Every finding on record at Hancock County Health System

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 1/5/26 through 1/7/26 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 1/5/26 through 1/7/26. 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 43 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 observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 2 of 3 sampled patients with home observation visits (Patients #1 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: According to the agency policy titled Medication Reconciliation-Drug Regimen Review, dated 12/2022, the client's medication profile identifies all medications the client is currently taking on a routine or as needed (prn) basis including: prescription and non-prescription medications, oxygen, vitamins, herbal, and nutritional supplements. During an interview on 1/7/26 at 9:20 AM the Administrator/Clinical Manager stated the Registered Nurse (RN) responsible to complete the Drug Regimen Review (DRR) at admission, recertification and discharge. 1.Patient #1 had a start of care date of 4/20/21. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 9/26/25 to 11/24/25 and 11/25/25 to 1/23/26, identified the patient had a diagnosis of Schizoaffective disorder and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at recertification, dated 12/5/25, completed by Staff B, RN, included documentation a DRR was completed. c. During a home observation visit on 1/6/26 at 7:30 AM with Staff B, RN, the patient interview revealed the following medication discrepancies orders and patient stated medication schedule: Systane Complete Optimal Dry Eye Relief preserved ophthalmic solution; Apply 1 drop 4 times a day as needed for dry eyes; Apply 1 drop to each eye. Patient stated had not been taking for a long time and did not have the medication in the home. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #3 had a start of care date of 5/6/25. Clinical record review revealed the following: a. The POCs, dated 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26, identified the patient had a diagnosis of Chronic atrial fibrillation and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at recertification, dated 11/18/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 12/9/25 at 2:00 PM with Staff C, RN, the surveyor noted Tums (calcium carbonate) 750 milligrams 2-3 tablets as needed for acid indigestion, heart burn. Patient family stated the patient had taken the medication for the last 5 months. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator/Clinical Manager.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on patient interview, clinical record review and agency policy review, the agency failed to provide services only as ordered by the physician for 1 of 7 sampled patients (Patient #4). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care Order, revised 3/2023, each patient receiving home care must have a written individualized plan of care that identifies patient specific measurable outcomes and goals. This plan of care must be established, reviewed no less than every 60 days. The individualized plan of care must include all medications and treatments. Patient #4 had a start of care date of 12/16/25. Clinical record review revealed: a. The POC, dated 12/16/25 to 2/13/26, identified the patient had diagnoses of Disc degeneration and left hip bursitis, and included skilled nurse orders to assess weight change. b. Skilled nurse note at start of care dated 12/16/25, included documentation of patient weight of 140.76 pounds. c. Review of the clinical record failed to include further documentation of the patient's weight. Agency staff failed to include assessment of the patient's weight. The above findings reviewed with the Administrator/Clinical Manager.

The recertification survey from 11/21/22 through 11/30/22 found the agency operating in substantial compliance with the emergency preparedness regulations.

The recertification survey conducted by the Department of Inspections and Appeals from 11/21/22 through 11/30/22, found the agency operating in compliance with the Conditions of Participation for home health, however found the agency operating out of compliance with several standard level deficiencies. The agency reported a current census of 59 patients.

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 and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part of the comprehensive assessments for 7 of 7 sampled patients (Patient #1, #2, #3, #4, #5, #6 and #7). Failure to ensure medications were reviewed at the time of each comprehensive assessment increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: According to the undated agency policy, titled Medication Reconciliation-Drug Regimen Review, the comprehensive assessment includes a review of all medications the client is currently using in order to identify any: potential adverse effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. A drug regimen review is completed on ALL patients at the time of comprehensive assessment regardless of their funding source at start of care, resumption of care, recertification, and discharge. If a patient is discharged outside of a visit, no drug regimen review will be conducted since the Registered Nurse is unable to determine the current medications to review. According to the undated policy, titled Comprehensive Assessment... the content of the comprehensive assessment will include....a drug regimen review of all medications the patient is currently using. During agency staff interview on 11/28/22 at 9:41 AM, the Administrator/Clinical Manager reported it is the nurses job on admission, recertification, and as needed with medication changes to complete the drug regimen review. The review is documented within the patient’s chart on the Plan of Care order. 1. Patient #7 had a start of care date of 5/15/22 and discharged from the agency on 11/20/22. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of start of care, dated 5/16/22, lacked documentation of a completed drug regimen review. b. The update to the comprehensive assessment at the time of recertification, dated 7/12/22, documented a completed drug regimen review, however the review lacked identification of an assessment of the patient's medication effectiveness. c. The update to the comprehensive assessment at the time of recertification, dated 9/8/22, documented a completed drug regimen review, however, the review lacked identification of an assessment of the patient's potential medication interactions. d. The update to the comprehensive assessment at the time of recertification, dated 11/9/22, documented a completed drug regimen review, however, the review lacked identification of an assessment of the patient's potential medication interactions and medication effectiveness. e. The update to the comprehensive assessment at the time of discharge, dated 9/20/22, documented a completed drug regimen review, however, the review lacked identification of an assessment of all of the required components. 2. Patient #3 had a start of care date of 11/12/19. Clinical record review revealed the following: a. The updates to the comprehensive assessment at the time of recertification, dated 6/24/22 and 10/24/22, documented a completed drug regimen review. The review lacked identification of an assessment of the patient's medication compliance. b. The update to the comprehensive assessment at the time of recertification, dated 8/24/22, documented a completed drug regimen review. The review lacked identification of an assessment of medication effectiveness. 3. Patient #6 had a start of care date of 9/9/21 and discharged from the agency on 9/20/22. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of start of care, dated 9/9/21, documented a completed drug regimen review. The review lacked identification of an assessment of the patient's duplicate medications for pain including ordered aspirin and duplicate bowel medications (patient was ordered to take both Senna and Docusate Sodium (both medications used for constipation. b. The update to the comprehensive assessment at the time of discharge, dated 9/20/22, documented a completed drug regimen review. The review lacked identification of an assessment of the patient's duplicate medications of Senna and Docusate Sodium/Senna (Senokot), both medications used for constipation. 4. Patient #1 had a start of care date of 6/1/2018. Clinical record review revealed updates to the comprehensive assessments at the time of recertification, dated 7/5/22, 9/5/22, and 11/7/22, documented a completed drug regimen review. The review lacked identification of the patient's use of duplicate medications Pradaxa and Aspirin (both medications used as blood thinners) and lacked identification of review of the component of potential drug interactions. The reviews also inaccurately identified the patient's use of acetaminophen that was not on the Plans of Care or medication profile. 5. Patient #2 had a start of care date of 11/10/22. Clinical record review revealed the initial comprehensive assessment, dated 11/10/22, documented a completed drug regimen review. The review lacked identification of the patient's use of duplicate medications Senna and Docusate/Senna (both medications used for constipation) and lacked identification of review of the component of medication effectiveness. 6. Patient #4 had a start of care date of 10/18/22. Clinical record review revealed the initial comprehensive assessment completed at start of care, dated 10/18/22, documented a completed drug regimen review. The review lacked identification of an assessment of the potential medication interactions and medication effectiveness. 7. Patient #5 had a start of care date of 3/24/21. Clinical record review revealed the updates to the comprehensive assessment at the time of recertification, dated 7/12/22, 9/13/22 and 11/11/22, documented a completed drug regimen review. The review lacked identification of an assessment of the patient's duplicate medications of finasteride and Tamsulosin (both medications used for benign prostatic hypertrophy) and duplicate medications for pain, including Tylenol, aspirin, and Eliquis (all medications used for pain) and assessment of potential interactions. The above findings were reviewed with the agency Administrator/Clinical Manager. Agency staff provided no additional 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 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 3 of 3 sampled patients with surveyor home visit observation(Patients #1, #2 and #3). Failure to maintain complete and accurate Plans of Care with current supplies/equipment and medications placed the patients at risk of receiving improper or inadequate care by not identifying the patients current needs Findings include: According to undated agency policy, titled Plan of Care-485,....the individualized plan of care must include the following:....the types of services, supplies and equipment required and ...all medications and treatments..... 1. Patient #2 had a start of care date of 11/10/22. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 11/10/22 to 1/8/23, identified the following equipment and supplies were needed to meet the patient's needs: walker, shower chair, hand held shower, shoe/sock aids, grab bars/safety rails, cane and reacher. During a home visit observation on 11/22/22 at 8:35 AM, with Staff D, Physical Therapist (PT), the surveyor observed the patient sitting on a couch with a medication planner next to the patient and a scale on the floor next to the patient. The patient reported use of the medication planner for years to help with medication compliance. The patient reported use of the scale for years to monitor the patient's weight. The Plan of Care lacked documentation of the medication planner and scale as equipment/supplies used to meet the patient's needs. b. During the same home visit observation with Staff D, Physical Therapist PT, the surveyor observed the patient getting in and out of bed in the bedroom. The surveyor observed a CPAP (Continuous Positive Airway Pressure) device on the bedside stand. The patient reported use of the CPAP machine for more than 5 years. The Plan of Care lacked documentation of the CPAP machine as equipment/supplies used to meet the patient's needs. d. During the same home visit observation with Staff D, Physical Therapist PT, the surveyor observed the patient getting in and out of the shower. The surveyor observed the patient did not have a hand held shower. The patient reported has not had a hand held shower for years since mother was living and in the home. The Plan of Care inaccurately identified a hand held shower as equipment/supplies used to meet the patient's needs. 2. Patient #3 had a start of care date of 11/12/19. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 6/29/22 to 8/27/22 and 8/28/22 to 10/26/22, identified the following equipment and supplies were needed to meet the patient's needs: grab bars/safety rails, hand held shower, reacher, cane, walker, CPAP machine, nebulizer compression, med planner, and electric chair lift. b. The Plan of Care, 10/27/22 to 12/25/22, identified the following equipment and supplies were needed to meet the patient's needs: grab bars/safety rails, hand held shower, cane, walker, med planner, and electric chair lift. During home visit with Staff C, RN on 11/22/22 at 11:15 AM, the surveyor observed the CPAP machine and nebulizer on a shelf next to where the patient was seated. The patient reported use of the CPAP machine and nebulizer for quite awhile, longer than one year. The Plan of Care, 10/27/22 to 12/25/22, lacked identification of the CPAP machine and nebulizer as equipment used to meet the patient's needs. c. During the same home visit with Staff C, RN, the patient showed the surveyor a box of 16 French straight catheters the patient receives from a medical supply company to intermittently self catheterize. The Plans of Care, 6/29/22 to 8/27/22, 8/28/22 to 10/26/22 and 10/27/22 to 12/25/22, lacked identification of the 16 French straight catheters as equipment used to meet the patient's needs. d. The Plans of Care, 6/29/22 to 8/27/22, 8/28/22 to 10/26/22 and 10/27/22 to 12/25/22 included orders for Albuterol 90 mcg (micrograms) per inhalation with instructions to take 2 puffs as needed every 4 to 6 hours for wheezing and ProAir 90 mcg per inhalation 2 puffs every 4 to 6 hours as needed for shortness of breath. During the same home visit, Staff C, RN reported she noticed the Plan of Care included duplicate orders for Albuterol/Pro Air. The RN was unsure why both were listed on the Plans of Care. The Plans of Care included duplicate orders for the same medication. 3. Patient #1 had a start of care date of 6/1/18. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 7/10/22 to 9/7/22 and 9/8/22 to 11/6/22, identified the following equipment and supplies were needed to meet the patient's needs: walker, electric wheelchair/scooter, lift chair, quad cane, ostomy supplies, medication planner, grabber, scale, and blood sugar machine. b. The Plan of Care, 11/7/22 to 1/5/23, identified the following equipment and supplies were needed to meet the patient's needs: reacher, cane, ostomy supplies, scooter/power chair, and ostomy supplies. During a home visit observation on 11/22/22 at 7:23 AM, with Staff B, Registered Nurse (RN), the surveyor observed the patient's blood sugar monitor. The patient reported use of the blood sugar monitor for the past 4-5 years. The Plan of Care lacked documentation of the blood sugar monitor as equipment/supplies used to meet the patient's needs. c. The Plan of Care, dated 11/10/22 to 1/8/23, included orders for Acetaminophen-codeine 300 milligrams (mg)/30 mg with instructions to take every 6 hours as needed for severe pain. During the same home visit observation with Staff B, RN, the patient told the surveyor he/she refused to fill the prescription for the acetaminophen/codeine as the patient had a bottle of hydrocodone/acetaminophen 5 mg/325 mg and reported he/she has been taking 1/2 tablet as needed for pain since returning home from the hospital. The bottle expired 10/17/17. The Plan of Care lacked documentation of the pain medication taken by the patient. The above findings were reviewed with the Administrator/Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review and review of the agency's home health aide job description, the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed direct observation of a home health aide's performance of all required health aide skills on a home health patient to determine satisfactory competency prior to allowing the home health aide to provide care independently to agency patients for 2 of 2 sampled home health aides (Staff E and F). At the time of the survey, the agency employed 3 home health aides and provided home health aide services to 34 patients. Failure to ensure home health aides successfully complete a competency evaluation in all basic home health aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: The Medicare Conditions of Participation require home health agencies to ensure all newly hired home health aides are competent in all of the basic home health aide skills by successfully demonstrating competency in the performance of all of the "hands on" basic home health aide skills with a home health patient, exactly as these tasks will be performed with an actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently. The list of "hands on" basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tub and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation, positioning, nutrition and fluid intake and range of motion. Basic home health aide competencies may not be demonstrated using a mannequin, pseudo-patient or volunteer or by using verbalization or simulation. According to the undated policy, titled Duties of the Home Care Aide, ....any duties that are an extension of nrusing services of the home health aide needs training on will have documented training as 'satisfactory' prior to performing on a patient. All home health aide duties as an extension of nursing services will be included in the Plan of Care. Patient #5 was admitted to the agency on 3/24/21 and received only home health aide services. The aide care plans for the time periods of 7/17/22 to 9/14/22, 9/15/22 to 11/13/22 and 11/14/22 to 1/12/23, included the task for the aide to perform transfers with gait belt and walker. Staff E and Staff F provided care to Patient #5 during these time periods. a. Staff E, Home Health Aide, had a hire date of 3/4/13. Staff E's personnel file included competency documentation on 6/26/18. The competency documentation lacked competency testing for use of a gait belt. Staff E provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills. b. Staff F, Home Health Aide, had a hire date of 1/6/20. Staff F's personnel file included competency documentation on 1/7/20. The competency documentation lacked competency testing for use of a gait belt. Staff F provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills. Interview on 11/29/22 at 2:41 PM with the Administrator/Clinical Manager reported the agency only has a competency for transfers and no competency was found specifically for gait belt use. Agency staff provided no additional 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, agency policy review, and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 3 of 6 sampled patients receiving home health aide services (Patients #1 #3, and #6). The agency reported 34 patients received care provided by a home health aide 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: According to the undated agency policy, titled Duties of the Home Care Aide, the home health aides are assigned patients by the home health Registered Nursed with written instructions for all home health aides. Interview on 11/28/22 at 9:41 AM with the Administrator/Clinical Manager reported the Registered Nurses complete the Home Care Aide care plan and perform supervision. 1. Patient #1 had a start of date of 6/1/2018 and received skilled nursing services two times per week and home health aide services three times per week from the agency. The Plans of Care, dated 7/10/22 to 9/7/22 and 9/8/22 to 11/6/22, and 11/7/22 to 1/5/23, documented a diagnosis of enterostomy complications. The recertification comprehensive assessments, dated 7/10/22, 9/7/22, and 11/7/22, documented the patient was unable to use the shower or tub, but was able to participate in bathing self in bed, at the sink, bedside chair, or on the commode, with the assistance or supervision of another person. Clinical record review revealed: a. The home health aide assignments for the Plan of Care timeframe, 7/10/22 to 9/7/22, directed the aides to perform the task of shampoo the patient's hair with ketoconazole shampoo 2% 0 to 1 time per week and perform foot care of cleaning and ensure dryness between toes 0 to 3 times per week. b. The home health aide assignments for the Plan of Care timeframes, 9/8/22 to 11/6/22 and 11/7/22 to 1/5/23, directed the aides to perform the task of shampoo the patient's hair with ketoconazole shampoo 2% 0 to 1 time per week and perform foot care of cleaning and ensure dryness between toes 0 to 3 times per week. c. The RN assigned tasks to the aide of shampoo the patient's hair with ketoconazole shampoo 2% and perform foot care of cleaning and ensure dryness between toes, but included a frequency range of "0" times per week to perform the task. The aide assignment was not specific and individualized to meet the needs of Patient #1. 2. Patient #3 had a start of date of 11/12/19 and received skilled nursing services and home health aide services weekly from the agency. The Plans of Care, dated 6/29/22 to 8/27/22 and 8/28/22 to 10/26/22, and 10/27/22 to 12/25/22, documented a diagnosis of hypertensive heart disease with chronic kidney disease with heart failure. The recertification comprehensive assessments, dated 6/24/22, 8/24/22, and 10/24/22, documented the patient was able to bathe in the shower or tub with the intermittent assistance of another person for intermittent supervision, encouragement, or reminders; to get in and out of the shower tub; or for washing difficult to reach areas. Clinical record review revealed: a. The home health aide assignments for the Plan of Care timeframes, 6/29/22 to 8/27/22 and 8/28/22 to 10/26/22, and 10/27/22 to 12/25/22, directed the aides to perform the task of shampoo the patient's hair 0 to 1 time per week. b. The RN assigned task to the aide of shampoo the patient's hair included a frequency range of "0" times per week to perform the task. The aide assignment was not specific and individualized to meet the needs of Patient #3. 3. Patient #6 had a start of date of 9/9/21, discharged from the agency on 9/20/21 and received skilled nursing services two to three times per week and home health aide services one to two times per week from the agency. The Plan of Care, dated 9/9/21 to 11/7/21, documented a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. The initial comprehensive assessment for start of care, dated 9/9/21, documented the patient was able to bathe in the shower or tub with the intermittent assistance of another person for intermittent supervision, encouragement, or reminders; to get in and out of the shower tub; or for washing difficult to reach areas. Clinical record review revealed: a. The home health aide assignments for the Plan of Care timeframes,9/9/21 to 11/7/21, directed the aides to perform the task of shampoo/set the patient's hair 0 to 2 times per week. b. The RN assigned task to the aide of shampoo/set the patient's hair included a frequency range of "0" times per week to perform the task. The aide assignment was not specific and individualized to meet the needs of Patient #3. The above findings were reviewed with the agency Administrator/Clinical Manager. The agency provided no additional information prior to the end of the survey.