weight parameters on the Plan of Care, the nurses should be documenting a weight every visit. 1. Patient #1 was admitted to the agency on 4/9/21 and received skilled nursing and home care aide services with primary diagnosis of lymphedema. Clinical record review revealed the following: a. The Plans of Care, dated 11/30/22 to 1/28/23 and 1/29/23 to 3/29/22, included vital signs parameters to report if weights were greater than 270 pounds. b. Skilled nurse visit notes, dated 12/27/22, 1/3/23, 1/13/23, 1/17/23, 1/24/23 and 1/27/23, lacked documentation of assessment of the patient’s weights as ordered on the Plans of Care. 2. Patient #2 was admitted to the agency on 6/21/21 and received skilled nursing visits with primary diagnosis of lymphedema. Clinical record review revealed: a. The Plans of Care, dated 12/13/22 to 2/10.23 and 2/11/23 to 4/11/23 included vital signs parameters to report if weights were less than 317 pounds or greater than 327 pounds. b. Skilled nurse visit notes, dated 1/3, 1/6, 1/13, 1/17, 1/20, 1/24, 1/27, 1/31, 2/3, 2/8, 2/10, 2/14, 2/17, 2/21, and 2/24/23 lacked documentation of assessment of the patient’s weights. Interview on 3/7/22 at 9:45 AM with Staff C, Registered Nurse reported if weights weren't done it may be due to the patient being very large and unable to obtain and the agency has coders that are in another state that may have assigned weights to a patient who does not require weights to be assessed. 3. Patient #3 was admitted to the agency on 1/16/23 and was discharged from the agency on 2/3/23 with a diagnoses of anxiety, depression and obsessive compulsive disorder. Clinical record review revealed: a. The Plan of Care, dated 1/16/23 to 3/16/23 included vital signs parameters to report if weights were less than 109 pounds or greater than 119 pounds. b. Skilled nurse visit notes, dated 1/25/23 and 2/1/23 lacked documentation of assessment of the patient’s weights as ordered on the Plans of Care. The above findings were reviewed with the agency Administrator. Agency staff provided no additional information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, patient interview, and agency staff interview, the agency failed to provide treatments only as ordered by the physician for 1 of 4 sampled patients (Patient #3). Failure to ensure staff obtain physician orders for treatments provided by agency staff, placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Physician Orders dated 12/2019, agency personnel will accept physician's verbal orders in accordance with state and federal laws...Orders are obtained , reviewed and updated in accordance with regulatory guidelines, company policy, and as appropriate, according to …changes in the patient's diagnosis, treatment, and procedures and or medications...Physician's orders are required prior to care being initiated....Care and/or treatment is to be provided according to the most recent order. Patient #3 was admitted to the agency on 1/16/23 and discharged from the agency on 2/3/23. Clinical record review and associated patient and staff interviews revealed: a. A physician referral, dated 1/13/23 documented the patient was having ongoing anxiety, depression, and obsessive compulsive disorder. b. The initial comprehensive assessment, dated 1/16/23, documented a routine visit with no taping or wound care ordered, completed by Staff C, Registered Nurse (RN). c. A communication note dated, 1/20/23, completed by Staff C, RN revealed the nurse called the patient and the patient refused the visit due to the agency not having orders to tape the foot. d. A communication note, dated 1/23/23 from Staff F, LPN documented talked to patient and requests nurse tape toes and requested surgeon be contacted for order. e. Skilled nurse visit note dated 1/25/23, completed by Staff D, RN, documented a new intervention patient/caregiver will perform the following intervention to decrease risk of breakdown: change tape to left foot second toe toe daily. The assessment did not include documentation the nurse performed the intervention.. f. An interim physician’s order, dated 2/1/23 ordered wound care for patient’s right foot skin tear with instructions for irrigate the skin tear with wound wash, pat dry, cover with nonadherent gauze, secure with Coban 2 times a week and as needed if excessive drainage. Nurse to complete 1 time per week and spouse to complete second time and as needed if leakage, may discontinue if healed. g. The skilled nurse visit note, dated 2/1/23 and completed by the Administrator/RN documented performed the dressing change to the right foot. Interview with the Administrator on 3/8/23 at 8:39 AM reported the skin tear was on the left foot and it was an error documented on the right for the order for dressing change and the care provided. Interview with Patient #3 on 2/28/23 at 5:26 PM reported the agency did not have orders to tape the patient's foot, but taped it anyway. Interview on 3/7/23 at 8:12 AM with the foot surgeon's office staff reported documentation in patient’s clinical record revealed on 1/19/23 surgeon told the patient to watch a video to tape the left foot. This was to be done by the patient and nothing was sent to the HHA. The surgeon's office staff received a phone call from the agency that the primary care physician referred the patient to HHA and there were no orders for taping. The patient called to the physician's office on 2/1/22 and noted the agency did not do the taping to the patient’s foot. The surgeon then requested the patient come in to be seen for the surgeon for reassessing before providing the taping order and the patient declined to be seen due to multiple appointments on 2/2/23. Interview on 3/7/23 at 8:32 AM with the primary care provider's office staff reported chart review documented on 2/1/23 the social worker for the clinic received a voicemail from the patient that the agency was not taping the foot correctly. Clinic coordinator gave the agency a verbal order for wound care for skin tear. Interview on 3/7/23 at 9:48 AM with Staff C, RN reported the RN documented in the initial assessment, the patient was referred for the agency's anxiety and depression program. On 1/20/23 another nurse had received a phone call that the patient had contacted the office wondering about orders yet received for taping the toes, so Staff C, RN called the patient back and the patient refused a visit. Interview on 3/7/23 at 1:15 PM with Staff D, RN reported when the RN arrived at the patient's home on 1/25/23, the patient asked the RN to tape the toe and the patient said the doctor and the RN's boss said to do it, so the RN did. The above findings were reviewed with agency Administrator. Agency staff provided no additional information prior to the end of the survey.