Every finding on record at Family Touch Home Health LLC

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 11/25/24 to 12/4/24 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 & Licensing conducted a Recertification Survey from 11/25/24 to 12/4/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a census of 489 patients at the time of the survey, including 247 patients who received services through the Council Bluffs office, 157 patients who received services through the Shenandoah branch office and 85 patients who received services through the Denison branch office.

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 staff interviews, clinical record reviews and agency policy review, 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 of Care for 6 of 17 sampled patients (Patients #1, #3, #10, #13, #14 and #16). Failure to follow a Plan of Care established by home health clinical associates in collaboration with the patient's physician, placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 5. Patient #1 had a start of care date of 8/27/23. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24, included physician orders for wound care 3 times per week for a diabetic ulcer on the anterior edge of the right foot. Order instructed the skilled nurse to cleanse the wound with soap and water, rinse and pat dry with gauze, cover with a 4 centimeter by 4 centimeter (cm) Mepilex dressing (foam dressing), and secure with a size E tubigrip (compression netting). b. During a home visit observation on 11/25/24 at 10:15 AM, the surveyor observed Staff D, RN, cleanse the wound with normal saline, pat the wound dry with gauze, and cover with a 4 cm by 4 cm Mepilex dressing, but failed to secure with the size E tubigrip dressing. The agency failed to perform wound care to the diabetic wound ulcer on the anterior edge of the right foot as ordered by the physician. 6. Patient #16 had a start of care date of 9/13/24 and a discharge date of 11/11/24. Clinical record review revealed the following: a. The POC, dated 9/13/24 to 11/11/24, included physician orders for skilled nurse to visit 1 time a week for 9 weeks effective 9/13/24. b. The clinical record lacked documentation of skilled nurse services for the week of 10/20/24, and lacked physician notification of missed visits during that week. The agency failed to implement clinical services in accordance with the POC. The above findings were shared with the Administrator/Clinical Manager. 3. Patient #10 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POCs, dated 9/17/24 to 11/15/24 and 11/16/24 to 1/14/24, included physician orders for skilled nurse to weigh patient every visit and to instruct patient to notify skilled nurse or physician of weight gain of more than 3 pounds in 24 hours. b. The skilled nurse visit note, dated 10/14/24, completed by Staff G, RN, lacked documentation of a weight obtained by the skilled nurse. The skilled nurse failed to assess and document the patient's weight every visit. 4. Patient #13 had a start of care date of 6/8/24 and discharge from the agency on 7/5/24. Clinical record review revealed the following: a. The POC, dated 6/8/24 to 8/6/24, included physician orders for skilled nurse to weigh patient every visit and to instruct patient to notify skilled nurse or physician of weight gain of more than 3 pounds in 24 hours. b. The skilled nurse visit note, dated 6/11/24, completed by Staff G, RN, lacked documentation of a weight obtained by the skilled nurse. The skilled nurse failed to assess and document the patient's weight every visit. According to the agency's policy titled Plan of Care, dated February 2022, the agency develops and implements 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 provider's written orders. If a provider orders services that cannot be completed, the provider is consulted to approve additions or modification to the original plan. 1.Patient #3 had a start of care date of 10/15/24. Clinical record review revealed the following: a. The POC, dated 10/15/24 to 12/13/24, included physician orders for skilled nurse to weigh patient every visit and to instruct patient to notify skilled nurse or physician of weight gain of more than 3 pounds in 24 hours. b. The skilled nurse visit note, dated 11/7/24, completed by Staff E, Registered Nurse (RN), lacked documentation of a weight obtained by the skilled nurse. The skilled nurse failed to assess and document the patient's weight every visit. 2. Patient #14 had a start of care date of 5/18/24 and a discharge date of 6/16/24. Clinical record review revealed the following: a. The POC, dated 5/18/24 to 7/16/24, included physician orders for physical therapy to visit 1 time a week for 1 week effective 5/19/24. b. The clinical record lacked documentation of physical therapy services. c. During an interview on 12/3/24 at 2:30 PM, the Administrator stated the agency had issues getting physical therapy services started timely in patient's service area. The agency failed to implement clinical services in accordance with the POC.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 9 of 17 sampled patients (Patients #1, #2, #3, #4, #5, #7, #11, #13 and #16). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 6. Patient #2 had a start of care date of 12/27/23. Clinical record review revealed the following: a. The POC, dated 10/22/24 to 12/20/24, included the following DME used by the patient: cane, elevated toilet seat, rails/grab bars, shower/tub equipment, vital signs equipment, walker, wheelchair, incontinence, urologicals, wound care, wound care advanced. b. The POC, dated 10/22/24 to 12/20/24, included orders for medications the for the patient. The orders included the medication Hydrochlorothiazide (diuretic) 25 mg every morning for blood pressure. c. During a home visit observation on 11/26/24 at 11:20 AM, with Staff E, RN, the surveyor identified the following additional DME in the home: wheelchair cushion. During this same visit, an interview with the patient revealed a type of wheelchair cushion had been utilized since the start of care. d. During the same home visit observation the patient stated he/she had not taken the medication hydrochlorothiazide for a long time. The POC failed to identify all DME the patient required for use including a wheelchair cushion and current medications. 7. Patient #5 had a start of care date of 8/6/24. Clinical record review revealed the following: a. The POC, dated 10/5/24 to 12/3/24, included the following DME used by the patient: wound care, wound care advanced. The POC also included medications ordered for the patient. b. During a home visit observation on 11/26/24 at 11:20 AM, with Staff G, RN, the surveyor identified the following additional DME in the home: shower chair and colostomy supplies. During this same visit, an interview with the patient revealed the DME had been utilized since the start of care. c. During the same home visit observation the patient stated he/she had the medications allergy medication 10 mg daily, Miralax 17 grams daily as needed for constipation and a fiber supplement 2 teaspoons daily as needed for loose stools. The patient identified the medication taken since the start of care. The POC failed to identify all DME the patient required for use including a shower chair and colostomy supplies and current medications. 8. Patient #11 had a start of care date of 11/12/24. Clinical record review revealed the following: a. The POC, dated 11/12/24 to 1/10/25, included the following DME used by the patient: glucometer, incentive spirometer, med planner, respiratory supplies, shower/tub equipment, support surfaces, vital signs equipment, glucose, nursing supplies and physical therapy. The POC included orders to instruct the patient to notify the skilled nurse/physician of weight gain greater than 2 pounds in 24 hours and 4 pounds in one week. b. Review of the medical record lacked documentation of the scale included as the patient's DME. The POC failed to identify all DME the patient required for use including a scale. 9. Patient #13 had a start of care date of 6/8/24 and discharge date of 7/5/24. Clinical record review revealed the following: a. The POC, dated 6/8/24 to 8/6/24, included the following DME used by the patient: glucometer, incentive spirometer, med planner, walker, rolling walker, nutrient thickeners, ostomy supplies, physical therapy supplies, wound care. The POC included orders to instruct the patient to notify the skilled nurse/physician of weight gain greater than 2 pounds in 24 hours and 4 pounds in one week. b. Review of the medical record lacked documentation of the scale included as the patient's DME. The POC failed to identify all DME the patient required for use including a scale. The above findings shared with the Administrator/Clinical Manager and Clinical Regional Director. 3. Patient #1 had a start of care date of 8/27/23. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24, included the following DME used by the patient: cane, walker, powered wheelchair, commode, elevated toilet seat, oxygen supplies, incontinence supplies, skin and wound care supplies, glucometer, medication planner, rails/grab bars, reacher, shower and tub equipment, vital signs equipment, and PT/INR testing supplies. b. During a home visit observation on 11/25/24 at 10:15 AM, with Staff D, RN, the surveyor identified a scale used to monitor weight changes. During this same visit, an interview with the patient revealed a pressure relief cushion was utilized in the recliner and power chair. The POC failed to identify all DME the patient required for use. 4. Patient #7 had a start of care date of 4/23/24. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24 included the following DME used by the patient: cane, rail/grab bars, shower/tub equipment, oxygen supplies, walker, vital sign equipment, glucometer, nebulizer, elevated toilet seat, nursing supplies, skin care, urological supplies, and medication planner. b. During a home visit observation on 12/05/24 at 1:30 PM, with Staff L, Licensed Practical Nurse (LPN), the surveyor identified the following additional DME in the home: scale and vaporizer. During this same visit, an interview with the patient revealed both devices have been utilized since the start of care. The POC failed to identify all DME the patient required for use. 5. Patient #16 had a start of care date of 9/13/214. Clinical record review revealed the following: a. The POC, dated 9/13/24 to 11/11/24, included the following DME used by the patient: cane, shower/tub equipment, glucometer, glucose, incontinence supplies, nursing supplies, skin care supplies, walker, lift, elevated toilet seat, vital sign equipment, and physical therapy supplies. b. The POC, dated 9/13/24 to 11/11/24, included a physician order for the skilled nurse to weigh the patient every visit, the POC failed to include scale as part of the DME utilized by the patient. The POC failed to identify all DME the patient required for use. The above findings were shared with the Administrator/Clinical Manager. According to the agency policy titled Plan of Care, dated February 2022, the agency develops and implements an individualized Plan of Care (POC) for each patient admitted to the agency. The plan of care is reviewed as often as the patient's condition or need warrants, but at least every 60 days. The contents of the patient's POC includes, but is not limited to the following: diagnoses and clinical problems, prescribed and over the counter (OTC) medications, medical supplies/equipment, frequency and duration of services and functional limitations. 1.Patient #3 had a start of care date of 10/15/24. Clinical record review revealed the following: a. The POC, dated 10/15/24 to 12/13/24 included the following durable medical equipment (DME) used by the patient: cane and nursing supplies. b. During a home visit observation on 11/26/24 at 11:20 AM, with Staff F, Registered Nurse (RN), the surveyor identified the following additional DME in the home: scale and pill cutter. During this same visit, an interview with the patient revealed both devices have been utilized since the start of care. The POC failed to identify all DME the patient required for use. 2. Patient #4 had a start of care date of 4/9/24. Clinical record review revealed the following: a. The POC, dated 10/6/24 to 12/4/24, included an order for the following medication: Gabapentin 300 milligram (mg) capsule with instructions to take one as needed for nerve pain. b. During a home visit observation on 12/2/24 at 11:30 AM with Staff H, RN, the surveyor identified the bottle of Gabapentin in the home is 300 mg capsules with instructions for the patient to take 1 tablet at bedtime. Staff H, RN confirmed she filled the patients medication box according to the instructions on the bottle. The medication was last filled on 10/8/24. c. The POC, dated 10/6/24 to 12/4/24, included the following DME used by the patient: cane, med planner, rails/grab bars, reacher, shower/tub equipment, vital sign equipment, walker, incontinence supplies and nursing supplies. d. During a home visit observation on 12/2/24 at 11:30 AM with Staff H, RN, the surveyor identified the following DME in the home: scale and right knee immobilizer brace. The patient stated he/she has been utilizing the scale to weigh self for at least a year and he/she has had to wear the immobilizer brace at all times since falling on 10/29/24. The POC failed to identify medication orders with accurate frequency and all DME the patient required for use.

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, agency policy review and staff interview, the agency failed to ensure all current physician orders for wound care recorded on the plan of care for 2 of 7 sampled patients with wounds (Patient's #2 and #6). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 2.Patient #6 had a start of care date of 10/11/24. Clinical record review revealed the following: a. The POC, dated 10/11/24 to 12/9/24 included physician orders for skilled nursing services and occupational therapy services. b. The interim physician order, dated 11/27/24, included orders to cleanse abdominal wound with soap and water, apply Vashe soaked gauze to wound bed for 3-5 minutes. Apply skin barrier to peri wound skin area, apply Hydrofera blue foam dressing to wound bed. Cover with mepilex like dressing and change 3 times weekly per nurse and as needed for soiled/wet dressing. May discontinue when wound is healed. c. The updated POC, dated 12/2/24, failed to include the interim order for wound care. The agency failed to record all patient care orders in the plan of care. The above findings were shared with the Administrator/Clinical Manager and the Clinical Regional Director. According to the agency policy, titled Plan of Care, dated February 2022, Plan of Care changes that occur between certification periods are documented with the Plan of Care Update Order. Orders will specify the service hours, frequency and duration, procedures and modalities, as applicable. During an interview on 12/3/24 at 8:59 AM, the Administrator/Clinical Manager, stated all interim physician orders go to an updated Plan of Care. She further stated the nurses typically look at the orders tab from their tablet to view the most current patient orders. 1. Patient #2 had a start of care date of 12/27/23. The clinical record review revealed: a. The Plan of Care (POC), dated 10/22/24 to 12/20/24, included orders for skilled nursing visits three times a week. b. Interim physician order, dated 11/12/24, included wound care orders for the coccyx, cleanse wound with normal saline, then use Vashe as directed to the wound. Apply skin prep around the peri wound. Primary dressing: Exufiber AG plus gelling fiber rope 0.8 by 17.7 inch, then apply mepilex border and secure with tape. Skilled nurse to change 3 times per week until healed. May discontinue when healed. c. The Updated POC, dated 11/26/24, did not include orders for wound care to the coccyx. Agency staff failed to include current wound care orders on the 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 only as ordered by the physician for 2 of 17 sampled patients (Patients #1 and #2). 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 #1 had a start of care date of 08/27/24. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/20/24 to 12/18/24, included orders for the anticoagulant medication Warfarin (blood thinning medication), and physicians orders for the skilled nurse to monitor anticoagulation therapy and regimen with a home PT/INR machine (device for testing blood coagulation speed). The POC included parameters to call the physician after testing if level is less than 2, but greater than 3. The POC lacked orders for specific time frames for when to perform the blood testing and how often. The clinical record lacked physician orders necessary for how often to perform PT/INR testing in the home . The above findings were reviewed with the Administrator/Clinical Manager According to agency policy, titled Physician Provider Orders, dated May 2020, orders are obtained, reviewed and updated in accordance with laws, regulatory guideline, company policy and as appropriate, according to: changes in the patient's physical and/or psychosocial status, patient's responses to care or services, changes in the patient's diagnosis, treatment, procedures and/or medications and patient's equipment needs. 1. Patient #2 had a start of care date of 12/27/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/22/24 to 12/20/24, documented the patient had diagnosis that included neuromuscular dysfunction of the bladder. b. During a observational home visit with Staff E, Registered Nurse (RN), the patient identified he/she required the use of intermittent catheterization 4 to 5 times a day. The clinical record lacked physician orders for intermittent catheterization.

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 2 of 7 sampled patients (Patient #1 and #8) with home observation visits. Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. According to agency policy titled Patient Assessment/Reassessment, dated 4/2023, assessments and reassessments will be conducted as frequently as the patients condition warrants. The provider will be contacted when assessment findings warrant a change in the plan of care or treatment plan. In an interview on 12/3/24 at 4:15 pm, the Clinical Manager acknowledged if a patient reported a change in skin integumentary to staff during a visit, the nurse would be expected to assess the concern during that visit, and communicate any change to the physician at the time of the visit. 1.Patient #1 had a start of care date of 8/27/24. Home observation and patient interview revealed the following: a. The Plan of Care (POC), dated 10/20/24 to 12/18/24, included physicians orders for skilled nursing 3 times per week, to assess vital signs and all body systems, to provide skilled monitoring and skilled teaching related to altered skin integrity and pressure ulcer prevention measures and to report significant changes to the physician for early intervention. b. During a home visit observation on 11/25/24 at 10:15 AM, with Staff D, Registered Nurse (RN), the patient reported a concern over a new open area that had been sore on the coccyx. The patient reported to the skilled nurse, the patient's spouse had been putting a cream on the area and thought it was almost healed. The patient also reported to the nurse that the clinic had sent home the new cushion the patient was using in the recliner and sometimes the powered wheelchair to reduce pressure to the coccyx. c. The skilled nurse completed the home visit without assessing the area to the coccyx. d. The skilled nursing visit note, dated 11/25/24,completed by Staff D, RN, lacked documentation of the patients concern, assessment of the area, and any contact with the physician over the patients concern. The agency failed to complete an assessment of a possible new wound based on the patient's information provided. 2. Patient #7 had start of care date of 4/23/24. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24, included physicians orders for the skilled nurse to visit once a week and included orders to assess vital sings and all body systems, and to report any significant changes to the physician to provide for early intervention. b.The missed visit notification, dated 11/21/24, documented the patient reported he/she had a cyst on his/her buttocks that required surgery and would be not available for the visit until the following week. c. The skilled nursing visit note, dated 11/25/24, revealed the patient reported to the nurse some intermittent rectal pain over the last week and that something was wrong with the rectum. Patient also stated an antibiotic had been prescribed following the procedure on the patient's rectum, but was not sure what it was and no longer had the bottle. The visit note documented that medical records were requested from the physician, but the visit note failed to document an assessment of the area. d. During a home visit observation on 12/05/24 at 1:30 PM, with Staff L, Licensed Practical Nurse (LPN), the patient reported experiencing occasional pain in his rectal area and he/she was not sure what physician really did during the procedure, but it still was bothersome some of the time. The LPN failed to assess the area during the visit. The agency failed to assess a possible new wound. The above findings were reviewed with the Administrator/Clinical Manager.

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 observations, clinical record reviews, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 5 of 7 sampled patients (Patient #1, #2, #5, #13 and #17) with wounds. 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. 2. Patient #2 had a start of care date of 12/27/23. Clinical record review revealed the following: a. The POC, dated 10/22/24 to 12/20/24, included physician orders for skilled nursing services 3 times weekly for physical assessment, education and wound management. b. The skilled Nurse visit notes, dated 10/28/24, 10/30/24 and 11/1/24, Staff E, RN, included documentation of a wound to the coccyx. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient's coccyx. 3. Patient #5 had a start of care date of 8/6/24. Clinical record review revealed the following: a. The POCs, dated 8/6/24 to 10/4/24 and 10/5/24 to 12/3/24, included physician orders for skilled nursing services 2 times weekly for physical assessment, education and wound management. b. The skilled Nurse visit notes, dated 10/8, 10/15, 10/22, 10/25/24, and 11/18/24, Staff G, RN, included documentation of a wound to the abdominal right upper quadrant. The notes lacked documentation of wound measurements. c. The skilled Nurse visit notes, dated 10/11, 10/18/24 and 11/22/24, Staff N, RN, included documentation of a wound to the abdominal right upper quadrant. The notes lacked documentation of wound measurements. d. The skilled nurse note, dated 11/5/24, Staff L, Licensed Practical Nurse, included documentation of a wound to the abdominal right upper quadrant. The measurements included length 5.9 centimeters (cm) by width 3.2 cm. The note lacked documentation of the wound depth. The skilled nurse failed to document wound measurements for the wound on the patient's abdominal right upper quadrant. 4. Patient #13 had a start of care date of 6/8/24 and discharge date of 7/5/24. Clinical record review revealed the following: a. The POC, dated 6/8/24 to 8/6/24, included physician orders for skilled nursing services 2 times weekly for physical assessment, education and wound management. b. The skilled Nurse visit notes, dated 6/11 and 6/14/24, Staff G, RN, included documentation of a wound to the right knee. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient's right knee. 5. Patient #17 had a start of care date of 8/23/24 and discharge date of 10/21/24. Clinical record review revealed the following: a. The POC, dated 8/23/24 to 10/21/24, included physician orders for skilled nursing services 2 times weekly for physical assessment, education and wound management. b. The skilled nurse note dated, 8/30/24, identified the following wounds: #4 Left distal forearm ruptured blister 1.2 cm x 0.5 cm x 0 cm. #5 anterior distal left great toe blister 2.4 cm x 1.4 cm x 0 cm. #6 anterior distal right forearm multi/scattered blood blisters. Not measured #8 anterior left pretibial mid ruptured blister. Not measured #9 anterior right mid pretibial ruptured blister 1.1 cm x 0.8 cm x 0 cm. #10 right lateral blister. Not measured. #11 mid dorsum blister 1.1 cm x 0.6 cm x 0 cm. #7 mid multi/scattered dermatitis coccyx. Not measured. c. The skilled Nurse visit notes, dated 8/27/24 and 8/28/24, Staff O, RN, included documentation of multiple wounds identified as blisters. The notes lacked documentation of wound measurements. d. The skilled nurse note, dated 10/18/24, Staff H, RN, included documentation of an open blister to the right anterior proximal upper arm. The depth description included partial thickness and measurements included length 11 cm by width 5 cm with no depth measurements documented. The skilled nurse failed to document wound measurements for the identified wounds. The above findings shared with the Administrator/Clinical Manager and Clinical Regional Director. According to the agency policy titled Documentation Practices, dated 2/2022, documentation will facilitate communication, promote good care, inform care providers on an ongoing basis about patients health status and care or services provided and meet professional standards. Clinicians will make accurate notes and use factual based language. During an interview on 12/3/24 at 8:59 AM, the Clinical Manager stated agency expectation for wound measurements were to include length, width and depth on a weekly basis. The Clinical Manager reported the agency has a wound care nurse on staff as a resource, and to assist with education and compliance. 1.Patient #1 had a start of care date of 8/27/23. Clinical record review revealed the following: a. The Plan of Care (POC), dated 10/20/24 to 12/18/24, included physician orders for skilled nursing services 3 times weekly for physical assessment, education and wound management. b. Skilled Nurse visit notes, dated 11/11/24 and 11/13/24, Staff E, Registered Nurse (RN), included documentation of a diabetic ulcer on the anterior edge of the right foot with an onset date of 7/2/24. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient's anterior edge of the right foot.

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 reviews and agency policy review the agency failed to complete and send a transfer summary to physician caring for the patient at an inpatient facility within 2 days of becoming aware of an unplanned transfer and the agency failed to send a completed discharge summary to the primary care provider within 5 business days of the patient's discharge for 2 of 5 sampled patients (Patients #13 and #14). Failure to send the physician and other healthcare professionals a summary of the patient's care while receiving services from the agency in a timely manner increases the risk for inadequate or inappropriate follow-up care. Findings include: 2. Patient #13 had a start of care date of 6/8/24 and a discharge date of 7/5/24. Clinical record review revealed the following: a. The skilled nurse visit note, dated 7/5/24, revealed the patient discharged from home health care services. b. The discharge summary, dated 7/16/24, completed by Staff M, RN, 7 business days after the patient's date of discharge. The agency failed to complete a discharge summary within 5 business days of becoming aware of an unplanned transfer. The above findings shared with the Administrator/Clinical Manager and Clinical Regional Director. According to the agency policy titled Discharge, dated February 2022, a completed transfer summary 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 the agency becomes aware of the transfer. A completed discharge summary is sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient's discharge. 1.Patient #14 had a start of care date of 5/18/24 and a discharge date of 6/16/24. Clinical record review revealed the following: a. A care coordination note, completed by Staff J, Licensed Practical Nurse, identified a missed visit on 5/31/24 due to patient being hospitalized. b. A home health transfer summary, dated 6/6/24, completed by Staff K, Registered Nurse (RN), 4 business days after transfer to inpatient facility. The agency failed to send a transfer summary to the hospital within 2 business days of becoming aware of an unplanned transfer.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 1/3/2022 through 1/11/2022 . The survey found the agency operating in substantial compliance with the 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 a recertification survey from 1/3/2022 through 1/11/2022 . The survey found the agency operating in substantial compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a current patient census of 476 patients, including 252 patients receiving services from the parent office, 185 patients receiving services from the Shenandoah branch office and 39 patients receiving services from the Denison branch office.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation, patient interview and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part of each comprehensive assessment and/or failed to include all medications, prescription and over-the-counter, used by the patient at the time of the drug regimen review to identify duplicate medications and actual or potential medication interactions when the duplicate medications were combined for 14 of 17 sampled patients (Patients #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17). The survey found the deficient practice occurring at the parent office, the Shenandoah and the Denison branch offices. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: 11. Patient #2 had a start of care date of 4/7/21 and received services from the Shenandoah branch office. Clinical record review revealed: a. Plan of Care, dated 4/7/21 to 6/5/21, included orders for duplicate medications, aldactone, spironolactone, and torsemide (fluid pills); gabapentin and Tylenol (pain meds); and aspirin and Coumadin (blood thinners). b. Plans of Care, dated 10/4/21 to 12/2/21 and 12/3/21 to 1/31/22, included orders for duplicate medications, spironolactone and torsemide (fluid pills) and aspirin and warfarin (blood thinners). c. Drug regimen reviews completed by the nurse with the start of care comprehensive assessment, dated 4/11/21, and with the recertification comprehensive assessments, dated 9/29/21, and 12/2/21, failed to identify the duplicate medications the patient was taking at the times of the comprehensive assessment as required by agency policy. The drug regimen reviews failed to identify duplicate medications the patient was taking. 12. Patient #3 had a start of care date of 10/22/21 and received services from the Shenandoah branch office. Clinical record review revealed: a.Plans of Care, dated 10/22/21 to 12/20/21 and 12/21/21 to 2/18/21, included orders for duplicate medications, acetaminophen, meloxicam and oxycodone (pain meds); bisacodyl and docusate sodium (bowel meds); and centrum silver, cholecalciferol (Vitamin D3) and Klor-Con (supplements). b. Drug regimen reviews completed by the nurse with the start of care comprehensive assessment, dated 10/22/21, and with the recertification comprehensive assessment, dated 12/16/21, failed to identify the duplicate medications the patient was taking at the times of the comprehensive assessments as required by agency policy. The drug regimen reviews failed to identify the duplicate medications the patient was taking. 13. Patient #8 had a start of care date of 5/29/21 and received services from the Shenandoah branch office. Clinical record review revealed: a. Plans of Care, dated 5/29/21 to 7/27/21, 7/28/21 to 9/25/21, and 9/26/21 to 11/24/21, included orders for duplicate medications, 24 hour allergy relief and Zyrtec (allergy meds); aspirin and warfarin (blood thinners); breo ellipta and proair (shortness of breath meds); bumetanide and spironolactone (fluid pills); and biotin, calcium citrate, centrum silver, cyanocobalamin (Vitamin B12), ocuvite, potassium chloride, and Vitamin C (supplements). b. Plan of Care, dated 11/25/21 to 1/23/22, included orders for duplicate medications, acetaminophen and tramadol (pain meds), 24 hour allergy relief and Zyrtec (allergy meds); aspirin and warfarin (blood thinners); breo ellipta and proair (shortness of breath meds); bumetanide and spironolactone (fluid pills); and biotin, calcium citrate, centrum silver, cyanocobalamin (Vitamin B12), ocuvite, potassium chloride, and Vitamin C (supplements). c. Drug regimen reviews completed by the nurse with the start of care comprehensive assessment, dated 6/15/21, and with the recertification comprehensive assessments, dated 7/23/21, 9/24/21, and 11/22/21, failed to identify the duplicate medications the patient was taking at the times of the comprehensive assessments as required by agency policy. The drug regimen reviews failed to identify the duplicate medications the patient was taking. 14. Patient #10 had a start of care date of 8/5/21 and received services from the parent office. Clinical record review revealed: a. Plan of Care, dated 8/5/21 to 10/3/21, 10/4/21 to 12/2/21, and 12/3/21 to 1/31/22, included orders for duplicate diabetes medications, levemir insulin, novolog insulin and metformin. b. Drug regimen reviews completed by the nurse with the start of care comprehensive assessment, dated 8/5/21, and with the recertification comprehensive assessments, dated 10/3/21 and 12/1/21, failed to identify the duplicate medications the patient was taking at the times of the comprehensive assessments as required by agency policy. The drug regimen reviews failed to identify the duplicate medications the patient was taking. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey. According to the agency policy, titled Medication Profile/Drug Regimen Review and dated 7/1/2018, documentation on the Medication Profile must include all medications the patient is taking, including over-the-counter medications. An initial drug regimen review will be completed at the time of the initial comprehensive assessment. Subsequent medication reviews will occur at the time of each applicable comprehensive assessment, "ie. resumption of care, recertification, significant change in condition or as new medications are added during the episode of care but no less often than every 60 days". At the time of the initial medication review and with each subsequent update to the Medication Profile, the assessing clinician is responsible for reviewing for clinically significant medication issues, including ineffective drug therapy, side effects, duplicate medication, drug interactions and omissions/dosage errors. The medication profile must be current and updated as changes occur with the patient's medication regimen. During agency staff interview on 1/3/2022 at 12:10 PM, the Administrator reported the clinicians assess all medications at the time of admission with each subsequent comprehensive assessment and with each new medication change by reconciling the patient's medications and updating the medication profile. Findings from the drug regimen review are documented within the comprehensive assessment or in a communication/coordination note to the physician. 1. Patient #4 had a start of care date of 10/13/2021 and received services from the parent office. Clinical record review, home visit observation and patient interview revealed the following: a. The Plan of Care, dated 10/13/2021 to 12/11/2021, documented Patient #4's diagnoses as hypertensive heart disease with heart failure, chronic kidney disease and adult failure to thrive. The Plan documented the patient took Hydrochlorothiazide, Losartan and Metoprolol, all medications used to treat high blood pressure and heart failure. The medication profile documentation included the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 10/13/2021. . The initial comprehensive assessment completed at the time of admission, dated 10/13/2021, documented the patient was non-compliant with medications. The assessment documented "no issues found during the medication review". Documentation in the initial comprehensive assessment lacked identification of the duplicate blood pressure medications and/or the potential for potentiation of the medications when combined, resulting in hypotension. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. b. The Plan of Care, dated 12/12/2021 to 2/9/2022, documented Patient #4's diagnoses as hypertensive heart disease with heart failure, chronic kidney disease and adult failure to thrive. The Plan documented the patient took Hydrochlorothiazide, Losartan and Metoprolol, all medications used to treat high blood pressure and heart failure. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 11/17/2021 and 12/12/2021; however, did not complete a drug regimen review during the last 5 days of the certification period to accompany the update to the comprehensive assessment. The update to the comprehensive assessment completed at the time of recertification, dated 12/8/2021, documented the patient was non-compliant with medications. Documentation in the update to the comprehensive assessment lacked identification of the duplicate blood pressure medications and/or the potential for potentiation of the medications when combined, resulting in hypotension. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. c. During home visit on 1/4/2022 at 10:00 AM while accompanied by Staff K, Registered Nurse (RN), the surveyor observed a package of Imodium, a medication taken to treat episodes of diarrhea. The box contained 2 milligram tablets of Imodium. During patient interview during the home visit, Patient #4 reported taking 1-2 tablets of Imodium with diarrheal episodes and had been using the medication on an as needed basis "for years". The Plans of Care, dated 10/13/2021 to 12/11/2021 and 12/12/2021 to 2/9/2022, did not include Imodium as a medication taken by the patient. The medication profile also lacked inclusion of the medication Imodium as taken by the patient. 2. Patient #7 had a start of care date of 6/7/2021 and received services from the Denison branch office. Clinical record review revealed the following: The Plans of Care, dated 10/5/2021 to 12/3/2021 and 12/4/2021 to 2/1/2022, documented Patient #7's diagnoses included hypertensive heart disease with heart failure and chronic kidney disease. The Plans documented the patient took Furosemide and Metoprolol, both medications used to treat high blood pressure and heart failure. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 10/4/2021. . The update to the comprehensive assessment completed at the recertification, dated 10/4/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. b. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 11/29/2021. The update to the comprehensive assessment completed at the recertification, dated 11/29/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. 3. Patient #9 had a start of care date of 2/27/2021 and received services from the Shenandoah branch office. Clinical record review revealed the following: The Plans of Care, dated 6/27/2021 to 8/25/2021, 8/26/2021 to 10/24/2021, 10/25/2021 to 12/23/2021 and 12/24/2021 to 2/21/2022, documented Patient #9's diagnoses included peripheral vascular disease. The Plans documented the patient took Furosemide and Spironlactone, both diuretics. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 6/22/2021. . The update to the comprehensive assessment completed at the recertification, dated 6/22/2021, did not include any documentation indicating the patient took multiple diuretics. The clinical record lacked any communication/coordination notes addressing the duplicate diuretics. b. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 8/23/2021. The update to the comprehensive assessment completed at the recertification, dated 8/23/2021, did not include any documentation indicating the patient took multiple diuretics. The clinical record lacked any communication/coordination notes addressing the duplicate diuretics. c. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 10/20/2021. . The update to the comprehensive assessment completed at the recertification, dated 10/20/2021, did not include any documentation indicating the patient took multiple diuretics. The clinical record lacked any communication/coordination notes addressing the duplicate diuretics. d. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 12/20/2021. . The update to the comprehensive assessment completed at the recertification, dated 12/20/2021, did not include any documentation indicating the patient took multiple diuretics. The clinical record lacked any communication/coordination notes addressing the duplicate diuretics. 4. Patient #11 had a start of care date of 6/11/2021 and received services from the parent office. The Plans of Care, dated 6/11/2021 to 8/9/2021 and 8/10/2021 to 10/8/2021, documented Patient #11 took Miralax, a medication containing stool softener, and Fiber tablets, a medication used to add water to the stool to soften. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 6/11/2021. . The initial comprehensive assessment completed at the time of admission, dated 6/11/2021, documented the patient was noncompliant with medication use but did not include any documentation indicating the patient took multiple stool softeners and/or the potential for diarrhea when the stool softeners were combined. The clinical record lacked any communication/coordination notes addressing the duplicate stool softeners. b. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 8/5/2021. . The update to the comprehensive assessment completed at the recertification, dated 8/5/2021, did not include any documentation indicating the patient took multiple stool softeners and/or the potential for diarrhea when the stool softeners were combined. The clinical record lacked any communication/coordination notes addressing the duplicate stool softeners. The Plans of Care, dated10/9/2021 to 12/7/2021 and 12/8/2021 to 2/5/2022, documented Patient #11 took Docusate Sodium, a stool softener, and Fiber tablets, a medication used to add water to the stool to soften. c. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 10/4/2021. . The initial comprehensive assessment completed at the time of admission, dated 10/4/2021, documented the patient was noncompliant with medication use but did not include any documentation indicating the patient took multiple stool softeners and/or the potential for diarrhea when the stool softeners were combined. The clinical record lacked any communication/coordination notes addressing the duplicate stool softeners. d. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 12/6/2021. . The update to the comprehensive assessment completed at the recertification, dated 12/6/2021, did not include any documentation indicating the patient took multiple stool softeners and/or the potential for diarrhea when the stool softeners were combined. The clinical record lacked any communication/coordination notes addressing the duplicate stool softeners. 5. Patient #12 had a start of care date of 1/10/2019 and received services from the Denison branch office. Clinical record review revealed the following: The Plans of Care, dated 6/28/2021 to 8/26/2021, 8/27/2021 to 10/25/2021, 10/26/2021 to 12/24/2021 and 12/25/2021 to 2/22/2022, documented Patient #12's diagnoses included hypertensive heart disease with heart failure and chronic kidney disease. The Plans documented the patient took Furosemide, Lopressor and Amiodarone, all medications used to treat high blood pressure and heart failure. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 6/23/2021. . The update to the comprehensive assessment completed at the combined resumption of care/recertification, dated 6/23/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. b. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 8/24/2021. The update to the comprehensive assessment completed at the recertification, dated 8/24/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. c. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 10/21/2021.The update to the comprehensive assessment completed at the recertification, dated 10/21/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. d. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 11/9/2021. The update to the comprehensive assessment completed at the time of resumption of care following hospitalization, dated 11/9/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. e. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 12/21/2021.The update to the comprehensive assessment completed at the recertification, dated 12/21/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. 6. Patient #13 had a start of care date of 6/23/2021, previously received services from the parent office and was discharged from agency services on 7/23/2021. Clinical record review revealed the following: The Plan of Care, dated 6/23/2021 to 8/21/2021, documented Patient #13's diagnoses included chronic low back pain and second degree burns to both feet. The Plans documented the patient took Hydrocodone with Acetaminophen and Naproxen, both pain medications. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 6/23/2021. The initial comprehensive assessment completed at the time of admission, dated 6/23/2021, lacked any documentation indicating the patient took multiple pain medications. The clinical record lacked any communication/coordination notes addressing the duplicate pain medications. b. The skilled nurse visit note, dated 6/28/2021, documented the patient added Tylenol and Ibuprofen to his/her medication regimen, alternating both for pain control with only occasional use of the Hydrocodone with Acetaminophen. The On-Call Report (update to the Plan of Care), dated 6/28/2021, did not add the two new medications to the Plan. The medication profile lacked addition of the medications and neither medication was added to the medication profile. c. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 7/19/2021 at the time of medication changes. The patient was discharged from agency services on 7/23/2021. The medication profile did not include documentation of a drug regimen review at the time of discharge. The update to the comprehensive assessment completed at the time of discharge, dated 7/23/2021, lacked documentation identifying the patient took Acetaminophen, Hydrocodone with Acetaminophen, Naproxen and Ibuprofen, all medications used for pain control. The clinical record lacked any communication/coordination notes addressing the duplicate pain medications. 7. Patient #14 had a start of care date of 5/24/2021, previously received services from the Shenandoah branch office and was discharged from agency services on 12/20/2021. Clinical record review revealed the following: The Plans of Care, dated 5/24/2021 to 7/22/2021, 7/23/2021 to 9/20/2021, 9/21/2021 to 11/19/2021 and 11/20/2021 to 1/18/2022, documented Patient #14's diagnoses included hypertensive heart disease with heart failure and chronic kidney disease. The Plans documented the patient took Losartan, Metoprolol and Amlodipine, all medications used to treat high blood pressure and heart failure. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 5/25/2021. . The initial comprehensive assessment completed at the time of admission, dated 5/24/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. b. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 7/19/2021. The update to the comprehensive assessment completed at the recertification, dated 7/19/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. c. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 9/17/2021. The update to the comprehensive assessment completed at the recertification, dated 9/17/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. d. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 11/17/2021. The update to the comprehensive assessment completed at the time of recertification, dated 11/19/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. e. The medication profile lacked documentation indicating a drug regimen review was completed after 11/17/2021. The update to the comprehensive assessment completed at discharge, dated 12/20/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications. The clinical record lacked any communication/coordination notes addressing the duplicate blood pressure medications with potential for medication interaction. 8. Patient #15 had a start of care date of 11/2/2018, previously received services from the Shenandoah branch office and was discharged from agency services on 8/24/2021 following transfer to the hospital with subsequent admission to a nursing home. Clinical record review revealed the following: The Plans of Care, dated 4/20/2021 to 6/18/2021, 6/19/2021 to 8/17/2021 and 8/18/2021 to 10/16/2021, documented Patient #15's diagnoses included hypertensive heart disease with heart failure, chronic kidney disease and osteoarthritis. The Plans documented the patient took Torsemide, Losartan, Cardizem and Guanfacine, all medications used to treat high blood pressure and heart failure; Zofran, Metoclopramide, Ranitidine and Pantoprazole, all medications taken for gastrointestinal (GI) upset/reflux; and Tramadol, Acetaminophen and Tylenol Arthritis, all medications taken for pain relief. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 4/15/2021. The update to the comprehensive assessment completed at recertification, dated 4/15/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications; took multiple pain medications and took multiple GI medications. The clinical record lacked any communication/coordination notes addressing any of the above. b. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 6/15/2021. The update to the comprehensive assessment completed at recertification, dated 6/15/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications; took multiple pain medications and took multiple GI medications. The clinical record lacked any communication/coordination notes addressing any of the above. c. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 8/15/2021. The update to the comprehensive assessment completed at the combined resumption of care/recertification, dated 8/15/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications; took multiple pain medications and took multiple GI medications. The clinical record lacked any communication/coordination notes addressing any of the above. 9. Patient #16 had a start of care date of 7/1/2021, previously received services from the parent office and was discharged from agency services on 8/30/2021. Clinical record review revealed the following: The Plan of Care, dated 7/1/2021 to 8/29/2021, documented Patient #16's diagnoses included hypertensive heart disease with heart failure, chronic kidney disease, pulmonary hypertension and diabetes. The Plan documented the patient took Torsemide, Losartan and Carvadilol, all medications used to treat high blood pressure and heart failure; Metamucil, Milk of Magnesia and Miralax, all medications taken for constipation; Lantus insulin and Humalog insulin, both medications taken to lower blood sugar; and Hydrocodone with Acetaminophen and Ibuprofen, both medications taken for pain relief. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 7/1/2021. The initial comprehensive assessment completed at admission, dated 7/1/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications; took multiple pain medications and took multiple insulins and/or the potential for hypoglycemia when combining; and took multiple medications to treat constipation and/or the potential for diarrhea when combining. The clinical record lacked any communication/coordination notes addressing any of the above. b. The clinical record included an update to the comprehensive assessment at the time of resumption of care following hospitalization, dated 7/13/2021. The clinical record lacked any documentation of a drug regimen review associated with the resumption of care assessment. c. The resumption of care orders, dated 7/29/2021, documented the physician added Metoprolol, a medication to lower blood pressure, to the patient's medications regimen and added Plavix, a blood thinner, to the patient's medication regimen. The patient also already took low dose Aspiring to thin the blood. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 7/29/2021. The update to the comprehensive assessment completed at the time of resumption of care following hospitalization, dated 7/29/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications; took multiple pain medications and took multiple insulins and/or the potential for hypoglycemia when combining; took multiple medications to treat constipation and/or the potential for diarrhea when combining; and failed to address the added duplication of multiple blood thinners and/or the potential for abnormal bleeding when combined. The clinical record lacked any communication/coordination notes addressing any of the above. d. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 8/13/2021. The update to the comprehensive assessment completed at the time of resumption of care following hospitalization, dated 8/13/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications; took multiple pain medications and took multiple insulins and/or the potential for hypoglycemia when combining; took multiple medications to treat constipation and/or the potential for diarrhea when combining; and took multiple blood thinners and/or the potential for abnormal bleeding when combined. The clinical record lacked any communication/coordination notes addressing any of the above. e. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 8/29/2021. The update to the comprehensive assessment completed at the time of discharge, dated 8/29/2021, did not include any documentation indicating the patient took multiple blood pressure medications and/or identification of the potential for hypotension when combining multiple blood pressure medications; took multiple pain medications and took multiple insulins and/or the potential for hypoglycemia when combining; took multiple medications to treat constipation and/or the potential for diarrhea when combining; and took multiple blood thinners and/or the potential for abnormal bleeding when combined. The clinical record lacked any communication/coordination notes addressing any of the above. 10. Patient #17 had a start of care date of 9/22/21, previously received services from the Denison branch office and was discharged from agency services on 11/11/2021. Clinical record review revealed the following: The Plan of Care, dated 9/22/2021 to 11/2021, documented the patient took Clear Lax (a generic form of Miralax), Milk of Magnesia and Bisacodyl, all medications taken for constipation, and took Tylenol Extended Released, Tylenol regular strength and Tramadol, all medications taken for pain relief. a. The medication profile included documentation the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 9/22/2021. The initial comprehensive assessment completed at admission, dated 9/22/2021, did not include any documentation indicating the nurse identified the patient took multiple bowel medications for constipation and/or the potential for diarrhea when the medications are combined, and took multiple pain medications. The clinical record lacked any communication/coordination notes addressing any of the above. b. The clinical record included an update to the comprehensive assessment at the time of discharge, dated 11/11/2021. The clinical record lacked any documentation of a drug regimen review associated with the discharge assessment.

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, patient interview and staff 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 for 11 of 17 sampled patients (Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #14 and #17). The survey found the deficient practice occurring at the parent office, the Shenandoah and the Denison branch offices. 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: 8. Patient #1 had a start of care date of 12/9/21 and received services from the Shenandoah branch office. Clinical record review revealed Plan of Care, dated 12/9/21 to 2/6/22, included rails/grab bars, shower/tub equipment, vital signs equipment, walker, incontinence, nursing supplies, physical therapy, and skin care, as equipment and supplies used by the patient. During a home observation visit on 1/4/22 at 10:25 AM, with Staff H, registered nurse (RN), the surveyor observed the patient using a walker, grab bars and a shower chair in the bathroom, a cane by the front door, and a medication planner on the table, filled by Staff H, RN. During an interview with Staff H, RN, during the home observation visit, Staff H reported on the Plan of Care, the medication planner would be listed under nursing supplies, physical therapy was added so therapists can order supplies or equipment if needed, skin care was added due to patient being at risk for skin breakdown, and incontinence was added for incontinence pads the patient wore. During an interview with Patient #1 during the home observation visit, Patient #1 reported using the cane when going out to the grocery store and does not use any forms of incontinence products. The Plan of Care failed to identify cane, medication planner and shower chair, as equipment used by the patient. The Plan of Care failed to identify accurate equipment and supplies used by the patient. 9. Patient #3 had a start of care date of 10/22/21 and received services from the Shenandoah branch office. Clinical record review revealed Plans of Care, dated 10/22/21 to 12/20/21 and 12/21/21 to 2/18/22, included cane, elevated toilet seat, rails/grab bars, walker, incontinence and wound care, as equipment and supplies used by the patient. During a home observation visit on 1/4/22 at 11:30 AM, with Staff J, Physical Therapy Assistant (PTA), the surveyor observed a cane, long handled shoe horn and a reacher by the recliner; and an elevated toilet seat and grab bar in the bathroom. During an interview with Patient #3 during the home observation visit, Patient #3 reported using a long handled shoe horn, sock aide, and reacher since hospital discharge; patient wears incontinence pads; used the walker at the time of admission to home health services and has transitioned from the walker to a cane during services. Plan of Care, dated 10/22/21 to 12/20/21, failed to identify the long handled shoe horn, sock aide, reacher, and incontinence pads as equipment and supplies used by the patient. Plan of Care, dated 12/21/21 to 2/18/22, failed to identify the long handled shoe horn, sock aide, reacher, incontinence pads, and cane as equipment and supplies used by the patient. The Plans of Care failed to identify accurate equipment and supplies used by the patient. 10. Patient #8 had a start of care date of 5/29/21 and received services from the Shenandoah branch office. Clinical record review revealed: a. Plans of Care, dated 9/26/21 to 11/24/21 and 11/25/21 to 1/23/22, included shower/tub equipment, incontinence, nursing supplies, and physical therapy, as equipment and supplies used by the patient. b. Skilled nursing visit note, dated 9/21/21, identified the patient used a tub chair and wore incontinence briefs. c. Skilled nursing visit note, dated 11/22/21, identified the patient used a tub chair and wore incontinence pads. The Plans of Care failed to identify specific equipment and supplies used by the patient. 11. Patient #10 had a start of care date of 8/5/21 and received services from the parent office. Clinical record review revealed Plans of Care, dated 10/4/21 to 12/2/21 and 12/3/21 to 1/31/22, included respiratory supplies, shower/tub equipment, incontinence, nursing supplies, physical therapy, and skin care, as equipment and supplies used by the patient. The Plan of Care failed to identify specific equipment and supplies used by the patient. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey. According to agency policy, titled Plan of Care, dated 7/1/18, the individualized plan of care must include medical supplies/equipment needed by the patient. The Plan of Care changes that occur between certification periods are documented with the Plan of Care Update Order. 1. Patient #4 had a start of care date of 10/13/2021 and received services from the parent office. Clinical record review, patient interview and home visit observation, revealed the following: The initial comprehensive assessment completed at admission, dated 10/13/2021, and the update to the comprehensive assessment at recertification, dated 12/8/2021, documented the patient used a tub chair when bathing. On 1/4/2022 at 10:00 AM, the surveyor accompanied Staff K, Registered Nurse (RN) to Patient #4's home. Patient interview during the home visit revealed the patient was able to bathe self independently but required the use of a tub chair to complete. Surveyor observation during the same visit revealed the patient used a medication planner set up by the agency nurse. The Plans of Care, dated 10/13/2021 to 12/11/2021 and 12/12/2021 to 2/9/2022, lacked identification of a tub chair and medication planner as equipment used by the patient to meet his/her individualized needs. 2. Patient #5 had a start of care date of 12/8/2021 and received services from the parent office. Clinical record review, patient interview and home visit observation, revealed the following: On 1/5/2022 at 2:00 PM, the surveyor accompanied Staff G, RN to Patient #5's home. Patient interview during the home visit revealed the patient bathed at the sink in the kitchen due to an inability to get the wheelchair used for locomotion through the bathroom door to use the tub/shower. Surveyor observation during the same visit revealed the patient used a pressure relief cushion placed in the recliner or wheelchair when using. The Plan of Care, dated 12/8/2021 and 2/5/2022, included identification of "shower/tub equipment" as needed by the patient even though the patient does not use a tub or shower. The Plan lacked identification of the pressure relief cushion as equipment used by the patient to meet his/her individualized needs. 3. Patient #5 had a start of care date of 10/10/2021 and received services from the parent office. Clinical record review and home visit observation, revealed the following: On 1/5/2022 at 9:00 AM, the surveyor accompanied Staff L, RN to Patient #6's home. Surveyor observation during the home visit revealed the patient used a sock aide, a device to allow the patient to put on compression stockings independently. Following wound care provided by the nurse, the patient used the sock aide to apply compression stockings to both lower extremities. The Plans of Care, dated 10/10/2021 to 12/8/2021 and 12/9/2021 to 2/6/2022, lacked identification of the sock aide as equipment used by the patient to meet his/her individualized needs. 4. Patient #7 had a start of care date of 6/7/2021 and received services from the Denison branch office. Clinical record review revealed the following: The updates to the comprehensive assessment completed at recertification, dated 10/4/2021 and 11/29/2021, documented the patient used a tub chair when bathing. The Plans of Care, dated 10/5/2021 to 12/3/2021 and 12/4/2021 to 2/1/2022, lacked identification of a tub chair as equipment used by the patient to meet his/her individualized needs. 5. Patient #9 had a start of care date of 2/27/2021 and received services from the Shenandoah branch office. Clinical record review revealed the following: The updates to the comprehensive assessment completed at recertification, dated 8/23/2021, 10/20/2021 and 12/20/2021, documented the patient used a tub chair when bathing. The Plans of Care, dated 8/26/2021 to 10/24/2021, 10/25/2021 to 12/23/2021 and 12/24/2021 to 2/21/2022, lacked identification of a tub chair as equipment used by the patient to meet his/her individualized needs. 6. Patient #14 had a start of care date of 5/24/2021, received services from the Shenandoah branch office and was discharged from agency services on 12/20/2021. Clinical record revealed the following: The updates to the comprehensive assessment completed at recertification, dated 9/17/2021 and 11/17/2021, documented the patient used a tub chair when bathing. The Plans of Care, dated 9/21/2021 to 11/19/2021 and 11/20/2021 to 1/18/2021, lacked identification of a tub chair as equipment used by the patient to meet his/her individualized needs. 7. Patient #17 had a start of care date of 9/22/2021, received services from the Denison branch office and was discharged from agency services on 11/11/2021. The initial comprehensive assessment, dated 9/22/2021, documented the patient used a tub chair when bathing. The Plan of Care, dated 9/22/2021 to 11/20/2021, lacked identification of a tub chair as equipment used by the patient to meet his/her individualized needs.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, surveyor observation, patient interview and agency staff interview, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 7 of 17 sampled patients (Patients #4, #8, #10, #12, #14, #16 and #17). The survey found the deficient practice occurring at the parent office, the Shenandoah and the Denison branch offices. Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to receive unsafe, non-individualized and inconsistent care designed to meet each patients' health care needs. Findings include: 6. Patient #10 had a start of care date of 8/5/21 and received services from the parent office. Clinical record review revealed: a. Plan of Care, dated 12/3/21 to 1/31/22, identified diagnoses of non-pressure chronic ulcer other part bilateral lower legs with fat layer exposed, venous insufficiency, lymphedema, and diabetes; and included orders for the skilled nurse to measure bilateral ankle circumference every visit if patient is unable to safely weigh. b. Skilled nursing visit notes, dated 12/7, 12/14, 12/21, 12/24, 12/28 and 12/31/21, lacked documentation the nurse measured bilateral ankle circumference or obtained a weight. The visit note reports, dated 12/7, 12/14, 12/21, 12/24, 12/28 and 12/31/21, identified the nurse had completed the task of measuring the ankle circumference, but lacked documentation of the measurements obtained. The clinical record lacked documentation of bilateral ankle circumference measurements as ordered by the physician on the plan of care and lacked documentation the physician was notified of the failure to measure the bilateral ankle circumference. 7. Patient #8 had a start of care date of 5/29/21 and received services from the Shenandoah branch office. Clinical record review revealed: a. Plan of Care, dated 9/26/21 to 11/24/21, identified diagnoses of osteoarthritis and congestive heart failure, and included orders for the skilled nurse to weigh the patient every visit. b. Skilled nursing visit note, dated 11/3/21, lacked documentation the nurse weighed the patient or a reason why the patient was not weighed. The visit note report, dated 11/3/21, identified the nurse had completed the task of weighing the patient, but lacked documentation of the weight obtained. The clinical record lacked documentation of a weight on 11/3/21 or a reason why a weight was not obtained as ordered by the physician on the plan of care and lacked documentation the physician was notified of the failure to weigh the patient on 11/3/21. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey. 1. Patient #4 had a start of care date of 10/13/2021 and received services from the parent office. Clinical record review, home visit observation, patient interview and agency staff interview revealed the following: a. The Plans of Care, dated 10/13/2021 to 12/11/2021 and 12/12/2021 to 2/9/2022, documented Patient #4's diagnoses included Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease and Adult Failure to Thrive. The Plans also directed the skilled nurse to visit the patient once weekly. During each weekly visit, the physician directed the nurse to weigh the patient, reporting any weight gain greater than 3 pounds in 24 hours. b. The skilled nurse visit notes, dated 12/3, 12/8, 12/16, 12/23 and 12/29/2021, lacked documentation indicating the nurse weighed the patient as directed in the Plan of Care. The visit notes lacked a reason for omission. c. On 1/4/2022 at 10:00 AM, the surveyor accompanied Staff K, Registered Nurse (RN), to Patient #4's home. During the home visit, surveyor observation revealed Staff K did not weigh the patient. Patient interview during the home visit revealed the patient's adult child had removed the patient's scale, previously used by the agency nurses from the home approximately one month prior. Staff K did not bring a scale to the patient's home to weigh the patient. The agency had not weighed the patient since 12/1/2022. The nurses did not follow the Plan of Care as directed by the physician. During agency staff interview on 1/5/2022 at 4:00 PM, the agency Administrator reported she reviewed the patient's clinical record and was unable to find documentation indicating why the nurses were not weighing Patient #4. 2. Patient #12 had a start of care date of 1/10/2019 and received services from the Denison branch office. Clinical record review revealed the following: a. The Plan of Care, dated 10/26/2021 to 12/24/2021, documented Patient #12's diagnoses included diabetes. The Plan directed the skilled nurse to monitor the patient's blood sugar every visit, reporting any blood sugar readings less than 50 or greater than 250. b. The skilled nurse visit note, dated 12/7/2021, documented the nurse monitored the patient's blood sugar and the reading was 279. The skilled nurse visit note lacked documentation of physician notification of the high blood sugar. The communication/coordination notes lacked any documentation indicating the nurse contacted the physician to report the high blood sugar. c. The skilled nurse visit note, dated 12/14/2021, lacked documentation indicating the nurse monitored the patient's blood sugar, as directed by the physician, during the home visit. The visit note lacked a reason for omission. 3. Patient #14 had a start of care date of 5/24/2021, previously received services from the Shenandoah branch office and was discharged from agency services on 12/20/2021. Clinical record review and agency staff interview revealed the following: a. The Plans of Care, dated 9/21/2021 to 11/19/2021 and 11/20/2021 to 1/18/2022, documented Patient #12's diagnoses included diabetes with chronic kidney disease. The Plans also directed the skilled nurse to visit the patient once weekly. During each weekly visit, the physician directed the nurse to weigh the patient, reporting any weight gain greater than 3 pounds in 24 hours. b. The skilled nurse visit notes, dated 10/5/2021, 12/10/2021 and 12/16/2021, lacked documentation indicating the nurse weighed the patient as directed in the Plan of Care. The visit notes lacked a reason for omission. c. During agency staff interview on 1/11/2022 at 9:30 AM, the agency Administrator reported she reviewed the patient's clinical record and was unable to find documentation of the nurse's monitoring of the patient's weight or documentation indicating why the nurse had not weighed the patient on the dates specified above. 4. Patient #16 had a start of care date of 7/1/2021, previously received services from the parent office and was discharged from agency services on 8/30/2021. Clinical record review and agency staff interview revealed the following: a. The Plan of Care, dated 7/1/2021 to 8/29/2021, documented Patient #16's diagnoses included Hypertensive Heart Disease with Heart Failure and Morbid Obesity. The Plans also directed the skilled nurse to visit the patient twice weekly. The Plan included physician direction for the nurse to weigh the patient each visit, reporting any weight gain greater than 3 pounds in 24 hours. b. The skilled nurse visit notes, dated 8/17/2021, 8/20/2021 and 8/24/2021, lacked documentation indicating the nurse weighed the patient as directed in the Plan of Care. The visit notes lacked a reason for omission. c. During agency staff interview on 1/11/2022 at 10:15 AM, the agency Administrator reported she reviewed the patient's clinical record and was unable to find documentation of the nurse's monitoring of the patient's weight or documentation indicating why the nurse had not weighed the patient on the dates specified above. 5. Patient #17 had a start of care date of 9/22/2021, previously received services from the Denison branch office and was discharged on 11/11/2021. Clinical record review and agency staff interview revealed the following: a. The Plan of Care, dated 9/22/2021 to 11/20/2021, included physician direction for the skilled nurse to visit the patient twice weekly for 2 weeks, then once weekly for 7 weeks. The Plan included physician direction for the nurse to weigh the patient each visit, reporting any weight gain greater than 3 pounds in 24 hours. If unable to weigh, the nurse should measure both of the patient's ankle circumference, reporting any increase in 2 centimeters in 24 hours. b. The skilled nurse visit note, dated 9/29/2021, included documentation indicating the patient refused weighing so the nurse measured only one ankle for circumference with measurement of 32 centimeters. The note lacked documentation indicating which ankle was measured and why the other was not measured. c. The skilled nurse visit note, dated 10/1/2021, included documentation indicating the patient refused weighing so the nurse measured only one ankle for circumference with measurement of 31 centimeters. The note lacked documentation indicating which ankle was measured and why the other was not measured. d. The skilled nurse visit note, dated 10/7/2021, included documentation indicating the patient refused weighing so the nurse measured only the left ankle for circumference with measurement of 31 centimeters. The note lacked documentation indicating why the other was not measured. e. The skilled nurse visit note, dated 10/14/2021, included documentation indicating the patient refused weighing so the nurse measured only one ankle for circumference with measurement of 31.5 centimeters. The note lacked documentation indicating which ankle was measured and why the other was not measured. f. The skilled nurse visit note, dated 10/21/2021, included documentation indicating the patient refused weighing so the nurse measured only the left ankle for circumference with measurement of 31 centimeters. The note lacked documentation indicating why the other was not measured. g. The skilled nurse visit note, dated 11/3/2021, included documentation indicating the patient refused weighing so the nurse measured only the left ankle for circumference with measurement of 28 centimeters. The note lacked documentation indicating why the other was not measured. h. The skilled nurse visit note, dated 11/11/2021, included documentation indicating the patient refused weighing so the nurse measured only the right ankle for circumference with measurement of 27 centimeters. The note lacked documentation indicating why the other was not measured. During agency staff interview on 1/11/2022 at 10:15 AM, the agency Administrator reported she reviewed the patient's clinical record and also noted the nurse was only measuring one ankle during the visits rather than both as directed by the physician on the dates specified above.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, surveyor observation, patient interview and agency staff interview, the agency failed to ensure that skilled professionals failed to communicate and coordinate patient care and services with the physician for 8 of 17 sampled patients (Patients #4, #8, #9, #10, #13, #14, #16 and #17). The survey found the deficient practice occurring at the parent office, the Shenandoah branch office and the Denison branch office. Failure to communicate the patient's status with the physician and coordinate care provided by other disciplines placed agency patients at risk for unidentified of conditions, inappropriate treatments, or unmet home health care needs. Findings include: 7. Patient #8 had a start of care date of 5/29/21 and received services from the Shenandoah branch office. Clinical record review revealed: a. Plan of Care, dated 9/26/21 to 11/24/21, identified diagnoses of osteoarthritis and congestive heart failure, and included orders for the skilled nurse to weigh the patient every visit. b. Skilled nursing visit note, dated 11/3/21, lacked documentation the nurse weighed the patient or a reason why the patient was not weighed. The visit note report, dated 11/3/21, identified the nurse had completed the task of weighing the patient, but lacked documentation of the weight obtained. The clinical record lacked documentation of a weight on 11/3/21 or a reason why a weight was not obtained as ordered by the physician on the plan of care and lacked documentation the physician was notified of the failure to weigh the patient on 11/3/21. 8. Patient #10 had a start of care date of 8/5/21 and received services from the parent office. Clinical record review revealed: a. Plan of Care, dated 12/3/21 to 1/31/22, identified diagnoses of non-pressure chronic ulcer other part bilateral lower legs with fat layer exposed, venous insufficiency, lymphedema, and diabetes; and included orders for the skilled nurse to measure bilateral ankle circumference every visit if patient is unable to safely weigh. b. Skilled nursing visit notes, dated 12/7, 12/14, 12/21, 12/24, 12/28 and 12/31/21, lacked documentation the nurse measured bilateral ankle circumference or obtained a weight. The visit note reports, dated 12/7, 12/14, 12/21, 12/24, 12/28 and 12/31/21, identified the nurse had completed the task of measuring the ankle circumference, but lacked documentation of the measurements obtained. The clinical record lacked documentation of bilateral ankle circumference measurements as ordered by the physician on the plan of care and lacked documentation the physician was notified of the failure to measure the bilateral ankle circumference. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey. 1. Patient #4 had a start of care date of 10/13/2021 and received services from the parent office. Clinical record review and agency staff interview revealed the following: a. The Plans of Care, dated 10/13/2021 to 12/11/2021 and 12/12/2021 to 2/9/2022, documented Patient #4's diagnoses included Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease and Adult Failure to Thrive. The Plans also directed the skilled nurse to visit the patient once weekly. During each weekly visit, the physician directed the nurse to weigh the patient, reporting any weight gain greater than 3 pounds in 24 hours. The skilled nurse visit notes, dated 12/3 12/,8, 12/16, 12/23 and 12/29/2021, lacked documentation indicating the nurse weighed the patient as directed in the Plan of Care. The visit notes lacked a reason for omission. The visit notes lacked documentation of physician notification of the omission of the task. The clinical record lacked documentation indicating the nurse reported the inability to weigh Patient #4 to the physician. During agency staff interview on 1/5/2022 at 4:00 PM, the agency Administrator reported she reviewed the patient's clinical record and was unable to find documentation indicating the nurses reported the inability to weigh Patient #4 as described above. b. The Plan of Care, dated 10/13/2021 to 12/11/2021 and 12/12/2021 to 2/9/2022, documented Patient #4's diagnoses included Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease and Adult Failure to Thrive. The Plans also included physician orders for home health aide services once weekly beginning on 10/17/2021 to assist with bathing and personal care. The patient's clinical record included no home health aide visit notes. The clinical record did include a physician's interim order, dated 11/2/2021 and 15 days after the physician ordered start of care, reported the patient refused the initiation of home health aide services. c. The Plan of Care, dated 12/12/2021 to 2/9/2021, included physician orders for occupational therapy services twice weekly for two weeks; then once weekly for an additional 2 weeks. The patient's clinical record did not include any occupational therapy visits after 12/12/2021. The clinical record included a discharge note, completed by the occupational therapist on 12/17/2021, indicting the nurse told the therapist the patient requested therapy services stop. The therapist made no additional visits and documentation lacked any physician notification of the therapy services ceasing 4 weeks early. 2. Patient #9 had a start of care date of 2/27/2021 and received services from the Shenandoah branch office. Clinical record review and agency staff interview revealed the following: The Plans of Care, dated 10/25/2021 to 12/23/2021 and 12/24/2021 to 2/21/2022, documented Patient #9's diagnoses included non pressure related ulcers on the left and right foot. The Plans directed the nurse to complete wound care to both feet 3 times weekly. The skilled nurse visit notes, dated 11/1, 11/2, 11/5, 11/10, 11/12, 11/15, 11/17, 11/19, 11/22, 11/24, 11/26, 11/29, 12/1, 12/3, 12/6, 12/8, 12/10, 12/13, 12/15, 12/17, 12/20, 12/22, 12/24, 12/29 and 12/31/2021, lacked documentation of wound measurements. The nurses either documented "unable to measure" or "measurements not due". During agency staff interview on 1/3/2022 at 12:10 PM, the agency Administrator reported all wounds should be measured weekly, including length, width and depth. During agency staff interview on 1/6/2022 at 12:00 PM, the agency Administrator reported knowledge that the nurses felt the wounds were hard to measure as were between the toes and area was macerated. She reviewed the clinical record and could find no documentation of communication with the physician to report the inability to measure the patient's wounds. 3. Patient #13 had a start of care date of 6/23/2021, previously received services from the parent office and was discharged from agency services on 7/23/2021. Clinical record review revealed the following: a. The Plan of Care, dated 6/23/2021 to 8/21/2021, documented Patient #13's diagnoses included chronic low back pain and second degree burns to both feet. The Plans documented the patient took Hydrocodone with Acetaminophen and Naproxen, both pain medications. a. The medication profile documented the nurse reviewed the patient's medications for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy on 6/23/2021. b. The skilled nurse visit note, dated 6/28/2021, documented the patient added Tylenol and Ibuprofen to his/her medication regimen, alternating both for pain control with only occasional use of the Hydrocodone with Acetaminophen. The On-Call Report (update to the Plan of Care), dated 6/28/2021, did not add the two new medications to the Plan. The medication profile lacked addition of the medications and neither medication was added to the medication profile. The clinical record lacked communication/coordination notes indicating the nurse notified the physician of the patient's use of the Acetaminophen and Ibuprofen. 4. Patient #14 had a start of care date of 5/24/2021, previously received services from the Shenandoah branch office and was discharged from agency services on 12/20/2021. Clinical record review and agency staff interview revealed the following: a. The Plans of Care, dated 9/21/2021 to 11/19/2021 and 11/20/2021 to 1/18/2022, documented Patient #12's diagnoses included diabetes with chronic kidney disease. The Plans also directed the skilled nurse to visit the patient once weekly. During each weekly visit, the physician directed the nurse to weigh the patient, reporting any weight gain greater than 3 pounds in 24 hours. b. The skilled nurse visit notes, dated 10/5/2021, 12/10/2021 and 12/16/2021, lacked documentation indicating the nurse weighed the patient as directed in the Plan of Care. The visit notes lacked a reason for omission. The visit notes lacked documentation of physician notification of the omission of the task. The clinical record lacked any communication/coordination notes documenting physician notification of the nurse omission of weighing the patient. c. During agency staff interview on 1/11/2022 at 9:30 AM, the agency Administrator reported she reviewed the patient's clinical record and was unable to find documentation of physician notification of the nurse omission of weighing the patient on the above stated dates. 5. Patient #16 had a start of care date of 7/1/2021, previously received services from the parent office and was discharged from agency services on 8/30/2021. Clinical record review and agency staff interview revealed the following: a. The Plan of Care, dated 7/1/2021 to 8/29/2021, documented Patient #16's diagnoses included Hypertensive Heart Disease with Heart Failure and Morbid Obesity. The Plans also directed the skilled nurse to visit the patient twice weekly. The Plan included physician direction for the nurse to weigh the patient each visit, reporting any weight gain greater than 3 pounds in 24 hours. b. The skilled nurse visit notes, dated 8/17/2021, 8/20/2021 and 8/24/2021, lacked documentation indicating the nurse weighed the patient as directed in the Plan of Care. The visit notes lacked a reason for omission. The visit notes lacked documentation of physician notification of the omission of the task. The clinical record lacked any communication/coordination notes notifying the physician of the omission of the weights on the above stated dates. c. During agency staff interview on 1/11/2022 at 10:15 AM, the agency Administrator reported she reviewed the patient's clinical record and was unable to find documentation of physician notification of the nurse omitting weighing the patient on the above stated dates. 6. Patient #17 had a start of care date of 9/22/2021, previously received services from the Denison branch office and was discharged on 11/11/2021. Clinical record review and agency staff interview revealed the following: a. The Plan of Care, dated 9/22/2021 to 11/20/2021, included physician direction for the skilled nurse to visit the patient twice weekly for 2 weeks, then once weekly for 7 weeks. The Plan included physician direction for the nurse to weigh the patient each visit, reporting any weight gain greater than 3 pounds in 24 hours. If unable to weigh, the nurse should measure both of the patient's ankle circumference, reporting any increase in 2 centimeters in 24 hours. b. The skilled nurse visit notes, dated 9/24, 9/29, 10/1, 10/7, 10/14, 10/21,11/3 and 11/2021, included documentation of indicating the patient refused weighing so the nurse measured ankle circumference; however, only measured one ankle rather than both as directed by the physician. The visit notes lacked documentation of why the other ankle was not measured and lacked documentation indicating the nurse notified the physician of the omission of measuring the other ankle. The clinical record lacked documentation of any communication/coordination notes indicating the nurse notified the physician of the inability to perform the task as directed in the Plan of Care. c. During agency staff interview on 1/11/2022 at 10:15 AM, the agency Administrator reported she reviewed the patient's clinical record and also noted the nurse was only measuring one ankle during the visits rather than both as directed by the physician on the dates specified above. She reported an inability to locate any documentation indicating the nurse notified the physician of the inability to perform the task as directed in the Plan of Care.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 4 sampled patients receiving home health aide services (Patients #10, #11 and #14). The survey found the deficient practice occurring at the parent office and the Shenandoah branch office. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: 3. Patient #10 had a start of care date of 8/5/21 and received services from the parent office. Clinical record review revealed: a. Plans of Care, dated 10/4/21 to 12/2/21 and 12/3/21 to 1/31/22, included physician orders for skilled nursing services and home health aide services twice weekly for assistance with personal care, hygiene and activities of daily living. b. The home health aide assignments, dated 10/6/21 and 12/3/21, directed the aides to complete the task to check the patient blood pressure every visit. c. The completed home health aide visit notes, dated 11/2, 11/5, 11/9, 11/12, 11/16, 11/23, 11/26, 11/30, 12/3, 12/7, 12/10, 12/14, 12/21, 12/24, 12/28 and 12/31/21, included documentation the task to check blood pressure had been completed. The Plans of Care failed to include physician orders directing the home health aide to complete the task to check the patient blood pressure as required by regulation. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey. 1. Patient #11 had a start of care date of 6/11/2021 and received services from the parent office. Clinical record review revealed the following: a. The Plan of Care, dated 6/11/2021 to 8/9/2021, included physician orders for home health aide services to assist with bathing and personal care. b. The Aide Care Plan for 6/11/2021 through 7/29/2021, included direction to the home health aide to monitor the patient's blood pressure every visit, reporting any systolic (upper number) readings of less than 90 or more than 160 to the nurse and reporting any diastolic (bottom number) readings less than 50 and more than 90. Monitoring of blood pressure is a nursing task delegated by the nurse to the aide. Delegated tasks provided as an extension of nursing services require physician orders prior to delegating. c. Home health aide visit notes, dated 6/17, 6/21, 6/24, 628, 7/1, 7/6, 7/8, 7/13, 7/16 and 7/20/2021, were completed by Staff N, Home Health Aide. All of the notes documented the aide monitored the patient's blood pressure. The aide performed a delegated task during the above stated visits without approval from the physician. 2. Patient #14 had a start of care date of 5/24/2021 and received services from the Shenandoah branch office. Clinical record review revealed the following: a. The Plan of Care, dated 7/23/2021 to 9/20/2021, included physician orders for home health aide services to assist with bathing and personal care. b. The Aide Care Plan for 7/23/2021 through 9/20/2021 and 9/21/2021 through 11/19/2021, included direction to the home health aide to monitor the patient's blood pressure every visit, reporting any systolic (upper number) readings of less than 90 or more than 160 to the nurse and reporting any diastolic (bottom number) readings less than 50 and more than 90. Monitoring of blood pressure is a nursing task delegated by the nurse to the aide. Delegated tasks provided as an extension of nursing services require physician orders prior to delegating. c. Home health aide visit notes, dated 7/27, 8/3, 8/10, 8/17, 8/24, 8/31, 9/10 and 9/14/2021, were completed by Staff O, Home Health Aide. All of the notes documented the aide monitored the patient's blood pressure. Home health aide visit notes, dated 9/22, 9/28, and10/18/2021, were completed by Staff P, Home Health Aide. All of the notes documented the aide monitored the patient's blood pressure. All other aide visit notes were completed by a nurse performing the aide tasks. The aide performed a delegated task during the above stated visits without approval from the physician.

The #97599-C complaint investigation, conducted by the Department of Inspections and Appeals from 6/7/21 through 6/9/21, 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 and under the Condition of Participation 42 CFR 484.75 Skilled Professional Services. The survey also found the agency operating out of compliance with unrelated standard level regulatory requirements.

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 and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 2 of 2 sampled patients with surveyor home visit observation(Patients #1 and #2). The agency reported a total current census of 487 patients at the time of the survey, including 232 patients from the Council Bluffs, parent office, 201 patients from the Shenandoah branch office, and 54 patients from the Denison branch office. The concerns were identified with patients receiving care from the Council Bluffs parent office and Shenandoah branch office. 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 Plan of Care, dated 7/1/18, the individualized plan of care must include prescribed and over the counter medications and medical supplies/equipment needed. The Plan of Care changes that occur between certification periods are documented with the Plan of Care Update Order. 1. Patient #1 had a start of care date of 3/26/21 and received services from the Shenandoah branch office. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 5/25/21 to 7/23/21, included orders for Alprazolam 2 milligrams (mg) with instructions for the patient to take 1.5 tablets daily. b. The Client Medication Report, dated 6/7/21, included orders for Alprazolam 2 milligrams (mg) with instructions for the patient to take 1.5 tablets daily. During a home visit observation on 6/7/21 at 9:00 am, with Staff C, Registered Nurse, RN/Regional Nurse Preceptor, the patient reported the Alprazolam is to taken only as needed as the doctor is trying to wean the patient off the medication. The bottle had a fill date of 5/19/21 and instructed to use sparingly and take as needed for anxiety. The Plan of Care lacked the correct frequency of Alprazolam used by the patient. c. The Plan of Care, dated 5/25/21 to 7/23/21, included orders for Epipen 0.3 mg/milliliters (ml) auto injector to be used as directed for allergic reaction. d. The Client Medication Report, dated 6/7/21, included orders for Epipen 0.3 mg/milliliters (ml) auto injector to be used as directed for allergic reaction. The Plan of Care lacked specific directions (frequency) for use of the the Epi Pen. e. The Plan of Care, dated 5/25/21 to 7/23/21, included orders for Miralax 17 grams daily for constipation. f. The Client Medication Report, dated 6/7/21, included orders for Miralax 17 grams daily for constipation. During a home visit observation on 6/7/21 at 9:00 am, with Staff C, Registered Nurse, RN and Regional Nurse Preceptor, the patient reported currently out of Miralax, but is only taken as needed. The Plan of Care lacked the correct frequency of Miralax used by the patient. g. The Plan of Care, dated 5/25/21 to 7/23/21, included orders for Saline Mist 0.65% nasal spray 1 spray daily. h. The Client Medication Report, dated 6/7/21, included orders for Saline Mist 0.65% nasal spray 1 spray daily. During a home visit observation on 6/7/21 at 9:00 am, with Staff C, Registered Nurse, RN/Regional Nurse Preceptor, the patient reported only taking the Saline Mist nasal spray as needed for dryness. The Plan of Care lacked the correct frequency of Saline Mist used by the patient. i. The Plan of Care, dated 5/25/21 to 7/23/21, included orders for Trazodone 50 mg at bedtime. j. The Client Medication Report, dated 6/7/21, included orders for Trazodone 50 mg at bedtime. During a home visit observation on 6/7/21 at 9:00 am, with Staff C, Registered Nurse, RN/Regional Nurse Preceptor, the patient reported only taking the Trazodone as needed for insomnia. The Plan of Care lacked the correct frequency of Trazodone used by the patient. k. The Client Medication Report, dated 6/7/21, included a discontinued order, dated 5/24/21, for Cetirizine 10 mg daily. During a home visit observation on 6/7/21 at 9:00 am, with Staff C, Registered Nurse, RN/Regional Nurse Preceptor, the patient reported use of the Cetirizine daily and was filled by the previous RN in the medication planner. The Plan of Care lacked a current order for the Cetirizine used by the patient. l. The Plan of Care, dated 5/25/21 to 7/23/21, included orders for Ondansetron HCl 4 mg three times per day used for nausea. m. The Client Medication Report, dated 6/7/21, included orders for Ondansetron HCl 4 mg three times per day used for nausea. n. During the same home visit observation on 6/7/21 at 9:00 am, with Staff C, Registered Nurse, RN/Regional Nurse Preceptor, the patient reported use of the Loperamide Hydrochloride 2 mg as needed for diarrhea and stated use of the medication when having loose stools. The Plan of Care lacked a current order for the Loperamide Hydrochloride used by the patient. o. During the same home visit observation on 6/7/21 at 9:00 am, with Staff C, Registered Nurse, RN/Regional Nurse Preceptor, the patient reported use of the Walgreens Headache Relief which contains Acetaminophen 250 mg, Aspirin 250 mg, and Caffeine 65 mg as needed for headaches. The Plan of Care lacked a current order for the Walgreens Headache Relief used by the patient. 2. Patient #2 had a start of care date of 5/8/21 and received services from the Council Bluffs parent office. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 5/8/21 to 7/6/21, included orders for Degludec 100 units per ml with instructions for the patient to take 100 units daily. b. The Client Medication Report, dated 6/7/21, included orders for Degludec 100 units per ml with instructions for the patient to take 100 units daily. During a home visit observation on 6/8/21 at 12:55 PM, with Staff F, RN, the nurse reviewed medications with the patient's caregiver. The caregiver reported the patient takes 320 units of the Degludec daily. The Plan of Care lacked the correct dosage of Degludec used by the patient. c. The Plan of Care, dated 5/8/21 to 7/6/21, included orders for Aspirin 325 mg daily. d. The Client Medication Report, dated 6/7/21, included orders for Aspirin 325 mg daily. During a home visit observation on 6/8/21 at 12:55 PM, with Staff F, RN, the nurse reviewed medications with the patient's caregiver. The caregiver reported the patient has not been taking the Aspirin for over one month. The Plan of Care identified the Aspirin as a medication used by the patient. e. The Plan of Care, dated 5/8/21 to 7/6/21, included orders for Refresh Tears 0.5% 1 drop four times per day for left eye dryness. f. The Client Medication Report, dated 6/7/21, included orders for Refresh Tears 0.5% 1 drop four times per day for left eye dryness. . During a home visit observation on 6/8/21 at 12:55 PM, with Staff F, RN, the nurse reviewed medications with the patient's caregiver. The caregiver reported the patient has not been taking the Refresh Tears since discharged from the hospital about a month ago. The Plan of Care identified the Refresh tears as a medication used by the patient. g. During a home visit observation on 6/8/21 at 12:55 PM, with Staff F, RN, the nurse reviewed medications with the patient's caregiver. The caregiver reported the patient's use of Lantanoprost Opth eye drops 0.005% 125 micrograms (mcg) per 2.5 ml and reported the patient has been using the medication for over 5 years. The Plan of Care, dated 5/8/21 to 7/6/21, did not identify Latanoprost Opth eye drops as medication used by the patient. h. The Plan of Care, dated 5/8/21 to 7/6/21, identified the following as medical equipment and supplies used by the patient: commode, elevated toilet seat, walker, glucometer, wound care supplies, and glucometer. During a home visit observation on 6/8/21 at 12:55 PM, with Staff F, RN, the patient was using a reacher. The patient and patient caregiver reported use of the reacher since had knee surgery over a year ago. The Plan of Care lacked identification of the reacher as medical equipment/supplies used by the patient. The above stated findings for Patients #1 and #2 were reviewed with the Regional Clinical Director. 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, clinical record review, and staff interview, 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 6 of 6 sampled patients with new verbal/interim orders. (Patients #1, #2, #3, #4, #5 and #6) The agency reported a total current census of 487 patients at the time of the survey, including 232 patients from the Council Bluffs, parent office, 201 patients from the Shenandoah branch office, and 54 patients from the Denison branch office. The concerns were identified with patients receiving care from all three offices. 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 Plan of Care, dated 7/1/18, Plan of Care updates that occur between certification periods are documented with the Plan of Care Update Order. On 6/7/21 at 2:23 PM, interview with the Regional Clinical Director revealed the Plan of Care is updated every 60 days and at that time new orders can be added or removed from the plan of care. If the agency receives a new order, it it sent to the doctor for signature and the nurses can see any changes made on the tablets used for documentation in the homes. On 6/9/21 at 2:29 PM, interview with the Regional Clinical Director revealed she spoke with the Senior Vice President of Clinical Services, who agreed the agency updates the Plan of Care every 60 days. 1. Patient #1 had a start of care date of 3/26/21 and received services from the Shenandoah branch office. Clinical record review revealed: a. The Plan of Care, dated 3/26/21 to 5/24/21, included physician orders for physical and occupational therapy to evaluate and treat the patient. b. The physical therapy visit note, dated 3/31/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 3/26/21 to 5/24/21. The plan included a frequency of weekly visits for four weeks and included physical therapy goals for the patient. c. The occupational therapy visit note, dated 3/31/21, included the initial evaluation completed by the occupational therapist and orders for a occupational therapy plan of care for the period of 3/26/21 to 5/24/21. The plan included a frequency of weekly visits for four weeks and included occupational therapy goals for the patient. d. The physical therapy visit note, dated 4/28/21, included the reassessment completed by the physical therapist and orders for a physical therapy plan of care for the period of 3/26/21 to 5/24/21. The plan included a frequency of weekly visits for four weeks and included physical therapy goals for the patient. e. A verbal physician order for an occupational therapy reassessment the week of 4/26/21. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 2. Patient #2 had a start of care date of 5/8/21 and received services from the Council Bluffs parent office. Clinical record review revealed: a. The Plan of Care, dated , included physician orders for physical therapy to evaluate and treat the patient. b. The physical therapy visit note, dated 5/18/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 5/8/21 to 7/6/21. The plan included a frequency of weekly visits for four weeks and included physical therapy goals for the patient. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 3. Patient #3 had a start of care date of 5/21/21 and received services from the Denison branch office. Clinical record review revealed: a. The Plan of Care, dated 5/21/21 to 7/19/21, included physician orders for physical therapy to evaluate and treat the patient. b. The physical therapy visit note, dated 5/25/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 5/21/21 to 7/19/21. The plan included a frequency of visits two times per week for three weeks, and then one time per week for one week and included physical therapy goals for the patient. c. A verbal physician order, dated 6/3/21, included orders to discontinue carvedilol 12.5 mg daily and adding carvedilol 12.5 mg 1/2 tablet every morning and evening. The agency failed to ensure the Plan of Care was updated to include all patient care orders, including the physical therapy visits and changes in carvedilol. 4. Patient #4 had a start of care date of 3/15/17 and received services from the Council Bluffs parent office. Clinical record review revealed: a. The Plan of Care, dated 4/23/21 to 6/21/21, included physician orders for skilled nursing services and metoprolol succinate extended release 50 mg every morning. b. A verbal physician order, dated 5/10/21, included orders to discontinue metoprolol succinate extended release 50 mg every morning and add metoprolol succinate extended release 25 mg every morning. c. A verbal physician order, dated 6/7/21, included orders to decrease leg wraps to once weekly and have occupational therapy evaluate and fit the patient for Velcro like compression stockings such as pharaoh wraps or circ wraps. The agency failed to ensure the Plan of Care was updated to include all patient care orders, including the changes in metoprolol succinate, decrease in skilled nursing visits, and occupational therapy evaluation. 5. Patient #5 had a start of care date of 5/12/21 and received services from the Shenandoah branch office. Clinical record review revealed: a. The Plan of Care, dated 5/12/21 to 7/10/21, included physician orders for physical and occupational therapy to evaluate and treat the patient. b. A client coordination note, dated 5/11/21, included signed orders from the physician on 5/12/21, ordering to stop the colace, multiple vitamin, and potassium. c. The physical therapy visit note, dated 5/14/21, included the initial evaluation completed by the physical therapist and orders for a physical therapy plan of care for the period of 5/12/21 to 7/10/21. The plan included a frequency of weekly visits for one week, then zero visits for three weeks, and then one visit for one and included physical therapy goals for the patient. d. e. An interim physician order, dated 5/14/21, stating per fax, stop the colace, multiple vitamin, and potassium. e. An interim physician order, dated 5/14/21, stating per signed communication note from the MD, discontinue the colace, multiple vitamin, and Myrbetriq 50 mg extended release at bedtime and add Myrbetriq 50 mg extended release every morning. f. The occupational therapy visit note, dated 5/17/21, included the initial evaluation completed by the occupational therapist and orders for a occupational therapy plan of care for the period of 5/12/21 to 7/10/21. The plan included a frequency of weekly visits for one week, then zero visits for three weeks, and then one visit for one and included occupational therapy goals for the patient. g. A verbal physician order, dated 5/19/21, for increasing skilled nursing visits for wound care to twice weekly. Wound care order to cleanse bilateral lower extremities with soap and water and apply bacitracin. Cover with Telfa secured with coban. Use clean/aseptic technique. May discontinue wound care when wounds healed. h. A verbal physician order, dated 5/21/21, to add potassium chloride 10 milliequivalants (meq) 2 tablets daily at noon and tamsulosin 0.5 mg at bedtime. i. A verbal physician order, dated 6/1/21, stating Foley catheter removed today in the physician's office. The agency failed to ensure the Plan of Care was updated to include all physical therapy, occupational therapy and patient care orders. 6. Patient #6 had a start of care date of 11/13/2020 and was discharged from the agency on 5/3/21 while receiving services from the Shenandoah branch office. Clinical record review revealed: a. The Plan of Care, dated 3/13/21 to 5/11/21, included physician orders for reporting parameters for temperature less than 95 or greater than 100, pulse less than 58 or greater than 100, respirations less than 12 or greater than 24, blood pressure readings systolic less than 90 or greater than 160 or diastolic less than 50 or greater than 90, pain greater than 7, and oxygen saturation less than 90. b. A verbal order, dated 4/9/21, included orders to change weight parameter to report to a low of 235 pounds and a high of 250 pounds, temperature less than 95 or greater than 100, pulse less than 48 or greater than 100, respirations less than 12 or greater than 24, blood pressure readings systolic less than 90 or greater than 160 or diastolic less than 50 or greater than 90, pain greater than 7, oxygen saturation less than 90, and random blood sugars less than 60 or greater than 300. c. A physician's order, per faxed order, dated 4/13/21, for skilled nurse to provide wound cares three times per week to left lower leg as follows: wash with soap and water, rinse and pat dry, apply mepilex AG to open areas of posterior and medial lower leg, vaseline to lower leg (not between toes), apply profore wrap to left lower extremity at 30% stretch and 50% overlay and to right lower leg as follows: wash with soap and water, rinse and pat dry, vaseline to lower leg (not between the toes), apply tubagrip 3 followed by small edema wear from base of toe to just below the knee. 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, #5, and #6 were reviewed with the Regional Clinical Director. The agency provided no additional information prior to the end of the survey.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of agency complaint logs, review of on-call logs, patient/ patient caregiver interview and agency staff interview, the agency failed to ensure agency staff coordinated the delivery of care in a way to meet patient individualized needs for 1 of 6 sampled patients (Patients #5) receiving agency services. The agency reported a current census of 487 patients at the time of the survey, including 232 patients from the Council Bluffs, parent office, 201 patients from the Shenandoah branch office, and 54 patients from the Denison branch office. The concern was identified with a patient receiving care from the Shenandoah branch office. Failure to ensure agency staff effectively coordinated the delivery of care resulted in the patients not receiving care to meet individualized patient needs. Findings include: Review of the agency's policy, titled Plan of Care (POC), dated 7/1/18, revealed a the nurse/therapist develops the initial and subsequent Plan of Care in consultation with the physician, pertinent agency staff (nurses, therapists, social workers, and home health aides as appropriate) and the patient and/or family/caregiver. Review of the agency's undated policy, titled Patient Rights and Responsibilities, dated 5/2020, identified the patient will be informed in advance about the care to be given and the frequency of visits. The patient has a right to voice grievances/complaints regarding treatment or care, lack of respect of property or recommend changes in policy, personnel or services without restraint, interference, coercion, discrimination, or reprisal. The patient has the right to have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated. Review of the agency's complaint log on 6/8/21 revealed the following: Patient #5's caregiver complained to the corporate office on 5/10/21, about the Director of Nursing not responding to a requested visit on 5/7/21. The caregiver stated the patient had a skin tear and wanted a nurse to come to evaluate the condition of the wound. The caregiver called twice during business hours and once after hours and never did receive a nurse visit on the day of the request. Staff I, Intake Coordinator, reported to Staff J, Director of Nursing (DON), the patient's caregiver had called and the patient needed a visit. Staff I, Intake Coordinator was not given any direction. Staff G, Registered Nurse (RN), stated the nurse received the first call after hours and reached out to Staff J, DON and asked why the patient was not seen during the day. Staff J, DON, redirected Staff G, RN to see a different patient and stated if the patient's injury to the leg was so bad the patient should go to the emergency room. Staff G, RN was very upset about this and contacted Staff D, Business Director and stated Staff G, RN quit. Staff D, Regional Director of Business Operations completed the investigation and stated Staff G, RN was still very upset during the interview at the time of investigation. Staff J, DON, did not make any attempt to contact Staff G, RN. The DON stated the patient was seen on 5/9/21 and the leg wound was assessed, however the investigation concluded. The note stated the nurse documented no issues under the skin assessment and last MD visit was 4/7/21. Patient #5 had a start of care date of 6/16/2020, received services from the Shenandoah branch office and was discharged from the agency on 5/10/21 due to the patient not having a proper face to face completed. The patient was readmitted to the agency on 5/12/21. Clinical record review revealed the following: a. The Plan of Care (POC), dated 4/13/21 to 6/11/21 , identified diagnoses of spastic hemiplegia affecting the left dominant side and intracranial injury sequela. The POCs included physician orders for skilled nursing services 1 visit every three weeks for three weeks and then 1 visit every 2 weeks for six weeks and physical therapy to evaluate and treat the patient. b. The update to the comprehensive assessment completed at the time of recertification, dated 4/12/21, identified the patient had slightly limited sensory perception -ability to respond meaningfully to pressure-related discomfort and further documented the patient responds to verbal commands, but cannot always communicate discomfort or need to be turned, or has some sensory impairment which limits the ability to feel pain or discomfort in 1 or 2 extremities, and the patient was chairfast and ability to walk was severely limited of nonexistent. The patient cannot bear own weight and/or must be assisted into a chair or wheelchair, and documented the patient's skin was intact. c. Skilled nursing visit notes, dated 4/23/21 and 4/26/21, completed by the nurse documented the patient was sitting in electric wheelchair and assessment complete. The assessment stated the skin was warm and dry and no issues noted with the skin and the skin was intact. d. The On-call log report, dated 5/7/21 to 5/10/21, included the patient's caregiver contacted the agency on 5/7/21 at 5:31 PM, informing the nurse of the need for nurse visit due to a laceration on the back of the patient's leg and was dispatched to Staff G, Registered Nurse (RN) at 5:32 PM. e. The On-call report, dated 5/7/21 to 5/10/21, included the patient's caregiver contacted the agency on 5/7/21 again at 6:03 PM, informing the nurse of a complaint and was dispatched to Staff G, RN at 6:07 PM. f. The On-call report, dated 5/7/21 to 5/10/21, included the patient's caregiver contacted the agency on 5/7/21 again at 6:28 PM, informing they were still waiting on a nurse and left message again and was dispatched to Staff G, RN. A note stating if Staff G, RN hasn't called back to call Staff G, RN back. Dispatched to Staff G, RN at 7:57 PM. g. Interview with Staff G, RN on 6/9/21 at 2:47 PM revealed the nurse did receive a call not long after 5:00 PM on 5/7/21 by the patient's caregiver. The caregiver reported the patient had a skin tear. The nurse spoke with the DON and was told that another nurse called in that day and the DON just found out so directed the nurse to make those visits and said the patient was told to go to the emergency room, as the agency can't do anything without an order. Staff G, RN requested the DON contact the patient to explain and the DON stated she was not in a location to make a phone call. The caregiver later called back upset and wanted to talk to someone from corporate. The nurse notified corporate of the complaint. h. The On-call report, dated 5/7/21 to 5/10/21, included the patient's parent then contacted the agency on 5/27/21 again at 9:25 PM, informing they were still waiting on a nurse and left message again and was dispatched to another staff member at 9:27 PM i. The On-call report, dated 5/7/21 to 5/10/21, included the patient's parent then contacted the agency on 5/8/21 again at 2:42 PM, wondering if anyone was coming that day and was dispatched to another staff member at 2:44 PM. j. The On-call report, dated 5/7/21 to 5/10/21, included the patient's parent then contacted the agency on 5/8/21 again at 6:01 PM, questioning if someone was coming to see the patient and left message again and was dispatched to another staff member at 6:55 PM. k. The skilled nurse visit note, dated 5/9/21, documented the nurse charted the skin was warm and dry and no issues noted with the skin and the skin was intact. l. On 6/9/21 at 10:58 AM, interview with the physician's office revealed the patient was seen by the MD on 5/10/21 and it was documented the patient had a healing sore to the left interior ankle and right posterior ankle. m. The skilled nursing visit note, dated 5/12/21, documented the patient had two wounds a left mid pretibial wound with a length of 1.5 cm, width of 1 cm, and depth of 0.1 cm and a right distal calf wound with a length of 0.8 cm, width of 0.5 cm and depth of 0.1 cm. n. The Plan of Care, dated 5/12/21 to 7/10/21, included orders for wound care as follows: cleanse bilateral lower extremities with soap and water, apply bacitracin, cover with Telfa secured with Coban using clean/aseptic technique. May discontinue when wound is healed. o. Interview on 6/9/21 with Staff D, Regional Director of Business Operations revealed that investigation revealed no one made visit on 5/7/21 when request was made. The agency failed to coordinate care delivery to meet the patient's needs, and involve the patient, representative and caregivers, in the coordination of care activities. The above stated findings were reviewed with the Regional Clinical Director. The agency provided no additional information prior to the end of the survey.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, wound care education provided to staff and staff interview, the agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 3 sampled patients who required wound assessments (Patients #2 and #4). The agency reported a current census of 487 patients at the time of the survey, including 232 patients from the Council Bluffs, parent office, 201 patients from the Shenandoah branch office, and 54 patients from the Denison branch office. The concern was identified with patients receiving care from the Council Bluffs parent office. Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. Findings: On 6/8/21 at 2:15 PM, interview with the Regional Clinical Director revealed the agency does not have a policy for wound documentation, but the expectation is weekly measurement and assessment. Assessment should include wound length, width and depth. The Regional Clinical Director provided the surveyor with the Wound Care Wisdom provided to staff nurses. The information states an essential part of the weekly wound assessment is the nurse's wound measurement. The nurse is to document all measurements in centimeters, including length, width, and depth. 1. Patient #2 had a start of care date of 5/28/21 and received services from the Council Bluffs parent office. Clinical record review revealed the skilled nursing visit note, dated 5/18/21, documented the nurse noted a new skin tear due to a fall. The note lacked any wound measurements, including length, width or depth of the skin tear. 2. Patient #4 had a start of care date of 3/15/17 and received services from the Council Bluffs parent office. Clinical record review revealed: a. The Plans of Care dated 2/22/21 to 4/22/21 and 4/23/21 to 6/21/21, included orders for skilled nursing visits three times per week for wound care. b. The skilled nursing visit notes, dated 4/5/21, 4/7/21, and 4/9/21, documented the nurse performed wound cares and identified the patient had blisters. The note lacked any wound measurements, including length, width or depth of the blisters for the week of 4/4/21. c. The skilled nursing visit notes, dated 4/12/21, 4/14/21, and 4/17/21, documented the nurse performed wound cares and identified the patient had blisters. The note lacked any wound measurements, including length, width or depth of the blisters for the week of 4/11/21. d. The skilled nursing visit notes, dated 4/19/21, 4/21/21, and 4/23/21, documented the nurse performed wound cares. The note lacked any wound measurements, including length, width or depth of the wounds for the week of 4/18/21. e. The skilled nursing visit notes, dated 5/3/21, 5/5/21, and 5/7/21, documented the nurse performed wound cares. The note lacked any wound measurements, including length, width or depth of the wounds for the week of 5/2/21. f. The skilled nursing visit notes, dated 5/17/21, 5/19/21, and 5/21/21, documented the nurse performed wound cares. The note lacked any wound measurements, including length, width or depth of the wounds for the week of 5/16/21. The above stated findings for Patients #2 and #4 were reviewed with the Regional Clinical Director. The agency provided no additional information prior to the end of the survey.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 3 of 6 sampled patients (Patients #1 , 2, and #4). The agency reported a current census of 487 patients at the time of the survey, including 232 patients from the Council Bluffs, parent office, 201 patients from the Shenandoah branch office, and 54 patients from the Denison branch office. The concern was identified with a patient receiving care from the Council Bluffs parent office and Shenandoah branch office. Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to not receive safe, individualized and consistent care designed to meet each patients' health care needs. Findings include: Review of the agency's policy, titled Plan of Care, dated 1/1/18, identified an individualized plan of care is signed by a physician for each client receiving home health services. The total plan of care shall be reviewed by the physician and agency personnel as often as the severity of the client's condition requires. 1. Patient #1 had a start of care date of 3/26/21 and received services from the Shenandoah branch office. The Plans of Care, dated 3/26/21 to 5/24/21 and 5/25/21 to 7/23/21, included orders for skilled nursing to reinforce diabetic care including blood glucose testing and perform blood sugar reading as needed for symptomology and report blood sugar readings less than 50 or great than 250 milligrams (mg) per deciliter (dl). Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 3/26/21, documented the patient checks the blood sugars before meals, at bedtime as needed for symptomology. b. Skilled nursing visit note, dated 4/9/21,documented the patient used to assess blood sugars three times a day, but machine is currently broken so not assessed. c. Skilled nursing visit note, dated 4/15/21,documented no glucometer and not assessed. d. Skilled nursing visit note, dated 4/28/21,documented the patient stated has no glucometer and no blood glucose readings obtained at the visit. e. Skilled nursing visit note, dated 5/5/21,documented the patient does not have a glucometer and is getting a new script from the physician and no blood sugar readings obtained at the visit. The agency did not provide care as ordered by the physician in the Plan of Care. 2. Patient #2 had a start of care date of 5/8/21 and received services from the Council Bluffs parent office. The Plan of Care, dated 5/8/21 to 7/6/21, included orders for skilled nursing to weigh the patient every visit and included reporting parameters for the weight. Clinical record review revealed skilled nursing visit notes, dated 5/11, 5/14, 5/28, and 6/1/21, lacked documentation of the patient's weight. The agency did not provide care as ordered by the physician in the Plan of Care. 3. Patient #4 had a start of care date of 3/15/17 and received services from the Council Bluffs parent office. The Plans of Care, dated 2/22/21 to 4/22/21 and 4/23/21 to 6/21/21, included orders for skilled nursing to instruct patient on detecting signs and symptoms of fluid retention and methods to alleviate fluid and keep a weight log. The Plans of Care included reporting parameters for blood sugars less than 50 and greater than 300 and weight less than 235 and greater than 250. Clinical record review revealed: a. Skilled nursing visit note, dated 4/5, 5/26, 5/28, 6/7/21, lacked documentation of assessment of blood sugar checks and stated controlled with current regimen. b. Skilled nursing visit note, dated 4/7, 4/26, 4/28, 5/5, 5/19/21 documented the patient checks blood sugars based on symptoms and no blood sugar readings were obtained during visit. c. Skilled nursing visit note, dated 4/9, 4/12, 4/19/21 documented the patient does not check blood sugars and no reading was obtained at the visit. d. Skilled nursing visit note, dated 5/31/21, documented A1C checked by the physician and no blood sugar readings obtained at the visit. e. Skilled nursing visit note, dated 6/2/21,documented no assessment of weight or blood sugar checks. f. Skilled nursing visit note, dated 6/4/21, documented the patient performs blood sugar checks as needed every morning and no blood sugars readings obtained this visit. The agency did not provide care as ordered by the physician in the Plan of Care. The above stated findings for Patients #1, #2, and #4 were reviewed with the Regional Clinical Director. The agency provided no additional information prior to the end of the survey.