Every finding on record at Fort Madison Community Hospital

The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 7/19/21 through 7/21/21. The survey identified the home health agency was found to be in substantial compliance in relation to emergency preparedness regulations.

The Department of Inspections and Appeals conducted a COVID-19 Focused Infection Control Survey in conjunction with a recertification survey from 7/19/21 through 7/21/21. The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey found the agency operating out of compliance with multiple standard level regulatory requirements.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5 and #6). The agency had no current patients at the time of the survey. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate increased the potential for unidentified medication interactions and side effect risks to the patient. Findings include: The agency policy, titled Medication Reconciliation, dated 02/2020, included Drug Regimen Reviews are to be completed at each comprehensive assessment to include: any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy and nonadherence with drug therapy. The agency policy, titled Initial Assessment/Comprehensive Assessment, dated 02/2020, included documentation each patient's comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, etcetera) to identify: significant side effects, significant drug interactions, noncompliance with medications, duplicate therapy, potential adverse effects. 1. Patient #1 had a start of care date of 3/20/21 and a death date of 5/21/21. Clinical record review revealed the following: a. Start of care (SOC) comprehensive assessment, dated 3/20/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no issues identified; did a complete drug regimen review identify potential clinically significant medication issues, no issues found during review; and has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etcetera) and how and when to report problems that may occur, yes. b. Resumption of care (ROC) comprehensive assessment, dated 4/6/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications; did a complete drug regimen review identify potential clinically significant medication issues, no issues found during review; and has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etcetera) and how and when to report problems that may occur, yes. c. Recertification of care comprehensive assessment, dated 5/14/21, lacked documentation a drug regimen review (DRR) had been completed. The comprehensive assessments failed to include a DRR or all the required components of a DRR. 2. Patient #2 had a start of care date of 3/9/21 and a discharge date of 5/7/21. Clinical record review revealed the following: a. SOC comprehensive assessment, dated 3/9/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications; did a complete drug regimen review identify potential clinically significant medication issues, no issues found during review; and has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etcetera) and how and when to report problems that may occur, yes. b. ROC comprehensive assessment, dated 4/13/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, new/changed medications identified, medication profile updated, senna; did a complete drug regimen review identify potential clinically significant medication issues, no issues found during review; and has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etcetera) and how and when to report problems that may occur, not applicable. c. Discharge comprehensive assessment, dated 5/7/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications; did the agency contact and complete physician prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC, yes; and at the time of, or any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur, yes. The comprehensive assessments failed to include all the required components of a DRR. 3. Patient #3 had a start of care date of 4/29/21 and a discharge date of 5/17/21. Clinical record review revealed the following: a. SOC comprehensive assessment, dated 4/29/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, new/changed medications identified, medication profile updated, pantoprazole; did a complete drug regimen review identify potential clinically significant medication issues, no issues found during review; and has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etcetera) and how and when to report problems that may occur, not applicable. b. Discharge comprehensive assessment, dated 5/17/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications; did the agency contact and complete physician prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC, yes; and at the time of, or any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur, yes. The comprehensive assessments failed to include all the required components of a DRR. 4. Patient #4 had a start of care date of 2/25/21 and a discharge date of 3/20/21. Clinical record review revealed the following: a. SOC comprehensive assessment, dated 2/25/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications; did a complete drug regimen review identify potential clinically significant medication issues, no issues found during review; and has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etcetera) and how and when to report problems that may occur, yes. b. Discharge comprehensive assessment, dated 3/20/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications; did the agency contact and complete physician prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC, yes; and at the time of, or any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur, yes. The comprehensive assessments failed to include all the required components of a DRR. 5. Patient #5 had a start of care date of 3/8/12 and a discharge date of 5/12/21. Clinical record review revealed the following: a. Recertification of care comprehensive assessment, dated 11/16/2020, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications. b. Recertification of care comprehensive assessment, dated 1/18/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications. c. Recertification of care comprehensive assessment, dated 3/18/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new issues identified, no new or changed medications. d. Discharge comprehensive assessment, dated 5/12/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no new or changed medications; did the agency contact and complete physician prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC, yes; and at the time of, or any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur, yes. The comprehensive assessments failed to include all the required components of a DRR. 6. Patient #6 had a start of care date of 3/17/21 and a discharge date of 6/15/21. Clinical record review revealed the following: a. SOC comprehensive assessment, dated 3/17/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no issues identified; did a complete drug regimen review identify potential clinically significant medication issues, no issues found during review; and has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etcetera) and how and when to report problems that may occur, no. b. Recertification of care comprehensive assessment, dated 5/14/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, new/changed medications identified, medication profile updated, Bactrim DS, issues identified: non-compliance with drug therapy. c. Discharge comprehensive assessment, dated 6/15/21, included documentation medication profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications, no issues identified, no new or changed medications; did the agency contact and complete physician prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC, not applicable; and at the time of, or any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur, yes. The comprehensive assessments failed to include all the required components of a DRR. The Administrator and Clinical Supervisor received the above findings and agency staff provided no further 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 clinical record review and staff interview, the agency failed to update the Plan of Care with all new physician orders for 2 of 2 sampled patients with interim physician orders. (Patients #6 and #7). The agency had no current patients at the time of the survey. Failure to update the Plan of Care increased the potential for coordination and communication issues between agency disciplines providing care. Findings include: The agency policy titled, Plan of Care and Physician Orders, dated 02/2020, identified all patient care orders, including verbal orders, must be recorded in the plan of care. 1. Patient #7 had a start of care date of 1/7/21 and discharged from agency services on 2/8/21. Review of the clinical record revealed the following: a. The Plan of Care, dated 1/7/2021 to 3/7/2021, included physician orders for skilled nursing services. b. The clinical record included documentation of a verbal interim physician order, dated 1/28/21, for the nurse to irrigate the patient's ears bilaterally with a bulb syringe and warm tap water. c. The clinical record lacked documentation of an updated Plan of Care with the 1/28/21 interim physician order. On 7/21/21 at 11:48 AM, during an interview, the Clinical Supervisor reported agency staff would have to add any interim order to the Plan of Care; the electronic system does not do this automatically. On 7/21/21 at 12:26 PM, during an interview, the Clinical Supervisor reported an inability to find an updated POC with the 1/28/21 interim physician order. 2. Patient #6 had a start of care date of 3/17/21 and discharged from agency services on 6/15/21. Clinical record review revealed the following: a. The Plan of Care, dated 3/17/21 to 5/15/21 and 5/16/21 to 7/14/21, included physician orders for skilled nursing services. b. The clinical record included documentation of faxed interim physician order, dated 5/5/21, 5/19/21 and 6/2/21, from the wound clinic with updated wound care orders. c. The clinical record lacked documentation of updated Plans of Care with the 5/5/21, 5/19/21 and 6/2/21, interim physician orders. The Administrator and Clinical Supervisor received the above findings and agency staff provided no further information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 4 of 6 sampled patients receiving home health aide services (Patients #1, #2, #3 and #5). The agency had no current patients at the time of the survey. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: The agency policy titled, Care Planning Process, dated 02/2020, identified the home health aide assignment sheet: developed by a registered nurse (physical therapist or speech language pathologist, if nursing not ordered) prior to home health aide rendering care. The assignment sheet/plan of care will be communicated to the home health aide by the appropriate discipline. The assignment sheet/plan of care will include specific procedure to be performed including amount, frequency and duration. On 7/21/21 at 11:35 AM, during an interview, the Administrator reported the aide care plan needed to be specific regarding tasks the aide was to perform. 1. Patient #1 had a start of care date of 3/20/21 and a death date of 5/21/21. Clinical record review revealed the following: a. The home health aide assignment, dated 3/20/21, directed the following task: ambulate patient using assistive device (cane, crutches, walker, oxygen). The assignment failed to specify which assistive device the patient was to use. b. Home health aide visit notes, dated 5/3, 5/5, 5/7, 5/10, 5/12, 5/14, 5/17 and 5/19/21, included documentation the aide had completed the task to ambulate patient using assistive device (cane, crutches, walker, oxygen). The aide failed to document which assistive device was used. 2. Patient #2 had a start of care date of 3/9/21 and a discharge date of 5/7/21. Clinical record review revealed the following: a. The home health aide assignment, dated 3/9/21, directed the following tasks: foot care, nail care and skin care. The assignment failed to describe what "foot care", "nail care" and "skin care" meant. b. Home health aide visit notes, dated 3/11, 3/15, 3/18, 3/22, 3/25, 3/29, 4/1, 4/6, 4/9, 4/13, 4/16, 4/20, 4/23, 4/27, 4/30, 5/3 and 5/6/21, included documentation the aide had completed the tasks of foot care, nail care and skin care. The aide failed to document what was performed for each task. 3. Patient #3 had a start of care date of 4/29/21 and a discharge date of 5/17/21. Clinical record review revealed the following: a. The home health aide assignment, dated 5/1/21, directed the following tasks: foot care, nail care and skin care. The assignment failed to describe what "foot care", "nail care" and "skin care" meant. b. Home health aide visit notes, dated 5/5 and 5/12/21, included documentation the aide had completed the tasks of foot care, nail care and skin care. The aide failed to document what was performed for each task. 4. Patient #5 had a start of care date of 3/8/12 and a discharge date of 5/12/21. Clinical record review revealed the following: a. The home health aide assignment, dated 10/24/2020, directed the following task: hygiene: other. The assignment failed to describe what "hygiene: other" meant. b. Home health aide visit notes, dated 3/22, 3/25, 3/29, 4/1, 4/5, 4/8, 4/12, 4/15, 4/19, 4/22, 4/26, 4/29, 5/3, 5/6 and 5/10/21, included documentation the aide had completed the task of hygiene: other. The aide failed to document what was performed for this task. The Administrator and Clinical Supervisor received the above findings and agency staff provided no further information prior to the end of the survey.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure the patient's clinical record included accurate and complete documentation of interventions provided for 3 of 7 sampled patients (Patients #1, #2 and #7). The agency had no current patients at the time of the survey. Failure to ensure the patient's clinical record included accurate and complete documentation placed agency patient's at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: 1. Patient #7 had a start of care date of 1/7/21 and discharged from agency services on 2/8/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/7/2021 to 3/7/2021, included physician orders for skilled nursing services weekly. Prior to 1/18/21, the clinical record included documentation of skilled nursing visit notes, dated 1/7 and 1/14/21. The visit notes included documentation a registered nurse (RN) completed the visits. The skilled nursing visit note, dated 1/18/21, included documentation the RN supervised a licensed practical nurse (LPN). The RN documented the LPN followed the assignment, had good documentation and the patient was satisfied with the services the LPN had provided. The clinical record lacked documentation a LPN had provided services to the patient. The RN inaccurately documented the supervision of a LPN. b. The POC included instructions to the home health aide to complete the tasks of providing a bath and using a shower chair when bathing the patient. The home health aide visit notes, dated 1/15 and 2/2/21, included documentation by Staff D, Home Health, the home health aide did not give the patient a bath, but did use the shower chair. On 7/21/21 at 10:58 AM, during an interview, Staff D, Home Health Aide reported on the days she did not give the patient a bath, she used the shower chair and gave the patient a sponge bath. She reported she would have called the RN and got permission to do a different bath type. She reported usually she would have documented what she did in the visit note. The home health aide failed to document the bath type and document whether or not she contacted the RN to get permission to do a different bath type then what was on the POC. 2. Patient #1 had a start of care date of 3/20/21 and a death date of 5/21/21. Clinical record review revealed the following: a. The POC, dated 3/20/21 to 5/18/21 and 5/19/21 to 7/17/21, included physician orders for skilled nursing services. b. Skilled nursing visit notes, dated 5/5, 5/7, 5/10, 5/12, 5/14, 5/17 and 5/19, included documentation of skin tears that included length and width of the skin tears. The visit notes lacked documentation of skin tear depth or reason why there was no depth measurement documented. On 7/21/21 at 10:49 AM, during an interview, Staff C, RN reported receiving education at time of hire, to measure wounds weekly, this included length, width and depth for open pressure wounds. Skin tears and venous stasis ulcers did not require a depth measurement. The RN failed to document a completed wound assessment, including depth on the identified wounds. 3. Patient #2 had a start of care date of 3/9/21 and discharged from agency services on 5/7/21. Clinical record review revealed the following: a. The POC, dated 3/9/21 to 5/7/21, included physician orders for skilled nursing services weekly. b. Skilled nursing visit notes, dated 3/15, 3/23 and 4/5/21, included documentation of wound measurements that included length and width, but lacked documentation of wound depth or reason why there was no depth measurement documented. c. Skilled nursing visit note, dated 3/29/21, included documentation of wounds present but lacked documentation of wound measurements. The RN failed to document weekly wound measurements and document a completed wound assessment, including depth on the identified wounds. The Administrator and Clinical Supervisor received the above findings and agency staff provided no further information prior to the end of the survey.