Every finding on record at Heartland Home Care

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing completed on 4/15/24 through 4/17/24 and the hospice was found to be operating out of compliance with the following standard level requirements of the Establishment of Emergency Preparedness.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on agency policy review and staff interview, the agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed hospice patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include:Review of the agency's emergency preparedness plan lacked a written policy and procedure for procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Interview on 4/17/24 at 11:00 AM, Staff A, Administrator, confirmed there was not a written policy and procedure. The above findings were reviewed with the Administrator and the Office Manager, the agency provided no further information prior to the end of the survey.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness policies and staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on patients they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place for to inform State and local officials of any patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include:Review of the agency's emergency preparedness plan lacked a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Interview on 4/17/24 at 11:00 AM, Staff A, Administrator, confirmed there was not a written policy and procedure. The above findings were presented to the Administrator and the Office Manager, the agency provided no further information prior to the end of the survey.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and related policies and staff interview, the agency failed to ensure the development of a policy and procedure for a medical documentation system that preserves patient documentation system that preserves patient information and confidentiality of patient information. Failure to have procedures in place for confidentiality of patient information placed patients at risk for not receiving needed assistance during or due to an emergency situation. Review of the emergency preparedness plan and related policies revealed the agency did not have a written policy and procedure for a system of medical documentation that preserves patient information and protects confidentiality of patient information. During an interview on 4/17/24 at 11: 30 AM, the Administrator reported she was unable to find a policy for the above concern. The above findings were reviewed with the Agency Administrator and the Office Manager, the hospice provided no further information prior to the end of the survey.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and related policies, the agency failed to have a written policy and procedure for the use of volunteers in an emergency, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Failure to ensure the home health agency developed policies and procedures to address the use of volunteers or other emergency staffing strategies during an emergency, placed agency patients at risk for not having help to meet safety and health care needs in the event of a man made or natural disaster. Findings include:a. Review of the agency's emergency preparedness plan and related policies revealed a lack of a plan/procedure for the use of volunteers in an emergency or disaster situation. b. Review of the agency's emergency preparedness plan lacked a written policy and procedure for the use of volunteers or other emergency staffing strategies during an emergency. Interview on 4/17/24 at 11:15 AM, Staff A, Administrator, confirmed there was not a written policy and procedure. The above findings were reviewed with the Administrator and the Office Manager, no additional information was presented prior to the end of survey.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and staff interview, the agency failed to ensure agency staff developed and maintained an emergency communication plan that included a method of sharing information and medical documentation for the agency clients to maintain the continuity of care. Failure to develop and maintain an emergency preparedness communication plan that included a method of sharing information and medical documentation for the agency patients to maintain the continuity of care during a time of disaster or emergency which could lead to poor client outcomes in the event of an emergency/disaster. Review of the agency's Emergency Plan and related policies revealed the plan failed to include a method of sharing information and medical documentation for the agency clients to maintain the continuity of care. On 4/17/24 at 11:00 AM, the Administrator acknowledged the agency's communication plan failed to include a method of sharing information and medical documentation for the agency clients to maintain the continuity of care. The above findings were reviewed with the Administrator and the Office Manager, no additional information was presented prior to the end of survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness to all current staff annually. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include:During the review of the agency's emergency preparedness plan, the plan lacked materials for training and documentation of training completion for staff . During an interview with the agency Administrator on on 4/17/24 at 11:30 AM, the Administrator indicated that no training for staff had been completed for the emergency preparedness plan. The above findings were reviewed with the Agency Administrator and the Office Manager, the agency provided no further information prior to the end of the survey.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on agency staff interview, agency policy review and review of testing documentation, the agency failed to conduct exercises to test the emergency plan by participating in a community based full scale exercise or an actual natural or man- made emergency that requires activation of the emergency plan, and an additional exercise that may include a second community based full-scale exercise, a mock disaster drill, or a tabletop exercise, that includes analyzing the facilities response to the event. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: During an interview on 4/17/24, at 11:00 AM, with Staff A, Agency Administrator, stated no documentation of testing the plan existed. The agency failed to provide documentation of any exercises performed since the last survey included participation in an actual event or any type of table top exercise. The above findings were reviewed with the Agency Administrator and the Office Manager, the agency provided no further information prior to the end of the survey.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 4/15/24 through 4/17/24. 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 3 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 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 update to the comprehensive assessment at discharge for 3 of 7 sampled patients requiring discharge from agency services (Patients #2, #6 and #7). 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. According to the agency policy titled Client/Patient Record Management, dated 5/23, the drug regimen review will be a part of the plan of care under medications, section 10. The comprehensive assessments that are done every start of care, resumption of care, significant change i care, discharge and recertification period will have a page of the patient's medications with the drug regimen review requirements as part of that document. In an interview on 4/16/24 at 8:59 AM, the Administrator/Clinical Manager reported that clinicians are expected to assess all medications at the time of discharge. 1. Patient #2 had a start of care date of 4/11/22. a. The plan of care (POC), dated 1/31/24 to 3/29/24 included orders for skilled nurse visit notes and orders for medications. b. The medication record identified the patient had orders for respiratory medications Atrovent and Albuterol sulfate. The orders also included duplicate bowel medications Miralax and Glycerin suppository. c. The drug regimen on the plan of care review failed to identify the patient had duplicate bowel and respiratory medications. 2. Patient #6 had a start of care date of 7/6/21 and discharge date of 3/10/22. The POC, dated 3/3/22 to 5/1/22, identified the patient received skilled nursing services and included medication orders. Review of the discharge summary, dated 3/10/22, lacked documentation of a drug regimen review completed on discharge. The agency failed to complete a drug regimen review upon discharge. 3. Patient #7 had a start of care date of 9/21/21 and discharge date of 2/2/22. The POC, dated 1/19/22 to 3/19/22, identified the patient received skilled nursing services and included medication orders. Review of the discharge summary, dated 2/2/22, lacked documentation of a drug regimen review completed on discharge. The agency failed to complete a drug regimen review upon discharge. The above findings shared with the Administrator/Clinical Manager. No further information provided 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 and equipment used by the patient in 6 of 7 sampled patients. (Pt #1, #2, #3, #4, #5, #6) Failure to maintain a complete and accurate plan of care, with current orders, placed the patients at risk to not receive services, medications and treatments, equipment and supplies, according to assessed needs and the physician orders. 4. Patient #2 had a start of care date of 4/11/22. Clinical record review revealed the following: a. The POC, dated 1/31/24 through 3/29/24, identified the following DME: feeding pump/supplies, gastrostomy-tube/supplies, tracheostomy/supplies, lift, ventilators, cough assistive/vests and oxygen/supplies. b. The comprehensive assessment, dated 1/29/24, included documentation the patient required use of a wheelchair, diapers, pull ups and ankle foot orthotics (AFOs). The agency failed to include the required DME wheelchair, diapers/pull ups and ankle foot orthotics on the patients POC. 5. Patient #3 had a start of care date of 10/6/17. Clinical record review revealed the following: a. The POC, dated 3/3/24 through 5/1/24, identified the following DME: wheel chair, ventilators, suction machine, suction catheters, retention catheters, Shiley trach and supplies, AMBU bag, lift, bed pan. b. The skilled nurse note, dated 3/30/24, included documentation the patient required use of a "warm up". c. During an interview on 4/16/24 at 2:00 PM the Administrator stated a warm up is a bean filled pack warmed up in the microwave for heat. The agency failed to include the required DME warm pack. 6. Patient #6 had a start of care date of 7/6/21. a. The POC's, dated 11/3/21 to 1/3/22, 1/2/22 to 3/2/22 and 3/3/22 to 5/1/22, lacked specific orders for the dose with the Synagis injection (given to premature babies at risk for severe respiratory illness) to be given monthly by the agency nurse as well as when to obtain patient weights to calculate the Synagis dosage. The agency failed to obtain complete physicians orders before administering medication to the patient. The above findings shared with the Administrator/Clinical Manager. No further information provided prior to the end of the survey. Findings Include: According to agency policy, titled Client/Patient Record Management, dated May 2023, The plan of care (POC) developed in consultation with Agency staff is written and updated by RN staff and covers all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications, and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, therapies, and any other appropriate items. 1. Patient #1 had a start of care date 3/7/2024. Clinical record review, home observation visit and accompanying interviews revealed the following: a. The Plan of Care, (POC) dated 3/7/24 through 5/5/24, identified G-tube (Gastronomy tube, a tube that enters the stomach to provide all of the nutrition the patient needs ) a feeding pump, and tracheostomy tube and supplies. (a tube that allows the patient to keep an open airway for breathing). b. During a home observation visit on 4/15/24 at 12:30 PM, with Staff A, Registered Nurse (RN), the patient was using a continuous pulse oximeter machine, (a monitor that keeps continuous record of the patients oxygen level and alarms if the oxygen level drops to low) c. During the same home observation visit, a humidifier was noted to be in use for the patient in the bedroom. d. During the same home observation visit, a nebulizer machine (used to inhale medications if patient has trouble with breathing or congestion) was noted as well as an ambu bag. (used to assist with breathing if patient should stop breathing in the case of emergency) The POC lacked identification of the pulse oximeter machine, nebulizer and an ambu bag, as medical equipment and supplies used by the patient. 2. Patient #4 had a start of care date of 11/15/21. a. The POC dated 11/15/21 lacked specific orders for the dose with the Synagis injection (given to premature babies at risk for severe respiratory illness) to be given monthly by the agency nurse as well as when to obtain patient weights to calculate the Synagis dosage. The agency failed to obtain complete physicians orders before administering medication to the patient. 3. Patient #5 had a start of care date of 10/11/21. a. The POC dated 10/11/21 lacked specific orders for the dose with the Synagis injection (given to premature babies at risk for severe respiratory illness) to be given monthly by the agency nurse as well as orders for when to obtain patient weights to calculate the Synagis dosage. The agency failed to obtain complete physicians orders before administering medication to the patient.

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 clinical record review, agency staff interview, and home observation visit, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 1 sampled patients (Pt #1) with home observation visits. Failure to follow physician orders for administration of medications or treatments provided by agency staff, placed the patient at risk for inconsistent care or treatment and possible harm. Findings include: Patient #1 had a start of care date of 3/7/2024. a. The Plan of Care, (POC) dated 3/7/2024, included orders for the patient to be upright or have the head of the bed elevated 30 degrees when feeding is administered to prevent aspiration. (liquid breathed into the airway) b. During a home observation visit on 4/15/24 at 12:15 pm, Surveyor observed Staff A, Registered Nurse begin a feeding through the gastronomy tube in the patients stomach. Patient was lying flat in the crib asleep at the time feeding was started. c. In an interview with the Staff A, Registered Nurse, (RN) on 4/17/24 at 9:00 AM, she acknowledged the POC included physician orders to ensure the patient is in an upright position or with the head of the bed elevated at least 30 degrees before administering the feeding. The RN failed to ensure the patient was in an upright position before administering the nutritional feeding. The above findings were reviewed with the agency Administrator and the Office Manager, the agency presented no additional information prior to the end of survey.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, and agency staff interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician, for 1 of 7 sampled patients. (Patient # 1) Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings Include: 1. Patient #1 had a start of care date of 3/7/24. a. The Plan of Care (POC) was dated 3/7/24 and included orders for 160 Milliliters of formula to be given through the G-tube. ( G-tube is a gastrostomy tube inserted through the abdomen that brings nutrition directly to the stomach) 6 times a day. Review of the nursing documentation completed on 3/17/24 at 8 AM, indicated that the parent of the patient only administered 75 milliliters of the formula for 2 separate feedings in the night and stated she did not want to disrupt the patients sleep. The documentation lacked any physician notification that patient did not receive all of the nutrition ordered. Failure to notify the physician, orders were not followed by the parent in the home for amount of nutrition the patient requires, placed the patient at further risk for weight loss and worsening of patient condition.

The recertification survey, conducted from 5/10/21 to 5/12/21, identified the following deficient practices related to emergency preparedness.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of documentation and staff interview, the agency did not ensure the emergency preparedness program included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach specific for the agency. Failure to ensure an agency and community based risk assessment utilizing an all-hazards approach specific to the location of the agency could potentially result in the agency's failure to develop strategies for addressing emergency events. Findings include: During an interview on 5/11/21 at 10:37 AM, Staff C, Human Resources director verified the agency had not completed a facility-based and community-based risk assessment, utilizing an all-hazards approach specific for the agency, but reported the agency was at highest risk for tornadoes, severe storms, power outages, and fires. The agency did not ensure the emergency preparedness program included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. The agency provided no further information prior to the end of the survey.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and related policies and agency staff interview, the agency failed to have a written policy and procedure for cooperation and collaboration with tribal, regional, state and federal emergency preparedness officials. The agency provided services to 5 patients at the time of the survey. Failure to have a process for cooperation and collaboration with tribal, regional, state and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency policy, titled Emergency Preparedness Policy, dated 5/2021, included the agency would provide medical record information to emergency personnel and would contact local officials. The policy failed to include the process for cooperation and collaboration with tribal, regional, state and federal emergency preparedness officials. Interview on 5/21/21 at 8:55 AM, Staff C, Human Resources, agreed the agency emergency preparedness policy lacked a procedure for cooperation and collaboration with tribal, regional, state and federal emergency preparedness officials. The agency provided no further information prior to the end of the survey.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on agency policy review and staff interview, the agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The agency reported a current census of 5 patients. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed hospice patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: During the review of the agency's emergency preparedness plan on 5/11/21 at 10:37 AM, the surveyor notified Staff C, Human Resources of inability to find a written policy and procedure for procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The agency provided no further information prior to the end of the survey.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness policies and staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on patients they are unable to contact in the event of an interruption of services related to an emergency. The agency reported a current census of 5 patients at the time of the survey. Failure to have procedures in place for to inform State and local officials of any patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: During the review of the agency's emergency preparedness plan on 5/11/21 at 10:37 AM, the surveyor notified Staff C, Human Resources of inability to find a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The agency provided no further information prior to the end of the survey.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on review of the agency facility emergency preparedness documentation, and staff interview the agency failed provide documentation that the agency developed and maintained an emergency plan that included primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. Failure to develop and maintain an emergency preparedness plan included primary and alternate means of communication with the agency staff and federal, state, tribal, regional and local emergency management agencies during a time of disaster or emergency which could lead to poor client outcomes in the event of an emergency/disaster. Findings include: During the review of the agency's emergency preparedness plan on 5/11/21 at 10:37 AM, the surveyor notified Staff C, Human Resources of inability to find a written policy and procedure that included primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. The agency had an emergency preparedness binder that included staff, patient, hospital and local emergency management phone numbers only. Staff C, Human Resources reported that each patient has a Memorandum of Understanding that includes addresses for the regional emergency management agency and the agency would physically go to the the regional emergency management to inform them. The agency failed to provide documentation that the agency developed and maintained an emergency plan that included primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. The agency provided no further information prior to the end of the survey.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on agency policy review and staff interview, the agency failed to develop and maintain an emergency training and testing program for all agency staff as part of its emergency preparedness plan. Lack of development of development and maintenance of an emergency preparedness training program for all staff puts patients at risk should an emergency situation arise as staff would be needed to assist patients to ensure patient safety. Findings include: According to agency policy, titled Employee Orientation, dated 5/2021, all new employees orientation will include Emergency Preparedness training. Interview with the Clinical Manager on 5/11/21 at 9:58 AM, revealed staff complete an online FEMA training titled, "Until Help Arrives". The Clinical Manager revealed it is impossible to have all staff attend a training simultaneously due to the locations of the patients and the care the agency provides. The above information was reviewed with the Clinical Manager. The agency provided no further information prior to the end of the survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness to 1 of 7 staff sampled staff consistent with their expected roles during orientation and two of two sampled staff biannually per regulation. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to agency policy, titled Employee Orientation, dated 5/2021, all new employees orientation will include Emergency Preparedness training. The surveyor reviewed documentation provided of Emergency Plan training. The Clinical Manager revealed staff review all policies annually, however no documentation was available to document the review of the Emergency Plan training. The above information was reviewed with the Clinical Manager. The agency provided no further information prior to the end of the survey.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on agency staff interview, agency policy review and review of testing documentation, the agency failed to conduct exercises to test the emergency plan by participating in a community based full scale exercise or an actual natural or man-made emergency that requires activation of the emergency plan, and an additional exercise that may include a second community based full scale exercise, a mock disaster drill, or a table top exercise, that includes analyzing the facilities response to the event. The agency reported a current census of 5 patients. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: Review of agency policy, titled Emergency Preparedness Policy, dated 5/21, failed to include a policy for testing the agency's plan. Interview on 5/11/21, at 9:55 AM, the Clinical Manager revealed no documentation of testing the plan exists and the Clinical Manager provides nursing staff a written test over Emergency Preparedness annually. The agency failed to provide documentation of any exercises performed since the last survey. The agency provided no further information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 5/10/21 through 5/12/21 . The survey found to be in 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.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on agency staff interview, home visit observation and admission packet review, the agency failed to provide agency patients with written contact information for the agency's administrator, including the administrator's name. The agency failed to provide this information for 2 of 2 sampled patients with a home visit observation (Patients #1 and #4). The agency reported a census of 5 patients at the time of the survey, including 1 patient receiving services from the parent office in Oskaloosa and 4 patients from the branch office in Iowa City. The survey identified the deficient practice occurred at the parent office in Oskaloosa and the branch office in Iowa City. Failure to provide the contact information for the agency's clinical manager left the patients without the needed information to contact the agency clinical manager for any concerns about their services. Findings include: Review of the agency's admission packet revealed a form that included the following: "Any person's who believe he or she has a valid complaint, may present the information to the Administrator (641) 672-2944 or (319) 339-8600." The form lacked the identification of the agency Administrator's name. 1. Patient #1 had a start of care date of 7/13/17 and received skilled nursing services from the parent office in Oskaloosa. On 5/11/21 at 2:30 PM, the surveyor accompanied Staff D, Licensed Practical Nurse (LPN), to Patient #1's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. Review of the agency folder, lacked contact information for the HHA administrator, including the administrator's name. 2. Patient #4 had a start of care date of 10/28/2020 and received skilled nursing services from the branch office in Iowa City. On 5/12/21 at 6:28 AM, the surveyor accompanied Staff E, Registered Nurse(RN), to Patient #4's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. Review of the agency folder, lacked contact information for the HHA administrator, including the administrator's name. The surveyor reviewed the above stated findings with the Clinical Manager. During agency staff interview on 5/12/21 at 8:00 AM, the Clinical Manager agreed the form did not include the Administrator's name. The Clinical Manager revealed the Emergency Phone numbers left in the home for Patient #1 did include the Administrator's name. The surveyor informed the Clinical Manager both Staff D, LPN, and the surveyor reviewed this sheet in the home and the Administrator was not included on the Emergency Phone numbers sheet. The Clinical Manager confirmed the Emergency Phone number sheet for Patient #4 did not include the Administrator's name. The agency provided no additional information prior to the end of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, caregiver interview and agency staff interview, the agency failed to complete an individualized Plan of Care established and periodically reviewed by a physician and/or failed to notify the physician of the inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 8 sampled patients (Patients #1 and #4). The agency reported a census of 5 patients at the time of the survey, including 1 patient receiving services from the parent office in Oskaloosa and 4 patients from the branch office in Iowa City. The survey identified the deficient practice occurred at the parent office in Oskaloosa and the branch office in Iowa City. Failure to complete an individualized Plan of Care and follow the 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: During agency staff interview on 5/11/2021 at 9:00 AM, the Clinical Manager reported she sends a note to the physician upon admission requesting the physician preference to be notified immediately of missed visits or notified of such in each patient's 60 day summary of care. The physician chooses a mode of notification and signs the request. The physician is then notified of missed visits accordingly. 1. Patient #1 had a start of care date of 7/13/17 and received skilled nursing services from the parent office in Oskaloosa. Clinical record review revealed the following: a. The Plans of Care, dated 12/24/2020 to 2/21/2021, 2/22/2021 to 4/22/2021 and 4/23/2021 to 6/21/2021, included physician orders for shift work skilled nursing visits 24 hours per day 7 days per week. The Plans of Care directed the nurse to change the patient's suprapubic urinary catheter (a rubber tube placed into the bladder directly through an ostomy in the patient's lower abdomen) "once per month". b. The treatment administration records for January, February, March and April 2021 documented the nurse changed the patient's suprapubic urinary catheter on 1/12/2021, 2/25/21 and 3/30/2021. The clinical record lacked documentation of the nurse changing the patient's urinary catheter in April 2021. The clinical record lacked documentation of communication with the physician related to the omission of the catheter change. c. Agency staff interview on 5/12/2021 at 11:15 AM revealed the Clinical Manager reviewed the patient's clinical record and concurred the documentation reflected the last date the nurse changed Patient #1's catheter was on 3/30/2021. The Clinical Manager called to the patient's home and had the nurse working in the home at the time of the call review the documentation remaining in the patient's home. The nurse reviewed the documentation and found nothing indicating the catheter was changed in April 2021. The Clinical Manager reported the nurse would change the catheter today during the visit. 2. Patient #4, a pediatric patient with a tracheostomy and ventilator use at night, had a start of care date of 10/28/2020 and received skilled nursing services from the branch office in Iowa City. Clinical record review, caregiver interview and agency staff interview revealed the following: a. The Plans of Care, dated 2/25/2021 to 4/25/2021 and 4/26/2021 to 6/24/2021, included physician orders for skilled nursing care "16 hours per day 7 days per week per EPSDT". b. During agency staff interview on 5/11/2021 at 8:30 AM, the Clinical Manager reported the 16 hours per day/ 7 days per week identified the amount of care the payer EPSDT (a Medicaid program for pediatric patients) would pay for. The Clinical Manager reported the patient's mother and guardian worked Wednesdays and Fridays. The mother was home all other days of the week and willing to care for the patient until the agency could establish appropriate staffing with the agency providing care every Wednesday and Friday so the mother could keep employment. c. The skilled nursing visit notes, dated 3/10, 3/12, 3/17, 3/19, 3/24, 3/26, 3/31, 4/2, 4/7, 4/9, 4/14, 4/16, 4/21, 4/23,28, 4/30 and 5/5,7/2021 (all Wednesdays and Fridays), documented 11-12 hours of care. Each note documented care was taken over from the mother and turned over to the mother upon exit. The agency attempted to fill additional hours of care to afford the mother reprieve from direct care of the patient; however, one of the nurses resigned, causing the agency to provide care only when the mother was working while attempting to hire another nurse to care for the patient. The agency provided care to the patient two extra days for 10 hours of care during the weeks of 3/21/-3/27/2021 and 3/28-4/3/2021; four extra days for 10 hours during the weeks of 4/4-10/2021; 4/11-17/2021 and 4/18-24/2021. d. Patient caregiver interview on 5/12/2021 at 9:30 AM revealed Patient #4's mother did work on Wednesdays and Fridays. The mother reported she was the primary caregiver for the patient. The mother reported the hours covering Wednesday and Friday were sufficient to allow her to maintain employment. The mother reported it was beneficial to have the extra days of service to allow a reprieve from the responsibility, indicating she did not pick up any additional work hours when the agency provided additional services, indicating feeling a need to stay in the home while the agency provided services to the patient. The agency established a Plan of Care, using the frequency of care and the number of hours of service the payer was willing to pay. The frequency of care and number of hours of service were not based on the individualized needs of the patient based on the nurse's assessment and the availability of primary caregiver assistance. The agency was not able to provide skilled nursing services 16 hours of care each day 7 days per week and the documented need of the patient was 2 days per week for 10-12 hours of service so the mother could maintain employment. The plans of care were not individualized to Patient #4. The above stated findings for Patients #1 and #4 with the Clinical Manager. The agency 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 clinical record review, agency policy review, home visit observation and patient/caregiver 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, accurate medication/treatment orders, advance directive information and/or emergency room/hospitalization risk with planned interventions to address the risk for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7 and #8). The agency reported a census of 5 patients at the time of the survey, including 1 patient receiving services from the parent office in Oskaloosa and 4 patients from the branch office in Iowa City. The survey identified the deficient practice occurred at the parent office in Oskaloosa and the branch office in Iowa City. Failure to maintain complete and accurate Plans of Care with current orders and required components 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 Client Plan of Care and dated 5/2021, the individualized plan of care must include the following: all pertinent diagnoses, orders for discipline frequency/duration/treatments, the patient's mental status, supplies and equipment required, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, all medications and treatments used by the patient and safety measures to protect against injury. The policy lacked identification of the components advance directives information and a description of the patient's risk for emergency hospitalization and hospital readmission, including interventions to address the risk. 1. Patient #1 had a start of care date of 7/13/17 and received skilled nursing services from the parent office in Oskaloosa. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 12/24/2020 to 2/21/2021, 2/22/2021 to 4/22/2021 and 4/23/2021 to 6/21/2021, documented Patient #1 had the diagnoses of traumatic quadriplegia (C1-C4 complete), neurogenic bowel and bladder requiring use of a suprapubic urinary catheter (a rubber tube placed into the bladder directly through the lower abdomen), had a tracheostomy and was ventilator dependent. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk. b. The Plans of Care, dated 12/24/2020 to 2/21/2021, 2/22/2021 to 4/22/2021 and 4/23/2021 to 6/21/2021, included physician orders for the skilled nurse to change the patient's suprapubic urinary catheter every month; however, the Plan did not include the type of catheter, size of catheter, size of bulb or amount of saline use in the bulb to ensure the catheter remained in the bladder. c. The Plans of Care, dated 12/24/2020 to 2/21/2021, 2/22/2021 to 4/22/2021 and 4/23/2021 to 6/21/2021, included the medications Zinc, Vitamin C and Goli Vinegar Chews administered to the patient PRN (as needed). The physician approved the patient's use of the medications but the Plan failed to include the approved reason for use of the PRN medications. d. On 5/11/2021 at 2:30 PM, the surveyor accompanied Staff D, Licensed Practical Nurse (LPN), to Patient #1's home. During the home visit the surveyor observed the following medication discrepancy: The Plan of Care, dated 4/23/2021 to 6/21/2021, documented the patient took Tylenol 650 milligram every 4 hours for pain or fever. The surveyor observed the patient had Tylenol 500 milligram tablets in the home and did not have any 650 milligram Tylenol. The Plan of Care, dated 4/23/2021 to 6/21/2021, documented the patient took a probiotic Fortify 50 billion- give one each day when on an antibiotic. The Fortify in the home was only 10 billion dose. e. On 5/12/2021 at 10:00 AM, the Clinical Manager reported the patient's caregivers must be picking up a different dose of over the counter medications and the agency is not getting the change documented. 2. Patient #2, a pediatric patient, had a start of care date of 2/13/2018 and received skilled nursing services from the branch office in Iowa City. Clinical record review revealed the following: a. The Plans of Care, dated 11/29/2020 to 1/27/2021; 1/28/2021 to 3/28/2021 and 3/29/2021 to 5/27/2021, documented Patient #2 had the diagnoses of seizure disorder, global developmental delay and used a gastrostomy tube for medication administration and feedings. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk and lacked any information related to advance directives, including guardianship and code status/medical wishes. b. The Medicaid Needs Assessments, dated 9/14/2020 and 3/22/2021, documented the patient's use of AFO's (braces)on the lower extremities when placed in the stander. The Plans of Care, dated 11/29/2020 to 1/27/2021; 1/28/2021 to 3/28/2021 and 3/29/2021 to 5/27/2021, lacked identification of the AFO's as needed by the patient when standing in the stander. 3. Patient #3 had a start of care date of 10/6/2017 and received skilled nursing services from the branch office in Iowa City. Clinical record review and agency staff interview revealed the following: a. The Plans of Care, dated 11/19/2020 to 1/17/2021; 1/18/2021 to 3/18/2021 and 3/19/2021 to 5/17/2021, documented Patient #3 had a diagnosis of ALS (Lou Gherig's Disease) requiring a tracheostomy and was ventilator dependent. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk. b. The Skilled Nursing Visit Notes, dated 3/25/2021, 4/1/2021 and 4/23/2021, documented the patient's use of a mechanical lift for transfers and use of a bed pan for bowel elimination. The Plans of Care, dated 11/19/2020 to 1/17/2021; 1/18/2021 to 3/18/2021 and 3/19/2021 to 5/17/2021, lacked identification of the mechanical lift or the bedpan as equipment needed by the patient to meet the patient's needs. 4. Patient #4, a pediatric patient, had a start of care date of 10/28/2020 and received skilled nursing services from the branch office in Iowa City. Clinical record review revealed the following: The Plans of Care, dated 12/27/2020 to 2/24/2021; 2/25/2021 to 4/25/2021 and 4/26/2021 to 6/24/2021, documented Patient #4 had a diagnoses of broncho-pulmonary dysplasia requiring a tracheostomy. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk and lacked any information related to advance directives, including guardianship and code status/medical wishes. 5. Patient #5, a pediatric patient, had a start of care date of 2/2/2021 and received skilled nursing services from the branch office in Iowa City. Clinical record review revealed the following: The Plans of Care, dated 2/2/2021 to 4/2/2021 and 4/3/2021 to 6/1/2021, documented Patient #5 had a diagnosis of pulmonary hypertension requiring a tracheostomy and gastrostomy tube for medication administration and tube feedings. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk and lacked any information related to advance directives, including guardianship and code status/medical wishes. 6. Patient #6, had a start of care date of 2/27/2018, received skilled nursing services from the branch office in Iowa City and was discharged from agency services on 2/25/2021. Clinical record review revealed the following: The Plans of Care, dated 12/13/2020 to 2/10/2021 and 2/11/2021 to 4/11/2021, documented Patient #6 had a diagnosis of congenital quadriplegia requiring tracheostomy and gastrostomy tube for medication administration and tube feedings. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk and lacked any information related to advance directives, including guardianship and code status/medical wishes. 7. Patient #7, a pediatric patient, had a start of care date of 4/4/2018, received skilled nursing services from the branch office in Iowa City and was discharged from the agency on 7/24/2020. Clinical record review revealed the following: The Plans of Care, dated 1/24/2020 to 3/25/2020; 3/26/2020 to 5/22/2020 and 5/23/2020 to 7/21/2020, documented Patient #7 had the diagnoses of Lennox Gastaut syndrome with severe developmental delays and seizure disorder. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk and lacked any information related to advance directives, including guardianship and code status/medical wishes. 8. Patient #8, a pediatric patient, had a start of care date of 9/17/2020, received skilled nursing services from the branch office in Iowa City and was discharged from the agency on 3/5/2021. Clinical record review revealed the following: The Plans of Care, dated 9/17/2020 to 11/15/2020; 11/16/2020 to 1/14/2021 and 1/15/2021 to 3/15/2021, documented Patient #8 had the diagnoses of Ehler Danlos syndrome and broncho-pulmonary dysplasia. The Plans lacked inclusion of the patient's risk for emergency room visits and hospitalization, including interventions to address the risk and lacked any information related to advance directives, including guardianship and code status/medical wishes. The above stated findings for Patients #1, #2, #3, #4, #5, #6, #7 and #8 were reviewed with the Clinical Manager. 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 agency 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, #4, #5, #6 and #8) . The agency reported a census of 5 patients at the time of the survey, including 1 patient receiving services from the parent office in Oskaloosa and 4 patients from the branch office in Iowa City. The survey identified the deficient practice occurred at the parent office in Oskaloosa and the branch office in Iowa City. Failure to update the Plan of Care increased the risk to the patient resulting in potential for injury or inaccurate provision of care. Findings include: According to agency policy, titled 485 Physician Supplemental Orders and dated 5/2021, all orders will be immediately documented, dated and signed by a registered nurse, licensed practical nurse or the Clinical Manager. The physician countersigns the orders as soon as possible. All supplemental orders taken during a certification period will be incorporated into the patient's Plan of Care by the Clinical Manager and, at the time of recertification, all supplemental orders that remain current will be added to the new recertification Plan of Care. Agency staff interview on 5/11/21 at 9:00 AM revealed the Clinical Manager was not aware of the requirement for a working Plan of Care, including update of the working Plan of Care with all physician supplemental/verbal orders. 1. Patient #1 had a start of care date of 7/13/2017 and received skilled nursing services from the parent office in Oskaloosa. Clinical record review revealed: a. The patient's clinical record lacked any working Plans of Care. The Plan of Care, dated 12/24/2020 to 2/21/21, lacked physician orders for eye drops. b. The clinical record included physician supplemental orders, dated 12/24/2020, initiating Polymyxin Sulf/TMP eye drops one drop into right eye 4 times daily for 7 days. The physician supplemental order, dated 1/6/2021, ordered continued use of the Polymyxin Sulf/TMP eye drops for an additional 7 days. The eye drops were never added to the Plan of Care. c. The physician supplemental order, dated 1/18/2021, ordered continued use of the Polymyxin Sulf/TMP eye drops for an additional 3 days and add Pataday Once Daily Relief one drop into the right eye once daily for 7 days. The eye drops were never added to the Plan of Care. d. The physician supplemental order, dated 1/22/2021, initiated Moxifloxacin 0.5% eye drops one drop into right eye 3 times daily; Prednisolone Accolate 1% one drop to right eye 4 times daily; Bio True or Refresh for flushing of the right eye as needed by the patient; continued use of the Pataday one drop to the right eye at bedtime; and continued the Polymyxin Sulf/TMP eye drops 4 times daily. The eye drops were never added to the Plan of Care. e. The physician supplemental order, dated 2/12/2021, discontinued the Moxifloxacin 0.5% eye drops; and initiated Tobramycin eye drops one drop in the right eye 4 times daily. The eye drops were never added to the Plan of Care. The Plan of Care, dated 2/22/2021 to 4/22/2021, was updated with the eye drop orders remaining current at the time of recertification. 2. Patient #2 had a start of care date of 2/13/2018 and received skilled nursing services from the branch office in Iowa City. Clinical record review revealed: a. The patient's clinical record lacked any working Plans of Care. The Plan of Care, dated 3/29/2021 to 5/27/21, lacked physician orders for Diazepam. b. The clinical record included physician supplemental orders, dated 3/30/2021, initiating Diazepam 2 milligrams take 1/2 to one whole tablet (1 milligram to 2 milligrams) every 6 hours as needed for prolonged episodes of agitation. The Diazepam was never added to the Plan of Care. 3. Patient #4 had a start of care date of 10/28/2020 and received skilled nursing services from the branch office in Iowa City. Clinical record review revealed: a. The patient's clinical record lacked any working Plans of Care. The Plan of Care, dated 12/27/2020 to 2/24/2021, lacked orders for Prednisolone sodium phosphate; Albuterol nebulizer solution; and ventilator trial orders. b. The clinical record included physician supplemental orders, dated 1/6/2021, initiating Prednisolone sodium phosphate 15 milligrams/5 milliters take 7 milliliters twice daily as need by Respiratory Action Plan; Albuterol 2.5 milligram/3 milliliters 3 milliliters every 4 hours as needed by Respiratory Action Plan; decrease ventilator settings to 22/10 and initiate Respiratory Action Plan trial. The orders were never added to the Plan of Care. The orders were added with the update to the Plan of Care, 2/25/2021 to 4/25/2021, at the time of recertification. The Plan of Care, dated 12/27/2021 to 2/24/21, lacked orders for Milk of Magnesia. c. The clinical record included a physician supplemental order, dated 1/7/2021, initiating Milk of Magnesia 3-4 milliliters daily as needed for constipation. The orders were never added to the Plan of Care. The orders were added with the update to the Plan of Care, 2/25/2021 to 4/25/2021, at the time of recertification. The Plan of Care, dated 2/25/2021 to 4/25/2021, documented Patient #4 had a gastrostomy tube. d. The clinical record included physician supplemental orders, dated 4/7/2021, discontinuing the gastrostomy tube, changing the diet order to oral intake and initiating a dressing to the old gastrostomy site to include Vaseline gauze, dry gauze and cover with a Tegaderm dressing. If still draining from the site in two weeks, contact the physician to report. The orders were never added to the Plan of Care. 4. Patient #5 had a start of care date of 2/2/2021 and received skilled nursing services from the branch office in Iowa City. Clinical record review revealed: a. The clinical record lacked any working Plans of Care. The Plan of Care, dated 2/2/2021 to 4/2/2021, included orders for skilled nursing visits once weekly for 6 weeks. b. The clinical record included a physician supplemental order, dated 3/12/2021, initiating an additional week of skilled nursing visits 1-2 times. The order was never added to the Plan of Care. 5. Patient #6 had a start of care date of 2/27/2018, received skilled nursing services from the branch office in Iowa City and was discharged from the agency on 2/25/2021. Clinical record revealed: a. The clinical record lacked any working Plans of Care. The Plan of Care, dated 12/13/2020 to 2/10/2021, included orders for Baclofen 35 milligrams per g-tube 3 times daily. b. The clinical record included a physician supplemental order, dated 1/21/2021, decreasing the dose of Baclofen to 30 milligrams per g-tube 3 times daily. The order to decrease the Baclofen was never added to the Plan of Care. The Plan of Care, dated 2/11/2021 to 4/11/2021, included the decreased dose of Baclofen. 6. Patient #8 had a start of care date of 9/17/2020, received skilled nursing services from the branch office in Iowa City and was discharged on 3/5/2021. Clinical record review revealed: a. The clinical record lacked any working Plans of Care. The Plan of Care, dated 9/17/2020 to 11/15/2020, included orders for skilled nursing visits twice weekly for 2 weeks. b. The clinical record included a physician supplemental order, dated 10/2/2020, initiating an additional 6 weeks of skilled nursing visits twice per week. The order was never added to the Plan of Care. The above findings were reviewed with the Administrator and the Clinical Manager. During agency staff interview on 5/12/2021 at 1:35 PM, the Administrator reported the agency had been transcribing the orders into a paper notebook stored in the patient's home to assure all clinicians in the home were aware of any changes. Agency staff provided no further information prior to the end of the survey.