Every finding on record at Franklin General Hospital

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 10/28/24 to 10/30/24 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 10/28/24 to 10/30/24. 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 current census of 35 patients at the time of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on home visit observations, patient interviews, staff interviews, clinical record reviews and agency policy review, the agency failed to perform complete an accurate drug regimen reviews with each comprehensive assessment and identify patient specific medication issues for 3 of 3 sampled patients with home visit observations (Patients #1, #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 3.Patient #2 had a start of care date of 7/24/23. Clinical record review revealed the following: a. The POCs, dated 7/18/24 to 9/15/24 and 9/16/24 to 11/14/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 9/11/24, completed by Staff C, RN, identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/29/24 at 8:00 AM, with Staff C, RN, an interview with Patient #2 revealed the patient sets up his/her own medication. The patient identified the following medication discrepancy: The patient identified he/she takes Iron 65mg (supplement) one tablet every day and has done so for at least one year. The POC lacked documentation of an order for Iron. The above findings were shared with the Administrator and Clinical Manager. According to the undated agency policy titled Medication Profile, the nurse shall record on the medication profile all prescribed and over-the-counter medications the client is currently taking. The medication profile shall be reviewed by a Registered Nurse (RN) at least weekly or with every visit if patient is seen less often than weekly and updated whenever there is a change or discontinuation in medication. During an interview on 10/30/24 at 8:25 AM the Clinical Manager stated the drug regimen review (DRR) completed at all assessment time points, start of care, recertification, resumption of care , significant changes and at discharge. 1.Patient #1 had a start of care date of 2/8/24. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 8/6/24 to 10/4/24 and 10/5/25 to 12/3/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 10/1/24, completed by Staff B, Clinical Manager, identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/29/24 at 2:30 PM, with Staff B, Clinical Manager, interview with Patient #1 revealed the nurse sets up his/her own medication. The patient identified the following medication discrepancies: 1)The patient identified he/she took melatonin (sleep aid) 5 milligrams (mg) at hour of sleep as needed. The POC lacked documentation of an order for melatonin. The patient stated the medication taken for a couple of months. 2. Patient #3 had a start of care date of 6/24/21. Clinical record review revealed the following: a. The POCs, dated 8/7/24 to 10/5/24 and 10/6/25 to 12/4/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 10/3/24, completed by Staff C, RN, identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/29/24 at 10:30 AM, with Staff C, RN, interview with Patient #3 revealed the patient sets up his/her own medication. The patient identified the following medication discrepancies: 1) The patient identified he/she took an Albuterol inhaler every 4 to 6 hours as needed. The POC lacked documentation of an order for albuterol inhaler. The albuterol filled on 8/14/24. 2) The bottle of furosemide (diuretic) dated 9/17/24, included orders to take 20 mg daily and 1 tablet as needed for swelling. The POC identified an order for furosemide 20 mg daily and lacked an order for 1 tablet as needed for swelling. 3) The bottle of calcium with vitamin D (supplement) identified a dosage of calcium 600 mg and vitamin D 20 micrograms (mcg). The POC failed to include the dosage of the ordered medication.

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 policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and information related to advanced directives for 2 of 3 sampled patients with home visit observations (Patients #1 and #3). 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: 2. Patient #1 had a start of care date of 2/8/24. 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 the following durable medical equipment (DME) and supplies used by the patient: medication planners and diabetic testing supplies. b. During a home visit observation on 10/29/24 at 2:30 PM, with Staff B, Clinical Manager, the surveyor identified the following DME in the home: glucometer. The POC failed to include the DME of a glucometer. 3. Patient #3 had a start of care date of 6/24/24. Clinical record review revealed the following: a. The POCs, dated 8/7/24 to 10/5/24 and 10/6/24 to 12/4/24, included the following durable medical equipment (DME) and supplies used by the patient: shower chair and walker. b. During a home visit observation on 10/29/24 at 10:30 AM, with Staff E, RN, the surveyor identified the following DME in the home: grab bars, toilet riser, medication planners, lifeline and lift chair. The POC failed to include the DME of grab bars, toilet riser, medication planner, lifeline and lift chair. The above findings shared with the Administrator and Clinical Manager. According to the undated agency policy titled Plan of Care, the Plan of Care (POC) is based on current assessment by a Registered Nurse. The client or caregiver will actively participate in developing the POC and the POC will be reviewed by the physician at least every 60 days. The POC should include but is not limited to: All pertinent diagnosis (es), type, frequency and duration of visits/services, medications, treatments and procedures, treatment goals and other appropriate items. Professional staff will promptly alert the physician to any changes that suggest a need to alter the POC. 1.Patient #2 had a start of care date of 7/24/23. Clinical record review revealed the following: a. The POC, dated 9/16/24 to 11/14/24 included the following durable medical equipment (DME) and supplies used by the patient: Cane, commode, home oxygen, incentive spirometer, nebulizer, shower chair, walker, wheelchair and wheelchair cushion. b. During a home visit observation on 10/29/24 at 8:00 AM, with Staff C, Registered Nurse (RN), the surveyor identified the following DME in the home: ramp, motorized scooter, pill cutter, hand held shower, grab bars and toilet safety frame. During the same visit, an interview with Patient #2 revealed he/she had been utilizing the ramp, motorized scooter, pill cutter, hand held shower, grab bars and toilet safety frame for more than 1 year. c. The POC, dated 9/16/24 to 11/14/24, identified the patient's Advanced Directives as: Do not resuscitate, full code, living will. On 10/29/24 at 8:30 AM, during an interview, Patient #2 identified he/she has been a full code (wants resuscitative measures) for greater than 6 months. The POC failed to include the DME of ramp, motorized scooter, pill cutter, hand held shower, grab bars and toilet safety frame and the POC failed to include accurate advanced directives for the patient.

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 agency staff interviews, clinical record reviews and policy reviews, the agency failed to complete and send a transfer summary to physician caring for the patient at the inpatient facility within 2 business days of a planned transfer for 1 of 2 sampled patients with transfers/discharges (Patient #2). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner increases the risk for inadequate or inappropriate follow-up during inpatient care. Findings include: According to the undated agency policy, titled Client Transfer Process, a client may be transferred as determined by the agency director or designated Registered Nurse (RN) in response to an identified need that cannot be met by the agency. If a client is transferred to another health facility, a copy of the record shall be faxed to the receiving facility. During an interview on 10/30/24 at 8:25 AM, Staff B, Clinical Manager identified a transfer summary must be sent to the facility the patient was transferred to within 48 hours. If the transfer summary is not sent within 48 hours, there must be documentation indicating the reason for lack of timeliness. Patient #2 had a start of care date of 7/24/23. Clinical record review revealed the following: a. A home health transfer summary completed by Staff C, RN, dated 8/2/24, included documentation Staff C advised patient to go to the emergency department due to a decline in condition. b. Hospital discharge records identified the patient was hospitalized from 7/29/24 to 8/5/24. The agency failed to send a transfer summary to the hospital within 2 business days of a planned transfer. The above findings were reviewed with the Administrator and Clinical Manager.

The recertification survey, dated 12/13/21 to 12/15/21, identified the home health agency was found to be in substantial compliance in relation to emergency preparedness regulations.

A recertification survey in conjunction with a A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals completed on 12/13/21 through 12/15/21. 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 survey identified the following standard deficient practices occurring at the time of the recertification survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 7 sampled patients (Patients #3 and #5). The agency reported a census of 33 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the undated agency policy, titled Care Plans, the Care Plan shall include, but not limited: Nursing Diagnosis(es)/problems and needs identified. Reasonable, measurable, and realistic nursing, therapy, social service, client and/or caregiver goals. Anticipated outcomes with a statement of expectation over a defined period of time. If a short time frame is not noted then the time period shall be 60 days. During agency staff interview on 12/15/2021 at 8:44 AM, the Administrator reported missed visits are documented by writing a interim physician order, (IPO) and faxing it to the physician. Then the 485 plan of care is updated in the electronic medical record, (EMR). 1. Patient #3 had a start of care date of 6/24/21. Clinical record review revealed the following: The Plans of Care, dated 8/19 to 10/21/21 and10/22 to 12/20/21, included physician orders for skilled nurse visits once every other week and home health aide visits twice weekly for eight weeks. The clinical record lacked documentation of a skilled nurse visit the week of 11/14 to 11/20/21. The clinical record lacked documentation of why the visit was not made and lacked any communication with the physician to discuss the inability to follow the Plan of Care. The clinical record lacked any interim physician orders for a change in skilled nurse visit frequency. 2. Patient #5 had a start of care date of 8/02/19 and a discharge date of 9/18/19. Clinical record review revealed the following: The Plan of Care, dated 8/02/19 to 9/30/19 included physician orders for skilled nurse visits 3 times a week for 8 weeks. The clinical record lacked documentation of 3 skilled nurse visits the weeks of 8/04/19 to 8/10/19, 8/11/19 to 8/17/19 and 8/25/19 to 8/31/19. During findings on 12/15/2021 at 10:15 AM the clinical manager reported unable to locate documentation of missed visits from the patient cared for in 2019. The clinical record lacked documentation of why the visit was not made and lacked any communication with the physician to discuss the inability to follow the Plan of Care. The clinical record lacked any interim physician orders for a change in skilled nurse visit frequency. The above findings were reviewed with the Administrator and Clinical Manager. The agency provided no further information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 2 of 7 sampled patients (Patients #1 and #6). The agency reported a current census of 33 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 2. Patient #1 had a start of care date of 3/06/2020. The patient's clinical record included skilled nurse visits 1 time a week for 8 weeks. The Plan of Care, dated 8/28/21 to 10/26/21 to , lacked inclusion of the medication planner used by the patient to meet his/her needs. The visit notes dated10/11, 10/18 and 10/25/21 documented the nurse setting up the medication planner for the patient. The Plan of Care, dated 10/27/21 to 12/25/21, lacked inclusion of medication orders for oxygen and duo nebs. The same Plan of Care lacked inclusion of the nebulizer machine oxygen concentrator and portable oxygen concentrator. On 12/13/21 beginning at 10:50 AM, the surveyor accompanied Staff B, Registered Nurse, to the patient's home. During the home visit, the surveyor identified the patient had a medication planner, nebulizer machine, oxygen concentrator and portable oxygen. The patient reported using oxygen at 2L per nasal cannula as needed and at bedtime. During the home visit the surveyor observed the patient use the portable oxygen machine at 2L per nasal cannula. On 12/15/21 beginning at 10:15 AM, the above stated findings were reviewed with the Administrator The agency provided no additional information prior to the end of the survey. 1. Patient #6 had a start of care date of 10/26/2020. The patient's clinical record included skilled nurse visits 1 time a week for 8 weeks. The Plans of Care, dated 8/22/21 to 10/20/21 and 10/21/21 to 12/19/21, included the following medical equipment used by the patient: glucose monitor, nebulizer, oxygen and medication planner. On 12/14/21 beginning at 11:00 AM, the surveyor accompanied Staff D, Registered Nurse, to the patient's home. During the home visit, the surveyor identified the patient had a hand held shower. The patient reported using the hand held shower and had it installed in July, 2021. The agency failed to include the hand head shower on the plan of care.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and staff interview, the agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 1 of 1 sampled patients (Patient #2) with a home visit observation of contracted staff. The agency reported a current census of 33 patients. Failure to follow agency expectations and accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: Review of the undated agency policy titled Infection Control Policy, standard precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect staff and prevent staff from spreading infections among patients. Standard precautions include hand hygiene. Patient #5 had a start of care date of 12/10/21. The Plan of Care (POC), dated 12/10/21 to 2/7/21, included orders for physical therapy services. On 12/13/21 at 1:20 PM, during a home visit observation, Staff C, Physical Therapist assisted the patient with physical therapy exercises. She touched the patient and wheeled walker during therapy services. At the end of the visit, she exited the patient's home without performing hand hygiene. The agency failed to ensure staff performed hand hygiene following patient care. The above findings were provided to the Administrator for patient #2. The agency provided no further information prior to the end of the survey.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to complete and send a transfer summary to other health care professionals responsible for providing care to the patient after transfer within 5 business days of the patient's transfer for 2 of 2 sampled patients requiring transfer. (Patients #4 and #7) The agency reported a current census of 33 patients at the time of the survey. Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up after discharge or transfer. Findings include: According to the undated agency policy titled Client Transfer Process, if a client is transferred to another health facility or home health agency, a copy of the record shall be faxed or mailed to the receiving agency or facility. A discharge summary also shall be completed upon transfer. The original shall be placed in the clinical record with a copy sent to the physician. 1. Patient #4 had a start of care date of 3/10/21 and was transferred from agency services on 5/10/21. The patient's clinical record included documentation of a Transfer Comprehensive Assessment, dated as initiated on 5/10/21. The patient's clinical record included a transfer summary, dated as completed and sent to the physician on 5/10/21. The agency failed to provide a Transfer summary to the receiving facility. 2. Patient #4 had a start of care date of 3/10/21 and was transferred from agency services on 5/10/21. The patient's clinical record included documentation of a Transfer Comprehensive Assessment, dated as initiated on 5/10/21. The patient's clinical record included a transfer summary, dated as completed and sent to the physician on 5/10/21. The agency failed to provide a Transfer summary to the receiving facility. 3. Patient #7 had a start of care date of 11/30/2020 and was transferred from agency services on 8/2/21. The patient's clinical record included documentation of a Transfer Comprehensive Assessment, dated as initiated on 8/2/21. The patient's clinical record included a transfer summary, dated as completed and sent to the physician on 8/2/21. The agency failed to provide a Transfer summary to the receiving facility. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on patient clinical record review and agency policy review, the hospice failed to ensure all clinical entry notes included a date and time and staff signature with title completed in a timely manner for 2 of 7 sampled patients (Patients #6 and #7). The agency reported a current census of 33 patients at the time of the survey. Failure to ensure all clinical record documentation was dated, timed and signed with staff title, and completed in a timely manner increased the risk of ineffective communication between staff members providing services to its patients. Findings include: According to the undated agency policy titled Clinical Documentation ongoing clinical documentation will occur within 5 days of visit completion and be uploaded into the courier server. Nurses will minimally upload information daily to assure the most current information is contained both on the courier server and the individual clinician laptops. During an interview on 12/14/21 at 11:20AM, the Clinical Manager stated she knew the agency had some issues with timely documentation and reported the expectation is for staff to complete documentation in 48 hours. 1. Patient #6 had a start of care date of 10/26/20. The Plan of Care, dated 10/21/21 to 12/19/21, included orders for skilled nursing and home health aide services. Electronic health record review revealed the following skilled nursing visit notes, documented later than the agency expectation of 48 hours: 10/17/21, with an electronic signature indicating completion on 10/22/21, (7 days late), 11/3/21, with an electronic signature indicating completion on 11/12/21, (7 days late), 11/10/21, with an electronic signature indicating completion on 11/14/21, (2 days late), 11/30/21, with an electronic signature indicating completion on 12/6/21, (4 days late) and 12/9/21, with an electronic signature indicating completion on 12/13/21, (2 days late), 2. Patient #7 had a start of care date of 11/30/20. The Plans Of Care, dated 9/26/21 to 11/24/21 and 11/25/21 to 1/23/22, included orders for skilled nursing and home health aide services. Electronic health record review revealed the skilled nursing visit notes, documented later than the agency expectation of 48 hours: 11/9/21, with an electronic signature indicating completion on 11/15/21, (4 days late), 12/1/21, with an electronic signature indicating completion on 12/13/21, (10 days late) and 12/9/21, with an electronic signature indicating completion on 12/13/21, (2 days late). The above findings were reviewed to the Administrator. No additional information provided by the end of the survey.