Every finding on record at Home Care Services of Boone County

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 12/8/25 through 12/10/25 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 12/8/25 through 12/10/25. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 43 patients at the time of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to provide a complete comprehensive assessment for patients with wounds during start of care, recertifications, resumption of care and discharge assessments for 4 of 4 sampled patients with wounds (Patients #1, #5, #6 and #7). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: 4. Patient #5 had a start of care date of 10/3/25. Clinical record review revealed: a. The POC, dated 10/3/25 to 12/1/25, identified the patient had a diagnosis of Severe sepsis with septic shock, identified the patient had wounds and included orders for skilled nursing services 1 time a week for 1 week and then 2-3 times a week. b. The start of care comprehensive assessment, dated 10/3/25, completed by Staff A, Administrator, identified the patient had an open area on the coccyx. The skilled nurse completed wound measurements of 1 centimeter (cm) by 1 cm but failed to measure the depth of the wound. The agency failed to include accurate and complete comprehensive assessments of the patient's wounds. The above findings were reviewed with the Administrator. According to the agency policy titled Wound Care Protocol, dated 4/2024, the primary care nurse or designee is responsible for performing wound/skin assessment and wound treatments per physicians order. During an interview on 12/9/25 at 8:55 AM, the Clinical Manager stated wound care and measurements documented under wound assessment in the medical record. Wounds are expected to be measured every 7 days and measurements include length, width and depth measured in centimeters. 1.Patient #1 had a start of care date of 12/5/25. Clinical record review revealed the following: a. The Plan of Care (POC), dated 12/5/25 to 2/2/26, identified the patient had diagnoses of fracture of the unspecified part of neck of femur and diabetes mellitus and included orders for skilled nursing services every 3 days. b. The start of care comprehensive assessment, dated 12/5/25, completed by Staff C, Registered Nurse (RN), identified the patient had an open pressure ulcer on the mid back. The skilled nurse completed wound measurements of 0.39 inches by 0.39 inches and failed to measure the depth of the wound. The skilled nurse failed to include a complete initial assessment of patient's wound. The agency failed to include accurate and complete comprehensive assessments of the patients wounds. 2. Patient #6 had a start of care date of 5/22/25 and discharged on 7/17/25. Clinical record review revealed the following: a. The POC, dated 5/22/25 to 7/19/25, identified the patient had diagnoses of right knee hemarthrosis and included orders for skilled nursing services 1 time a week. b. The skilled nurse note, dated 7/1/25, completed by Staff D, RN, identified the patient had a skin tear on the right forearm and an open wound on the right knee. 1) The skilled nurse completed wound measurements of the right forarm skin tear of 0.8 inches by 2.8 inches and failed to measure the depth of the wound. The skilled nurse failed to document a a complete assessment of patient's wound. 2) The skilled nurse completed wound mearements of the right knee of 0.79 inches by 1.588 inches and failed to measure the depth of the wound. The skilled nurse failed to document a complete assessment of the patient's wound. The agency failed to include accurate and complete comprehensive assessments of the patients wounds. 3. Patient #7 had a start of care date of 12/5/25 and discharge date of 10/20/25. Clinical record review revealed the following: a. The POC, dated 9/30/25 to 11/28/25, identified the patient had diagnoses of dementia and included orders for skilled nursing services 1 time a week. b. The start of care comprehensive assessment, dated 12/5/25, completed by Staff D, RN, identified the patient had a small skin tear on the top of the right arm, near the elbow. The wound wrapped in gauze. Staff failed to document an assessment of the wound. The agency failed to include accurate and complete assessments of the patients wound.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 2 of 3 sampled patients with home observation visits (Patients #1 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Medication Regimen Review, dated 4/2024, when the patient is admitted to the Home Health Program the Registered Nurse takes a medication history and obtains an accurate list of all prescribed and over-the-counter medications being taken regularly and on an as needed basis by the patient. During an interview on 12/9/25 at 8:55 AM the Clinical Manager stated the agency nurse looks at the medications in the patient's home. 1.Patient #1 had a start of care date of 12/5/25. Clinical record review revealed the following: a. The Plan of Care (POC), dated 12//525 to 2/2/26, identified the patient had diagnoses of Fracture of unspecified part of neck of femur and diabetes mellitus and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at start of care, dated 12/5/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 12/8/25 at 1:00 PM with Staff C, RN the patient interview revealed the following medication discrepancies orders and patient stated medication schedule: 1) Jardiance 25 mg tablet daily. Patient stated had not been taking since prior to home care admission. 2) Metoprolol succinate 50 mg twice a day. Patient stated takes 1 time a day. 3: Metformin 1000 mg daily. Patient stated not taking since prior to home care admission. 4) Aspirin 81 mg 1 tablet daily. Patient stated taking 2 tablets daily. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #3 had a start of care date of 10/31/25. Clinical record review revealed the following: a. The POC, dated 10/31/25 to 12/29/25, identified the patient had a diagnosis of Chronic diastolic congestive heart failure and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at start of care, dated 10/31/25, completed by Staff B, RN, included documentation a DRR was completed. c. During a home observation visit on 12/9/25 at 2:00 PM with Staff H, Physical Therapist, the surveyor noted Tylenol 500 mg capsules in the home. In an interview during the same home visit the patient stated he/she takes 2 capsules every morning and every evening and has since prior to home health admission. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home observation visit, patient interview and staff interview, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all medical supplies/equipment and all medications and treatments used by the patient for 3 of 7 sampled patients (Patients #2, #4 and #5). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: 1.Patient #2 had a start of care date of 12/6/22. Clinical record review revealed: a. The Plan of Care (POC), dated 11/20/25 to 1/18/26, identified the patient had a diagnosis of Ventricular fibrillation and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: scale, pillboxes, nebulizer supplies, incontinence supplies, walker, cane and bilevel positive airway pressure (BIPAP). b. The skilled nurse recertification visit note, dated 11/17/25, completed by Staff D, Registered Nurse (RN), identified the patient checks his/her blood sugars regularly. c. During a home observation visit on 12/9/25 at 10:00 AM with Staff D, RN, the surveyor identified the following medical supplies/equipment used by the patient: pill cutter and diabetic supplies. The patient stated during the same home visit he/she had been checking his/her blood sugars for about one year. Staff D reported she had been utilizing the pill cutter to cut patients pills for greater than 1 month. The agency failed to include all medical supplies/equipment on the patient's POC, including a pill cutter and diabetic supplies. 2. Patient #4 had a start of care date of 5/16/25. Clinical record review revealed: a. The POC, dated 11/12/25 to 1/10/26, identified the patient had a diagnosis of Chronic pulmonary embolism. The POC included the following medical supplies/equipment used by the patient: walker, cane, scooter, medication boxes, continuous positive airway pressure (CPAP) and supplies, sharps container, hearing aids, eye glasses, walk in shower, grab bars, grabber and scale. b. The skilled nurse recertification visit note, dated 11/11/25, completed by Staff G, RN, identified the patient uses elastic hose for edema and also identified the patient uses diabetic supplies to check blood sugars. The agency failed to include all medical supplies/equipment on the patient's POC, including elastic hose and diabetic supplies. 3. Patient #5 had a start of care date of 10/3/25. Clinical record review revealed: a. The POC, dated 10/3/25 to 12/1/25, identified the patient had a diagnosis of Severe sepsis with septic shock and identified the patient had wounds. The POC included the following medical supplies/equipment used by the patient: wheelchair, walker, utility cart, sara steady, reacher, shoe horn, sock assist, ramps, bed rails, mechanical bed, shower chairs, commode, gait belt and sharps disposal. b. The start of care comprehensive assessment, dated 10/3/25, completed by Staff A, Administrator, identified the patient hah a closed wound to right upper chest treated by cleansing, antimicrobial fabric and foam cover changed Monday, Wednesday and Friday. The assessment identified an open wound to coccyx treated with cream twice a day and covered with Mepilex and also identified the patient used an incentive spirometer and wears tubigrips. c. The occupational therapist visit note, dated 10/8/25, completed by Staff I, Occupational Therapist (OT), identified the patient used a lift chair and wheelchair cushion. The agency failed to include all medical supplies/equipment and treatments on the patient's POC, including incentive spirometer, tubigrips, lift chair, wheelchair cushion and wound care orders. The above findings were reviewed with the Administrator.

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 2 of 6 sampled patients receiving home health aide services (Patients #3 and #7). The agency reported 16 patients who received home health aide services. 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 include: According to the agency policy, titled Home Care Aide Policy, dated 1/2025, the Registered Nurse (RN) will provide written instructions to the aide and the significant other. On the job instruction will be given to the Home Care Aide as needs identified. During an interview on 12/9/25 at 8:55 AM AM the Clinical Manager the nurse completes the care plan and it is reviewed at a minimum of every 2 weeks. If the aide is unable to complete an assigned task, the aide needs to document a reason as to why the task wasn't completed. 1.Patient #3 had a start of care date of 10/31/25. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/31/24 to 12/29/25, identified the patient had a diagnosis of Chronic diastolic congestive heart failure and included physician orders for physical therapy and home health aide services. b. The aide visit notes, dated 11/14/25, 11/18/25, 11/21/25 and 11/25/25, included RN instructions to assist with the patient's weight. Staff E, Home Health Aide failed to include documentation the task of assist with the patient's weights accomplished or the reason the task not accomplished. c. The aide visit notes, dated 12/2/25 and 12/5/25, included RN instructions to assist with the patient's weight. Staff F, Home Health Aide failed to include documentation the task of assist with the patient's weights accomplished or the reason the task not accomplished. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. 2. Patient #7 had a start of care date of 9/30/25 and discharge date of 10/20/25. Review of the clinical record revealed the following: a. The POC, dated 10/31/24 to 12/29/25, identified the patient had a diagnosis of dementia and included physician orders for skilled nursing and home health aide services. b. The aide visit notes, dated 10/7/25 and 10/10/25, included RN instructions to complete the task of shower/partial bath and bed bath. Staff K, Home Health Aide failed to include documentation the actual task complete, shower, partial bath or bed bath. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings reviewed with the Administrator.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on agency staff interview, clinical record reviews and agency policy review, 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 2 of 6 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patients #2 and #6). The agency reported 16 patients who received home health aide services with every 14 day supervision. 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: 2. Patient #6 had a start of care date of 5/22/25 and discharge date of 7/17/25. Clinical record review revealed: a. The POC, dated 5/22/25 to 7/20/25, identified the patient had a diagnosis of right knee hemarthrosis and included physician orders for skilled nursing and home health aide services. b. The skilled nurse visit note, dated 7/1/25, Staff D, RN, included documentation of home health aide supervision. c. The skilled nurse visit note, dated 10/29/25, Staff J, RN, included documentation of home health aide supervision 16 days after the previous documented aide supervision (2 days late). The agency failed to provide home health aide supervision every 14 days. The above findings reviewed with the Administrator. According to the agency's Home Care Aide policy, dated 1/2025, the Registered Nurse (RN) will supervise outcome of service by the Home Health Aide as needs indicate but at least every 14 days. During an interview on 10/9/25 at 8:55 AM, Staff B, Clinical Manager, reported home health aide supervision is completed a minimum of every 14 days and documented by the RN in the skilled nurse visit note. 1.Patient #2 had a start of care date of 12/6/22. Clinical record review revealed: a. The Plans of Care (POC), dated 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26, identified the patient had a diagnosis of Ventricular fibrillation and included physician orders for skilled nursing and home health aide services. b. The skilled nurse visit note, dated 9/23/25, Staff D, Registered Nurse (RN), included documentation of home health aide supervision. c. The skilled nurse visit note, dated 10/29/25, Staff D, RN, included documentation of home health aide supervision (22 days late). The agency failed to provide home health aide supervision every 14 days.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in patient condition and honoring patient rights for 3 of 6 sampled patients receiving home health aide services (Patients #2, #5 and #7). A total of 15 patients received home health aide services requiring every 14 day supervision and the agency employed 4 home health aides at the time of the survey. Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. Findings include: 3. Patient #7 had a start of care date of 0/30/25 and discharge date of 10/20/25. Clinical record review revealed: a. The POC, dated 9/30/25 to 11/28/25, identified the patient had a diagnosis of dementia and included orders for skilled nursing and home health aide services. b. Skilled nursing notes, dated 10/13/25, included documentation home health aide supervision was completed and the aide followed the care plan. The notes lacked documentation the nurse assessed the aide's ability to meet the following required supervisory elements: maintaining an open communication process with patient/caregiver and family, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in patient condition and honoring patient rights. The agency failed to supervise home health aide services to include all supervisory elements. The above findings were reviewed with the Administrator. According to the agency's Home Care Aide policy, dated 1/2025, the Registered Nurse (RN) will supervise outcome of service by the Home Health Aide as needs indicate but at least every 14 days. During an interview on 10/9/25 at 8:55 AM, Staff B, Clinical Manager, reported home health aide supervision is documented by the RN in the skilled nurse visit note. 1.Patient #2 had a start of care date of 12/6/22. Clinical record review revealed: a. The Plans of Care (POC), dated 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26, identified the patient had a diagnosis of Ventricular fibrillation and included orders for skilled nursing and home health aide services. b. Skilled nursing notes, dated 10/29/25, 11/5/25, 11/12/25, 11/17/25, 11/24/25 and 12/4/25, included documentation home health aide supervision was completed and the aide followed the care plan. The notes lacked documentation the nurse assessed the aide's ability to meet the following required supervisory elements: maintaining an open communication process with patient/caregiver and family, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in patient condition and honoring patient rights. The agency failed to supervise home health aide services to include all supervisory elements. 2. Patient #5 had a start of care date of 10/3/25. Clinical record review revealed: a. The POCs, dated 10/3/25 to 12/1/25 and 12/2/25 to 1/30/26, identified the patient had a diagnosis of Severe sepsis with septic shock and included orders for skilled nursing and home health aide services. b. Skilled nursing notes, dated 10/16/25, 10/29/25, 11/19/25, 11/26/25 and 11/28/25, included documentation home health aide supervision was completed and the aide followed the care plan. The notes lacked documentation the nurse assessed the aide's ability to meet the following required supervisory elements: maintaining an open communication process with patient/caregiver and family, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in patient condition and honoring patient rights. The agency failed to supervise home health aide services to include all supervisory elements.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the home health agency failed to ensure all clinical documentation was completed in a timely manner for 3 of 7 sampled patients (Patients #2, #3 and #5). Failure to ensure all clinical record documentation was completed in a timely manner increased the risk of ineffective communication between staff members providing services to its patients. Findings include: 3. Patient #3 had a start of care date of 10/31/25. Clinical record review revealed: a. The POC, dated 10/31/25 to 12/29/25, identified the patient had a diagnosis of chronic diastolic congestive heart failure and included orders for home health aide services 2 times a week. b. The home health aide visit note, dated 11/18/24, completed and signed 11/23/25 by Staff E, Home Heath Aide Aide 5 days after the visit and 2 days late (per agency policy). Agency staff failed to complete documentation in a timely manner. The above findings reviewed with the Aministrator. According to the agency's Home Care Aide policy, dated 1/2025, documentation by the home care aide will be completed in the medical record within one business day of the completed visit. During an interview on 12/8/25 at 3:57 PM, Staff A, Administrator, reported documentation has to be completed, done and signed within three business days. 1.Patient #2 had a start of care date of 12/6/22. Clinical record review revealed: a. The home health aide visit note, dated 10/13/25, signed completed 10/17/25 (3 days late) by Staff E, Aide. b. The home health aide visit note, dated 10/27/25, signed completed 10/31/25 (3 days late) by Staff E, Aide. c. The home health aide visit note, dated 11/12/25, signed completed 11/17/25 (4 days late) by Staff E, Aide. d. The home health aide visit note, dated 11/19/25, signed completed 11/23/25 (3 days late) by Staff E, Aide. e. The home health aide visit note, dated 11/26/25, signed completed 12/1/25 (4 days late) by Staff F, Aide. Agency staff failed to complete documentation in a timely manner. 2. Patient #5 had a start of care date of 10/3/25. Clinical record review revealed: The home health aide visit note, dated 10/13/24, signed completed 10/17/25 (3 days late) by Staff F, Aide. Agency staff failed to complete documentation in a timely manner.

The recertification survey, conducted 10/31/22 through 11/2/22, found the agency operating in substantial compliance and identified no concerns related to emergency preparedness.

The recertification survey conducted by the Department of Inspections and Appeals from 10/31/22 through 11/2/22, found the agency operating out of compliance with the following standard level deficiencies. The agency reported a total current census of 71 patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure staff fully completed an update to the comprehensive assessment which included assessment information on the patient's current health status for 1 of 2 sampled patients with an update to the comprehensive assessment at the time of discharge (Patients #6). Failure to fully complete an individualized patient comprehensive assessment placed agency patients at risk for having unidentified health care needs after discharge from agency services. Findings include: Review of the agency policy, titled Patient Assessment, dated 3/2020, identified staff will provide a patient-specific comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate progress towards achievement of desired outcomes. Staff will complete an update to the comprehensive assessment at least every 60 days, upon resumption of care after a hospital admission and at the point of discharge. Patient #6 had a start of care date of 5/16/22 and discharged from agency services on 6/10/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/16/22 to 7/14/22, identified a diabetes with chronic kidney disease and included orders for skilled nursing services. The POC identified a goal for the patient to check blood sugar levels daily and for the blood sugar readings to remain at 220 or less for the course of the 9 weeks of services. The POC included orders for the skilled nurse to assess the patient's progress towards goals each visit and to complete diabetic teaching on signs and symptoms of the disease process, etiology, blood sugar testing, diet and nutrition, diabetic foot care, rest and activity. b. The update to the comprehensive assessment completed at the time of discharge, dated 6/10/22, included documentation the nurse monitoring diabetic foot care during the course of services, but lacked any other assessment information regarding the patient's endocrine system, diabetic health care status or progress with goal outcomes related to the patient's primary diagnosis of diabetes. 11/2/22 at 2:05 PM, during an interview, the Administrator reported an inability to find any information in the discharge comprehensive assessment that addressed the patient’s endocrine system and diabetes. The Administrator received the above findings and agency staff provided no further information prior to the end 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 identifying all duplicate drug therapy as part of the comprehensive assessment at the required timepoints for 3 of 7 sampled patients (Patient #3, Patient #4, and Patient #5). Failure to ensure accurate medication reviews occurred at the time of each drug regimen review increased the potential for medication interactions and side effect risks to the patient at the time of the comprehensive assessment. Findings include: According to agency staff policy, titled, Medication Regimen Review Process, dated 4/2020, when the patient is admitted to the home health program, the Registered Nurse (RN) takes a medication history and obtains an accurate list of all prescribed and over the counter medications being taken regularly and on a as needed basis by the patient. Ask the patient if you may look at all their medications to do the reviews. The RN will review each medication taken by the patient for potential drug interactions, duplicate drug therapy and inaccurate or incorrect instructions or dosages. The RN is assisted with this task by the computer printouts on medications provided by the pharmacy and/or drug reference books supplies to each RN. The electronic health record also triggers a "Perform Drug Regimen Review" task any time a clinician finishes a task where medications are added or changed. This task is generated when the EHR (electronic health record) checks for drug-drug interaction, duplicate therapies (redundant medication; two or more drugs serving the same purpose), or potential allergic reactions to drugs' (based on allergies and medications entered in the patient's electron chart). Due to the EHR not having a complete Drug Regimen Review in the system a review will also be completed using a paper form to cover all required components. Problems identified are reported to a physician for direction. Interview on 11/1/22 at 9:24 AM with the Administrator/Clinical Manager reported nursing always completes and does the comprehensive assessment with the Drug Regimen Review (DRR). DRR is documented on the paper form and scanned in the attachments and is done with each comprehensive assessment. 1.Patient #3 had a start of care date of 3/16/21. Clinical record review revealed: a. Updates to the comprehensive assessment completed at recertification dated 5/6/22, 7/5/22, and 9/6/22. b. Paper Drug Regimen Review forms, dated 5/6/22, 7/5/22 and 9/6/22, addressed all the required components of a DRR, however identified duplicate drug therapy as "no". c. The Plan of Care, dated 5/10/22 to 7/8/22, included orders for Pain relief cream and Tylenol (both medications ordered for pain) and multivitamin and vitamin B12 (both used as supplements). d. The Plan of Care, dated 7/9/22 to 9/6/22, included orders for Pain relief cream and Tylenol (both medications ordered for pain) and multivitamin and vitamin B12 (both used as supplements), and finasteride and alfuzososin (both medications ordered for Benign Prostatic Hyperplasia). e. The Plans of Care, dated 9/7/22-11/5/22, included orders for Pain relief cream and Tylenol (both medications ordered for pain) and multivitamin and vitamin B12 (both used as supplements), and finasteride and tamsulosin (both medications ordered for Benign Prostatic Hyperplasia). The Drug Regimen Review did not identify the duplicate drug therapies ordered on the Plans of Care. 2. Patient #5 had a start of care date of 4/25/22. Clinical record review revealed: a. Updates to the comprehensive assessment for recertification, dated 8/19/22, and 10/17/22, and an update to the comprehensive assessment for resumption of care, dated 9/19/22. b. Paper Drug Regimen Review forms, dated, 8/19/22, 9/19/22, and 10/17/22, addressed all the required components, however identified duplicate drug therapy as "lasix, metolazone, benadryl and melationin". c. The Plans of Care, dated 8/23/22 to 10/21/22, included orders for ceftriaxone and vancomycin (both prescribed for IV antibiotics) and acetaminophen and Norco (both prescribed for pain). d. The Plans of Care, dated 10/22/22 to 12/20/22 included orders for acetaminophen and Norco (both prescribed for pain). The Drug Regimen Reviews did not identify the duplicate drug therapies ordered on the Plans of Care. 3. Patient #4 had a start of care date of 7/5/22. Clinical record review revealed: a. An Initial comprehensive assessment completed at start of care, dated 7/5/22 and an update to the comprehensive assessment completed at recertification, dated 8/30/22. b. Paper Drug Regimen Review forms, dated 7/5/22 and 8/30/22 addressed all the required components, however identified duplicate drug therapy as "acetaminophen, pregabalin, meloxicam, and tramadol and Montelukast and cetirizine". c. The Plans of Care, dated 7/5/22 to 9/2/22 and 9/3/22 to 11/1/22, included orders for buspirone and venlafaxine (both ordered for mood management). The Drug Regimen Reviews did not identify the duplicate drug therapies ordered on the Plans of Care. The above findings were reviewed with the Clinical/Administrator. Agency staff provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, agency policy review, patient caregiver interview and staff interview, the agency failed to ensure agency staff accurately completed all of the components comprising the Plan of Care for 4 of 7 sampled patients (Patients #1, #2, #3 and #5). Failure to maintain complete and accurate Plans of Care placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 3. Patient #3 had a start of care date of 3/16/21. Clinical record review, home visit observation, and accompanying interviews revealed: a. The Plans of Care, dated 5/10/22 to 7/8/22, 7/9/22 to 9/6/22, and 9/7/22-11/5/22, included orders for Tylenol 325 milligrams (mg) every 4-6 hours for mild to moderate pain. During home visit observation, on 11/1/22 at 10:30 AM, the surveyor observed Staff D, Registered Nurse (RN) review of medications with the patient's caregiver. The caregiver revealed the patient was not taking Tylenol and can’t remember when the patient last used. The caregiver showed the nurse a bottle of Tylenol 500 mg located on the kitchen counter. b. Medication Profile documented Tylenol 325 mg 1 tablet every 4-6 hours prn for mild to moderate pain. The Plans of Care lacked documentation of the correct dosage of Tylenol in the home. During the same home visit observation, on 11/1/22 at 10:30 AM, the surveyor observed Staff D,RN review of medications with the patient's caregiver. The caregiver sets up medications for the patient in a medication planner. The caregiver revealed the patient was not taking Tylenol and can’t remember when the patient last used. The caregiver showed the nurse a bottle of Tylenol 500 mg located on the kitchen counter. c. Medication Profile documented Tylenol 325 mg 1 tablet every 4-6 hours prn for mild to moderate pain. The Plans of Care lacked documentation of the correct dosage of Tylenol in the home. During the same home visit observation, on 11/1/22 at 10:30 AM, the surveyor observed Staff D,RN review of medications with the patient's caregiver. The caregiver sets up medications for the patient in a medication planner. During review a bottle of Metoprolol Succinate 100 mg, filled 9/22/22 qty of 45 tablets, with instructions to take ½ tablet at bedtime. The caregiver revealed the patient has been taking this medication since experienced heart attack 2 years ago. d. The Medication Profile, lacked documentation of Metoprolol Succinate used by the patient. The Plans of Care, dated 5/10/22 to 7/8/22, 7/9/22 to 9/6/22, and 9/7/22-11/5/22 lacked documentation of the Metoprolol Succinate used by the patient. e. The Plan of Care, dated 9/7/22-11/5/22, identified the following equipment and supplies were needed to meet the patient's needs: intramuscular supplies, medication boxes, cane, walker, lifeline, grab bars in bathroom, sharps container, and hearing aides. During the same home visit observation, on 11/1/22 at 10:30 AM, the surveyor observed the patient sitting in a chair in the living room. The patient stood up and the surveyor noted the patient had a donut cushion in the chair. The patient's caregiver revealed the patient's use of the cushion for a month to month and a half due to complaints of a sore tailbone. The caregiver stated the patient has 3 or 4 of them around. The Plans of Care lacked documentation of the cushion as equipment used to meet the patient's needs. f. Plans of Care, dated 5/10/22 to 7/8/22, 7/9/22 to 9/6/22, and 9/7/22-11/5/22, identified the following equipment and supplies were needed to meet the patient's needs: intramuscular supplies, medication boxes, cane, walker, lifeline, grab bars in bathroom, sharps container, and hearing aides. During the same home visit observation, on 11/1/22 at 10:30 AM, the surveyor observed the patient ambulate to the bathroom to assess weight. Located in the bathroom was a talking scale used due to vision problems. The patient revealed having the scale for quite a few years. The Plans of Care lacked documentation of the scale as equipment used to meet the patient's needs. 4. Patient #5 had a start of care date of 4/25/22. Clinical record review revealed: a. The Plans of care, dated 6/24/22 to 8/22/22, 8/23/22 to 10/21/22 and 10/22/22 to 12/20/22, identified the following equipment and supplies were needed to meet the patient's needs: tegaderm foam dressing, tub bench, cane, walker, grab bars in shower/tub area, lift chair, sharps container, INR machine and supplies, wound supplies, incontinence supplies, CPAP, IV med and supplies and added 7/30/22 toilet riser. b. The physical therapy visit notes, dated, 9/27/22 and 10/25/22 documented the patient's use of a grabber. Interview with Staff B, RN on 11/2/22 at 11:33 AM revealed the patient does have a reacher, but was unsure how long the patient has had it, but will add to the POC. Interview with Staff E, Home Care Aide (HCA) on 11/2/22 at 11:45 AM revealed the patient does have a reacher which the patient has had the whole time the aide has been in her home. The aide first provided care for the patient on 5/2/22. The Plans of Care lacked identification of the patient's use of a reacher. c. The skilled nurse visit notes, dated 9/20/22 and 10/5/22 documented the patient's use of soaker pads. Interview with Staff B, RN on 11/2/22 at 11:33 AM revealed the patient does have a reacher soaker pads, but was unsure how long the patient has them, but will add to the POC. Interview with Staff E, Home Care Aide (HCA) on 11/2/22 at 11:45 AM revealed the patient does have a soaker pads which the patient has had the whole time the aide has been in her home. The aide first provided care for the patient on 5/2/22. The Plans of Care lacked identification of the patient's use of a soaker pads. d. The skilled nurse visit notes, dated 9/21/22, 10/3/22 and 10/5/22 included documentation of patient's use of a gel cushion. Interview with Staff B, RN on 11/2/22 at 11:33 AM revealed the patient does have a gel cushion in use and the nurse was unsure how long the patient has hadit, but stated will add to the POC. Interview with Staff E, Home Care Aide (HCA) on 11/2/22 at 11:45 AM revealed the patient does have a gel cushion in use, but is unsure how long the patient has used the gel cushion. The Plans of Care lacked identification of the patient's use of a gel cushion. The surveyors reviewed the above findings with agency Administrator/Clinical Manager. Agency staff provided no additional information prior to the end of the survey. Review of the agency policy, titled Medical Supervision of Patients, dated 10/2020, identified patient care follows a written plan of treatment established and periodically reviewed by a physician. Agency staff deliver care and services under the supervision of a physician. Agency staff review and update the plan of care at least once every 60 days. The plan of care will include services, medications, treatments, medical equipment and supplies. 1. Patient #1 had a start of care date of 10/21/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 10/21/22, identified the patient performed self-catherization on the patient using a 14 French straight urinary catheter. b. The Plan of Care (POC), dated 10/21/22 to 12/19/22, failed to identify the patient used a urinary catheter for medical equipment and supplies. 2. Patient #2 had a start of care date of 8/1/22. Review of the clinical record revealed the following: a. The POCs, dated 8/1/22 to 9/29/22 and 9/30/22 to 11/28/22, included orders for skilled nursing services and included an order for Magnesium Chloride 64 milligrams (mg) 1 tablet 3 times per day. On 10/31/22 at 1:10 PM, in an interview, during a home visit observation with Staff B, RN, the patient reported taking Magnesium Chloride 64 mg 3 tablets 3 times per day since prior to the start of agency services. The POCs incorrectly identified the dose of Magnesium Chloride. b. A skilled nursing documentation note, dated 9/7/22, identified the patient was using an automatic blood pressure machine to measure the patient's own blood pressure. 1) A skilled nursing visit, dated 9/9/22, included documentation the patient reported using the automatic blood pressure machine. 2) The POC, dated 9/30/22 to 11/28/22, identified the patient used the following medical equipment and supplies: wound care supplies, diabetic supplies, compression socks, walker, medication box and heart support pillow. On 10/31/22 at 1:10 PM, during a home visit observation with Staff B, RN, the surveyor observed the patient had an automatic blood pressure machine sitting on the patient's dining room table. Staff B, RN, reviewed the blood pressures the patient had taken using the patient’s machine since the last nursing visit. The POC failed to identify all medical equipment used by 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 policy review, home visit observation and agency staff interview, the agency staff failed to provide care and treatments only as ordered by the physician for 2 of 7 sampled patients (Patients #2 and #3). Failure to ensure staff obtain/follow physician orders for provision of care and treatments placed agency patients at risk for inconsistent care/treatment. Findings include: 2. Patient #3 had a start of care date of 3/16/21. Clinical record review revealed: a. The Plans Of Care, dated 5/10/22 to 7/8/22, 7/9/22 to 9/6/22, and 9/7/22-11/5/22,/22, identified a diagnosis of lumbar region discitis with an additional diagnosis of heart failure and included vital signs reporting parameters of temperature less than 96.0 degrees fahrenheit or greater than 100.4 degrees fahrenheit, pulse less than 50 and greater than 110 beats per minute, Respiratory rate less than 6 or greater than 35 per breaths per minute, BP less than 80/50 or greater than 180/100, pulse ox less than 88% and weight gain of 3 lbs in 1 day or 5 pounds in 1 week. b. The skilled nurse visit notes, dated 9/20/22, 10/4/22, and 10/19/22 lacked identification of the assessment of the patient's weight. The nurse visits lacked documentation of assessment of weight for the nurse to be able to report weights out of parameter to the physician as ordered on the POC. The surveyors reviewed the above findings with agency Administrator/Clinical Manager. Agency staff provided no additional information prior to the end of the survey. Review of the agency policy, titled Medical Supervision of Patients, dated 10/2020, identified patient care follows a written plan of treatment established and periodically reviewed by a physician. Agency staff deliver care and services under the supervision of a physician. Agency staff review and update the plan of care at least once every 60 days. Staff will provide treatment only as ordered by the physician. 1. Patient #2 had a start of care date of 8/1/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 8/1/22 to 9/29/22, included orders for skilled nursing services 2 to 3 times per week and for the nurse to complete wound cares on the left groin by doing a wound vacuum (machine used to apply suction to assist in wound healing) dressing change on Mondays, Wednesdays and Fridays. 1) An interim physician order, dated 9/4/22, included an order for one as needed skilled nursing visit due to issues with the wound vacuum. 2) A skilled nursing visit, dated 9/4/22, a Sunday, included documentation the nurse completed wound cares due to issues with the wound vacuum. 3) The clinical record lacked documentation of a skilled nursing visit on Monday, 9/5/22, and lacked documentation of a physician order to cancel the visit. 4) The clinical record lacked documentation of a skilled nursing visit on a Monday, dated 9/26/22, and lacked documentation of a physician order to cancel the visit. 5) The clinical record included documentation of a skilled nursing visit on Tuesday, dated 9/27/22, which included documentation the nurse performed wound cares with a wound vacuum dressing change. The clinical record lacked documentation of a physician order to change the visit to a Tuesday. b. The POC, dated 9/30/22 to 11/28/22, included orders for wound care to the left groin and left thigh on Mondays, Wednesdays and Fridays. The orders included a wound vacuum dressing change to the left thigh wound and an order to cleanse the left groin wound with soap and water or wound cleanser and apply Mepilex AG (type of wound dressing) and tape. 1) The clinical record included documentation of a routine skilled nursing visit, dated 10/9/22, a Sunday. The nurse documented she completed wound care to the left groin and thigh. The clinical record lacked documentation of a physician order for the nurse to complete a skilled nursing visit on a Sunday to provide wound care treatment. 2) The clinical record lacked documentation of skilled nursing visit on Monday, 10/10/22. The clinical record lacked documentation of an order to cancel or change wound care for the left groin and thigh to a different day. 3) An interim physician order, dated 10/11/22, included an order for one as needed skilled nursing visit due to issues with the wound vacuum. 4) A skilled nursing visit, dated 10/11/22, a Tuesday, included documentation the wound vacuum was alarming. The nurse documented she completed a wound vacuum dressing change to the left thigh and completed a wound care dressing change to the left groin. 5) The clinical record lacked documentation of skilled nursing visit on Wednesday, 10/12/22. The clinical record lacked documentation of an order to cancel the visit on 10/12/22. c. The POC, dated 9/30/22 to 11/28/22, identified a diagnosis of encounter aftercare following a heart transplant and included a health management order for vital sign parameters including reporting to the physician a weight gain of 3 pounds in one day and 5 pounds in a week. The skilled nursing visit notes, dated 10/7, 10/9, 10/11, 10/14, 10/17, 10/19, 10/21, 10/24, 10/26 and 10/28/22, lacked documentation the nurse assessed the patient's weight. On 10/31/22 at 1:10 PM, during a home visit observation, Staff B, Registered Nurse (RN), completed wound cares and an assessment of the patient. Staff B, RN, did not weigh or ask the patient about the patient's weight during the visit. On 11/1/22 at 2:35 PM, during an interview, the Administrator confirmed the patient had a health management order for vital sign parameters including reporting to the physician a weight gain of 3 pounds in one day and 5 pounds in a week for the POC, dated 9/30 to 11/28/22.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and staff interview, the agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 1 of 3 sampled patients with a home visit observation (Patient #1). Failure to follow agency expectations and accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: Review of the agency policy, titled Bag Technique, dated 12/2019, identified staff should perform hand hygiene prior to entering the staff's bag and prior to cleaning reusable patient equipment after use on the patient in order to prevent contamination of the bag and contamination between patients. Staff should clean reusable patient equipment prior to returning the equipment to the bag. Patient #1 had a start of care date of 10/21/22. Review of the clinical record revealed the following: A Plan of Care, dated 10/21/22 to 12/19/22, identified a diagnosis of right wrist drop and included orders for skilled nursing, home health aide, occupational and physical therapy. On 10/31/22 at 2:45 PM, during a home visit observation, Staff C, Occupational Therapist (OT), entered the home, set her bag on a chair and moved chairs around in the patient’s home to set up a place to provide therapy cares. Staff C, OT, reached into an outer pocket on her bag without sanitizing her hands and pulled out a thermometer and pulse oximeter. She used the thermometer to take a forehead temperature reading and placed the used thermometer on the patient’s chair. She placed the pulse oximeter on the patient’s right index finger to measure the patient’s pulse and blood oxygen saturation level. She placed the used pulse oximeter on the patient’s chair next to the thermometer and her bag. Staff C, OT, then sat in a chair next to the patient and performed hand-over-hand exercises on the patient’s right wrist. Staff C, OT, then reached into an inner pocket of her bag without sanitizing her hands and removed an electrical impulse machine (TENS unit) with attached electrodes and a plastic bag with attachable, reusable pads. Staff C, OT, removed 2 pads with adhesive backing from the plastic bag and placed the pads on the patient’s right forearm. She connected wires from the pads to the TENS unit and turned the machine on. The machine provided electrical impulses to the patient’s arm for approximately 7 minutes. Staff C, OT, then disconnected the machine, wrapped the wire and electrodes around the TENS unit and placed the unit on the chair next to her bag. She then removed the pads and placed them back in the plastic bag. She told the patient the pads were the patient’s and she would bring them with her each time she came to work with the patient. She placed the plastic bag with the pads and TENS unit back in the inside pocket of her bag without sanitizing her hands or the machine. She then reached into the outer pocket of her bag, where she had kept the thermometer and pulse oximeter, and pulled out a bag with sanitizing wipes and a bag with gloves. She did not sanitize her hands prior to reaching into the bag. She then donned the gloves and wiped off the thermometer and pulse oximeter prior to placing them back in the outer pocket of the bag. She then reached her gloved hands into the inner pocket of the bag and wiped off the TENS unit without unwrapping the wires. She placed the TENS unit back in the inner pocket of the bag. Staff C, OT, wiped off her clipboard and the outside of her bag, removed her gloves and discarded the gloves and sanitizing wipe. She then used hand sanitizer on her hands. In an interview, during the same home visit observation, Staff C, OT, reported they used the TENS unit for multiple patients. 11/1/22 at 3:40 PM, during an interview, the Administrator reported all staff should be following the bag technique policy. She confirmed Staff C, OT, did not follow policy based on the surveyor’s observation of the home visit. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.