Every finding on record at Hegg Home Health Care

A Recertification Survey was conducted by the Department of Inspections and Appeals from 10/23/23 through 10/25/23 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections and Appeals conducted a Recertification Survey from 10/23/23 through 10/25/23. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a census of 38 patients at the time of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 4 of 7 sampled patients(Patients #1, #2, #3 and #4). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 3. Patient #1 had a start of care date of 9/14/20 and received services from the agency. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 8/30/23 to 10/28/23, included an order for hydrocodone-acetaminophen 5-325 milligrams (mg); 1 tablet morning, noon, and bedtime. b. The Client Medication Profile, dated 10/25/23, included an order for hydrocodone-acetaminophen 5-325 mg; 1 tablet morning, noon, and bedtime with a start date of 9/14/20. During a home visit observation on 10/23/23 at109:15 AM, with the Clinical Manager, Registered Nurse (RN), placed ½ tablet of hydrocodone-acetaminophen 5-325 mg in the patient’s pill planner for morning, noon, and bedtime doses. In an interview on 10/25/23 at 2:18 PM, the Clinical Manager reported that she placed ½ tablet of hydrocodone-acetaminophen in the patient’s pill planner instead of 1 tablet because the patient would have done it anyway as he self adjusts medication. When the Clinical Manager was asked if the patient’s primary provider was aware that the patient self adjusted medication doses, the Clinical Manager did not answer. c. The Plan of Care, dated 8/30/23 to 10/28/23 lacked the following: Order for Blue Emu cream Order Lipo Flavonoid Scale Knee braces Compression hose d. The Medication Profile dated 10/25/23 revealed Blue Emu cream and Lipo Flavonoid had start dates of 10/24/23. In an interview on 10/23/23 at 10:15 AM, the patient reported the following: He has been applying Blue Emu cream to his knees daily for the past 3 months for pain. He started taking Lipo Flavonoid twice per day 2 months ago and it has been effective in helping with ringing in his ears. He weighs himself weekly. He has been wearing knee braces since the 1970s and continues to wear them daily. He requests home health aide assistance to have his compression hose applied occasionally, but has not needed to wear them as often since his feet are less swollen since he obtained a power wheelchair in August 2021 that allows his feet to be elevated. In the same interview, the Administrator and Clinical Manager reported that the they were not aware that the patient started using Blue Emu cream and Lipo Flavinoid; that the patient had a scale or knee braces. They reported that the patient is known to do what he wants with his medications. When asked if the observed home visit was for recertification of his Plan of Care with a comprehensive assessment performed to include review of the patient’s medications and DME, the Administrator and Clinical Manager agreed the home visit was for a recertification comprehensive assessment. 4. Patient #3 had a start of care date of 9/13/23, the Plan of Care date 9/13/23 to 11/11/23 had a mental status of oriented. Clinical record review, home visit observation and accompanying interviews revealed the following: The POC dated 9/13/23 to 11/11/23 lacked orders for ibuprofen and Lomotil. The Medication Profile dated 10/25/23 revealed ibuprofen and Lomotil had start dates of 10/24/23. Concurrent observation and patient interview during a home visit on 10/24/23 at 9:15 AM revealed: Patient reported to the Clinical Manager that she/he took both ibuprofen and a prescription medication to treat diarrhea on 10/23/23. In an interview with the patient that she/he has been taking ibuprofen regularly since hip fracture that occurred April 2023 and that had taken Lomotil prior to admission to home health care. Lomotil prescription label revealed the medication was filled on 8/30/23. In an interview on 10/25/23 at 2:20 PM, the Administrator and Clinical Manager reported that the patient did not disclose that he/she took the 2 medications prior to the home visit on 10/24/23; that the patient couldn’t remember anything and was very forgetful. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. According to agency policy, titled Care Planning and Coordination, dated 9/2023, the plan of care includes at least the following information: a list of all medical (DME) equipment used by the patient. 1. Patient #2 had a start of care date of 2/8/22. Clinical record review and home visit observation revealed the following: a. The Plan of Care, dated 10/1/23 to 11/29/23, included orders for Calcium carbonate-vitamin D3 (supplement) 500 milligram (mg)-600 unit 1 tablet every morning and evening. b. The Client Medication Report, dated 10/3/23, included orders for Calcium carbonate-vitamin D3 (supplement) 500 mg-600 unit (15 micrograms (mcg) 1 tablet every morning and evening. During a home visit observation on 10/22/22 at 11:30 AM, with Staff C, Licensed Practical Nurse, the nurse set up the patient's medications for a 1 week supply in a medication planner. The bottle included Calcium carbonate-vitamin D3 600 mg-20 mcg. The bottle had a fill date of 9/28/23. The Plan of Care lacked the correct dose of Calcium carbonate-vitamin D3 used by the patient. 2. Patient #4 had a start of care date of 1/26/23. Clinical record review revealed the following: a. The Plan of Care, dated 9/23/23 to 11/21/23, included the patient's required durable medical equipment including: ostomy supplies, cell phone, bathroom grab bars, walker, medbox and BP cuff. b. The Home Care Aide Plan of Care, identified the patient required the use of the following Durable medical equipment: lift chair, shower wand and shower chair. The Plan of Care lacked the DME incontinent supplies, lift chair, shower wand and shower chair used by the patient.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, wound care education provided to staff and staff interview, the agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 2 sampled patients who required wound assessments (Patients #4 and #7). Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. Findings include: According to the agency policy titled Skin/Wound/Pressure Ulcer Assessment, dated 8/2023, a wound is defined as a break in the epidermis or dermis that can be related to trauma or to pathological changes within the skin or body. Wounds will be measured at the time of discovery and admission to home care unless it is a surgical wound that has a dressing that cannot be removed. Wound assessment should take into account the following: wound dimensions including length, width and depth. 1. Patient #4 had a start of care date of 1/26/23. The Plan of Care (POC), dated 9/23/23 to 11/21/23, a. The skilled nurse visit note, dated 8/24/23, identified the patient had surgical wounds. The midline wound measured 26 cm and had staples. The upper right quadrant measured 1.5 cm with staples identified and the lower right quadrant measured 1 cm and described well approximated. b. The skilled nurse visit notes, dated 8/28, 9/5, and 10/14/23, included documentation the patient had the surgical wounds. The wounds were not measured. c. The skilled nurse visit note, dated 9/28/23, identified the upper portion of the abdominal incision was dehiscing but is healing. The wound was not measured. d. The skilled nurse visit note, dated 10/5/23, identified the upper portion of the abdominal incision area where dehisced now had hypergranulation tissue. Discussed with wound therapy and notified the physician. Wound therapy stated it will not approximate/close until the tissue is removed. New dressing applied. The wound not measured. e. The skilled nurse visit note, dated 10/12/23, identified one small area (penny sized) at the top of the abdominal incision was dehiscing but is healing. The wound therapist used silver nitrate to treat. The wound not measured. During an interview on 10/25/23 at 3:20 PM the Clinical Manager stated the patient's Doctor was watching him/her in the office. The dressing was placed at the doctor's office and the agency did not do anything with the wound. She further stated she did see the wound and did not measure it. The agency failed to measure the patient's open wound. 2. Patient #7 had a start of care date of 6/16/23 and discharge date of 9/26/23. The Plan of Care (POC), dated 6/16/23 to 8/14/23, included orders for skilled nursing services. a. The occupational therapy visit note, dated 7/17/23, identified the patient had a fall over the weekend. The patient identified to have a laceration on the head. No further assessment of the laceration documented. b. The aide visit note, dated 7/17/23, failed to include documentation of the patient fall or change in skin integrity. c. The physical therapy nurse visit note, dated 7/18/23, identified the patient had a fall and had some bruising on the left eye. d. The skilled nurse visit note, dated 7/18/23, failed to include identification of the patient fall or assessment of the patient's laceration/bruising. The agency failed to assess the patient's wound. The above findings shared with the agency Administrator and Clinical Manager. No further information presented prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review and staff interview, the agency failed to ensure the Home Health Aides (HHA) successfully completed competencies in all home health aide skills that exceed basic skills, which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 5 of 7 sampled HHA (Staff D, E, F, G, and H). The agency identified a census of 38 current patients. Failure to ensure HHA were competent in any assign skill which exceeded the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: In an interview on 10/25/23 at 2:18 PM, the Administrator reported: a. The agency does not have a policy regarding competency evaluations for HHA skills that exceed basic HHA skills. b. She was told that competency testing was no longer required when she started as agency Administrator 1 year ago and did not perform competency evaluations for HHA skills that exceed basic HHA skill. 1. Patient #1 had a start of care date of 9/14/20. The HHA orders on the Plan of Care (POC) dated 8/30/23 to 10/28/23 directed the HHA to shave the patient and apply compression hose. The clinical record identified Staff D and G provided care to Patient #1. Staff D, HHA, had a hire date of 8/31/2022. Staff D's personnel file lacked documentation of Registered Nurse (RN) signature and date of competency testing to ensure completion of the competency evaluation for shaving and compression hose prior to providing care for Patient #1. Staff G, HHA, had a hire date of 6/21/2023. Staff G's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for shaving and compression hose prior to providing care for Patient #1. 2. Patient #3, had a start of care date of 9/13/23. The POC, dated 9/13/23 to 11/11/23, directed the HHA to apply ointment. The POC lacked orders for the HHA to change a simple dressing. The clinical record identified Staff D and H provided care to Patient #3. Staff D, HHA, had a hire date of 8/31/2022. Staff D's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for applying ointment prior to providing care for Patient #3. Staff H, HHA, had a hire date of 11/8/05. Staff H's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for applying ointment and simple dressings prior to providing care for Patient #3. 3. Patient #5, had a start of care date of 1/27/22. The POC, dated 9/19/23 to 11/17/23, directed the HHA to weigh the patient. The clinical record identified Staff D, F, and H provided care to Patient #3. Staff D, HHA, had a hire date of 8/31/2022. Staff D's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for weighing patients prior to providing care for Patient #5. Staff F, HHA, had a hire date of 7/27/2022. Staff H's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for weighing patients prior to providing care for Patient #5. Staff H, HHA, had a hire date of 11/8/05. Staff H's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for weighing patients prior to providing care for Patient #5. 4. Patient #6, had a start of care date of 7/26/23. The POC, dated 7/26/23 to 9/23//23, directed the HHA to apply lotion and apply compression hose to the patient. The clinical record identified Staff D, E, F, and G provided care to Patient #3. Staff D, HHA, had a hire date of 8/31/2022. Staff D's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for applying lotion and applying compression hose prior to providing care for Patient #6. Staff E, HHA, had a hire date of 6/14/21. Staff H's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for applying lotion and applying compression hose prior to providing care for Patient #6. Staff G, HHA, had a hire date of 6/21/2023. Staff G's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for applying lotion and applying compression hose prior to providing care for Patient #6. Staff F, HHA, had a hire date of 7/27/2022. Staff H's personnel file lacked documentation of RN signature and date of competency testing to ensure completion of the competency evaluation for applying lotion and applying compression hose prior to providing care for Patient #6. The above findings were reviewed with the Administrator and Clinical Manager. No further information was provided prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 6 sampled patients receiving home health aide services (Patients #3, #4 and #5). The agency reported 22 patients who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: 3. Patient #3 had a start of care date of 9/13/23. The Plan of Care (POC), dated 9/13/23 to 11/11/23, included physician orders for weekly skilled nursing services and HHA services 5 times per week. Clinical record review revealed: No orders for a dressing change to the patient’s coccyx. Home Assist Aide Visit on 9/18/23 revealed in pertinent part, changed bandage on coccyx. In a concurrent home visit observation and patient interview on 10/24/23 at 9:15 AM, the patient had an Allevyn dressing and reported that this was the dressing that the HHA changed on her coccyx on 9/18/23. In an interview on 10/25/23 at 2:18 PM, the Administrator and Clinical Manager reported that if a HHA had passed a competency evaluation, they could change a simple dressing to an area of intact skin only. The above findings were reviewed with the Administrator and Clinical Manager. No further information was provided prior to the end of the survey. According to the agency policy titled Care Planning, dated 9/2023, any reviews of and/or changes to the plan of care are dated and signed by the appropriate discipline whenever it is reviewed, whether or not there are changes to the plan of care. Any changes are communicated to other members of the healthcare team either verbally or in writing. 1. Patient #4 had a start of care date of 1/26/23. The Plans of Care, dated 9/23/23 to 11/21/23, included physician orders for skilled nursing services for assessment every other week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan included direction to the aide to complete a shower. The plan identified the patient unable to shower at this time due to open area on abdominal incision. b. The Home health aide visit note, dated 9/25/23, documented the task of a shower accomplished. The home health aide failed to follow the aide plan of care and documented the shower accomplished. 2. Patient #5 had a start of care date of 1/27/22. The Plans of Care, dated 7/21/23 to 9/18/23 & 9/19/23 to 11/17/23, included physician orders for skilled nursing services for assessment every month and home health aide services 3 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan, dated October, 2023, included direction to the aide to record the patient's weight every Friday. b. The Home health aide visit note, dated 8/25, 9/8, 9/29, 10/6 and 10/20/23, failed to include documentation of the patient's weight. During an interview on 10/25/23 at 3:10 PM the Administrator stated the aide reported she could not find the patient's scale to complete the weights during the home care aide visits. The home health aide failed to follow the aide plan of care and document the patient's weight.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 3 of 6 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patients #1 and #5). The agency reported 8 patients who received personal care assistance by a home health aide while also receiving skilled service provision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: 3. Patient #1 had a start of care date of 9/14/20 and received services from the agency. The Plan of Care (POC), dated 8/30/23 to 10/28/23, included physician orders for skilled nursing and HHA services. Review of the clinical record revealed documentation of a skilled nursing visits with HHA supervision, dated 8/2923 and 9/28/23. No other HHA supervision visits occurred between these 2 dates. In an interview on 10/25/23 at 2:18 PM, the Administrator reported that the reason no other HHA supervision was performed in between the 2 dates was because a Licensed Practical Nurse (LPN) performed the ordered visits in between the 2 dates. The above findings were reviewed with the Administrator and Clinical Manager. No further information was provided prior to the end of the survey. According to the agency's Home Health Aide policy titled Supervisory Visits-Home Health Aides and Licensed Practical Nurse, dated 9/2023, when (Medicare, Medicaid, private insurance and other payor sources such as Veteran's Administration) and the client is receiving both Registered Nurse (RN) and Home Health Aide (HHA) services; there shall be an on-site aide supervisory visit (ASV) every 2 weeks. The HHA need not be present during the ASV. Documentation of supervisory visits must be included in the patient's clinical record. 1. Patient #5 had a start of care date of 1/27/22. Record review revealed the following: a. The Plans of Care (POCs), dated 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23, included physician orders for skilled nursing and home health aide services. b. The skilled nursing updated comprehensive assessment visit note, dated 9/7/23, included home health aide supervision. c. A supervisory visit note, dated 10/6/23, included documentation the nurse supervised the aide (exceeding aide supervision requirements by 15 days). During an interview on 10/25/23 at 3:10 PM the Administrator stated the patient private pay and are not considered skilled patients. Supervisory visits every 14 days completed on patients who have payor source for example Medicare, Medicaid and Veterans Administration services.