Every finding on record at Home Sweet Home Care

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 2/10/25 to 2/11/25 and the home health agency was found to be operating out of compliance with the requirements of the Establishment of Emergency Preparedness.

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), §485.542(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 emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan that included a process for cooperation and collaboration with local, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency's efforts to contact such officials and of its participation in collaborative and cooperative planning efforts. Failure to have a process for cooperation and collaboration with local, 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's Emergency Preparedness Plan and related policies, the agency failed to address the process for cooperation with state and federal emergency preparedness officials efforts to maintain an integrated response during a disaster or emergency situation. During an interview on 2/11/25 at 1:30 PM, the Assistant Administrator stated she acknowledged the Emergency Preparedness Program failed to address state and federal emergency preparedness officials. The agency failed to have a written policy and procedure for cooperation and collaboration with local, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The above findings reviewed with the Assistant Administrator.

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 the agency emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan that included procedures to inform State and local officials of any on duty staff they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place to inform State and local officials of any on duty staff they are unable to contact in the event of an interruption of services related to an emergency placed agency staff and 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 and related policies identified a lack of procedures 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. During agency staff interview on 2/11/25 at 1:30 PM, the Assistant Administrator verified an inability to find language in the plan to include procedures to inform State officials of on duty staff they are unable to contact and to inform both local and State officials of patients they are unable to contact in the event of an interruption of services related to an emergency. The above findings were reviewed with Assistant Administrator.

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), §485.542(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 to provide documentation 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 including 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: Review of the agency's Emergency Plan and related policies revealed the agency failed to include primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. On 2/11/25 at 1:30 PM, the Assistant Administrator acknowledged the agency's communication plan failed to include 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 above findings were reviewed with the Assistant Administrator.

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 emergency preparedness plan policy review and review of emergency preparedness exercises conducted by the agency, the agency failed to ensure agency staff participated in at least one full scale community emergency preparedness exercise, or if a full scale community exercise was unavailable, then a facility based functional exercise in 2023 or 2024. Failure to conduct or participate in emergency preparedness exercises placed agency patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: Review of the agency's emergency preparedness plan revealed the agency will conduct annual testing of the emergency preparedness program through exercising. Review of agency's testing of the emergency preparedness plan for 2023 and 2024, revealed a lack of documentation of a full-scale community wide exercise, facility wide, mock disaster or table top drill or documentation of an actual event. On 2/11/25 at 1:30 PM, during an interview, the Assistant Administrator reported the agency did not complete any testing of the emergency preparedness plan for the years 2023 or 2024. The agency failed to maintain documentation of an after action report to either an actual event which triggered the activation of their emergency program or a community wide full-scale exercise, or facility wide if a community wide exercise was not available. The above findings reviewed with the Assistant Administrator.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 2/10/25 to 2/11/25. 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 census of 49 patients at the time of the survey, including 3 patients who received services through the Atlantic office and 46 patients who received services through the Clarinda branch office.

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 1 of 2 sampled patients with wounds (Patient #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: According to the agency policy titled Wound Policy, revised 8/23/2016, an initial wound assessment is completed when the area is first discovered and it includes measurements of length by width by depth in centimeters, description of wound bed, surrounding skin, wound edges, drainage, pain, odor and treatment. Follow up assessments are completed weekly and include description of the wound and measurements of length by width by depth in centimeters. During an interview on 2/11/25 at 12:15 PM, Staff C, Clinical Manager stated wounds are measured every skilled nurse visit and wound measurements include length by width by depth in centimeters. Patient #7 had a start of care date of 1/9/25 and a discharge date of 1/20/25. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/9/25 to 3/9/25, identified the patient had diagnoses of pyogenic arthritis, disruption of external operation and atrial fibrillation and included orders for skilled nursing services one time a week. b. The start of care comprehensive assessment, dated 1/9/25, completed by Staff C, Clinical Manager, identified she did not observe patient's wound with new dressing intact. The skilled nurse failed to complete an initial assessment of patient's wound. c. The skilled nurse visit note, dated 1/14/25, completed by Staff E, Registered Nurse (RN), included the following documentation of patient's wound: Wound to right leg has area halfway down the length of the calf with bloody drainage, no odor. The area measures 5 centimeters (cm) by 13 cm. The measurements lacked depth measurement. The agency failed to include accurate and complete comprehensive assessments of wounds. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager.

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 ensure the drug regimen review identified ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #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 effects to the patients. Findings include: 4. Patient #3 had a start of care date of 10/8/2020. Clinical review revealed the following: a. The POCs, dated 11/16/24 to 1/14/25 and 1/15/25 to 3/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease. The POC included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 10/8/2020, completed by Staff F, Registered Nurse, included documentation a DRR was completed and patient demonstrated noncompliance with medication use, as prescribed by physician and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to identify the findings. c. During an observational home visit on 2/10/25 at 3:45 PM with the Clinical Manager, the surveyor noted the patient had the following medications: An interview during the same home visit, the patient stated he/she had the medications an extended time. The identified medications not listed on the patient medication profile. 1.) Aspirin and Caffeine (pain medication) tablet 500 mg/32.5 mg as needed for pain, taken for 10 years. 2.) Rybelsus (diabetic medication) 14 mg 1 tablet daily , taken for 3 months. The agency failed to complete an accurate DRR to include all current medications and results of the adverse findings of the DRR. 5. Patient #4 had a start of care date of 12/18/23. Clinical review revealed the following: a. The POCs, dated 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25, identified the patient had a diagnosis of cerebral palsy. The POC included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 12/18/23, completed by Staff C, Clinical Manager, included documentation a DRR was completed and patient demonstrate noncompliance with medication use, as prescribed by physician and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to identify the findings. The agency failed to complete an accurate DRR to include the results of the findings of the DRR. 6. Patient #6 had a start of care date of 11/18/24 and was discharged from the agency on 1/13/25. Clinical review revealed the following: a. The POC, dated 11/18/24 to 1/16/25, identified the patient had a diagnosis of cerebral palsy. The POC included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 12/18/23, completed by the Clinical Manager, included documentation a DRR was completed and patient demonstrate noncompliance with medication use, as prescribed by physician and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to identify the results of the findings. The agency failed to complete an accurate DRR to include the results of the adverse findings of the DRR. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager. According to the agency policy titled Drug Regimen Review, dated 4/21/14, patient medications will be reviewed for potential adverse side effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. All medications, including over-the-counter medications will be ordered by a physician. During an interview on 2/11/25 at 12:15 PM, Staff C, Clinical Manger, reported drug regimen reviews (DRR) are completed at admission, recertification, resumption of care, discharge and when a new medication is added. 1.Patient #1 had a start of care date of 9/29/22. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/16/25 to 3/16/25, identified the patient had diagnoses of hypertension, gout and peripheral neuropathy and included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 1/15/25, completed by Staff C, Clinical Manager, included documentation a DRR was completed and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. c. During a home observation visit on 2/10/25 at 12:30 PM, Staff C, Clinical Manager, set up patient's medications. The following medication discrepancies were identified: 1) The POC identified the patient takes Melatonin 10 milligrams (mg) orally at bedtime as needed for insomnia. The bottle in the home is Melatonin 5mg tablets. Patient reported he/she takes one tablet as needed for insomnia. 2) The POC identified the patient takes Tylenol 325 mg orally with instructions to take two tablets every 6 hours as needed for pain. The bottle in the home is Extra Strength Pain Relief 500 mg tablets. Patient reported taking two tablets as needed for pain. 3) The POC identified the patient takes Cyclobenzaprine 10 mg orally at bedtime as needed for back pain. The patient reported he/she does not have Cyclobenzaprine in the home and has not taken the medication for several months. The DRR failed to specify what issues were identified and failed to include an accurate list of all medications taken by the patient. 2.Patient #2 had a start of care date of 1/24/25. Clinical record review revealed the following: a. The POC, dated 1/24/25 to 3/24/25, identified the patient had diagnoses of paraplegia, new ostomy and hypertension and included physician orders for medications, skilled nursing services and home health aide services. b. The start of care comprehensive assessment, dated 1/24/25, completed by Staff E, Registered Nurse (RN), included documentation a DRR was completed and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to specify what issues were identified. 3.Patient #7 had a start of care date of 1/9/25 and a discharge date of 1/20/25. Clinical record review revealed the following: a. The POC, dated 1/9/25 to 3/9/25, identified the patient had diagnoses of pyogenic arthritis, disruption of external operation and atrial fibrillation and included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 1/9/25, completed by Staff C, Clinical Manager, included documentation a DRR was completed and potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications have been identified. The DRR failed to specify what issues were identified.

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 visits, patient interviews, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment and all medications and treatments used by the patient for 5 of 7 sampled patients (Patients #1, #2, #4, #5 and #6). 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: 4. Patient #4 had a start of care date of 12/18/23. Clinical review revealed the following: a. The POCs, dated 12/12/24 to 2/9/25 and 2/10/25 to 4/10/25, identified the patient had a diagnosis of cerebral palsy. The POC included the following DME required by the patient: elevated toilet seat, grab bars and shower bench. b. The comprehensive assessment at start of care, dated 12/18/23, identified the patient required the use of a motorized scooter and medication planner. The agency failed to include all DME on the patient's POC including a motorized scooter and medication planner required by the patient. 5. Patient #6 had a start of care date of 11/18/24 and discharged from the agency on 1/13/25. Clinical review revealed the following: a. The POC, dated 11/18/24 to 1/13/25, identified the patient had a diagnosis of diabetes mellitus. The POC included the following DME required by the patient: shower bench, diabetic supplies and suprapubic catheter supplies. b. The comprehensive assessment at start of care, dated 11/18/24, identified the patient required the use of an electric wheelchair and prosthetics. The assessment also identified the patient required the use of a suprapubic catheter. c. The skilled nurse visit note, dated 12/25/24, identified the patient had a #18 French suprapubic catheter in place. d. Review of the medical record lacked orders for the size and balloon size for the suprapubic catheter. The agency failed to include all DME and orders on the patient's POC including an electric wheelchair and prosthetic and suprapubic catheter orders required by the patient. The above findings were reviewed with the Administrator, Assistant Administrator and Clinical Manager. According to the agency policy titled Plan of Care, dated 4/21/14, the plan of care developed in consultation with the physician and agency staff includes but is not limited to all pertinent diagnoses, types of services and equipment, medications and treatments, frequency of visits and functional limitations. Orders for each service must include specific procedures and modalities to be used and the frequency and duration of services. 1.Patient #1 had a start of care date of 9/29/22. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/16/25 to 3/16/25, identified the patient had diagnoses of hypertension, gout and peripheral neuropathy. The POC included the following durable medical equipment (DME) used by the patient: grab bars and shower bench. b. During a home observation visit on 2/10/25 at 12:30 PM with Staff C, Clinical Manager, the surveyor identified the following DME used by the patient: medication cassette, lift chair and glucometer. The patient stated during the same home visit that he/she had the medication cassette, lift chair and glucometer for greater than 3 months. The agency failed to include all DME on the patient's POC including a medication cassette, lift chair and glucometer used by the patient. 2.Patient #2 had a start of care date of 1/24/25. Clinical record review revealed the following: a. The POC, dated 1/24/25 to 3/24/25, identified the patient had diagnoses of paraplegia, new ostomy and hypertension. The POC included the following DME used by the patient: manual wheelchair, motorized wheelchair, trapeze, hospital bed, gloves, drainage bag, catheter leg bag, elevated toilet seat, grab bars, shower bench and ostomy supplies. b. The start of care comprehensive assessment, dated 1/24/25, completed by Staff E, Registered Nurse (RN), identified the patient required use of a suprapubic catheter. c. During a home observation visit on 2/10/25 at 2:00 PM with Staff E, RN, the surveyor identified the following DME used by the patient: reacher device. d. Review of the medical record lacked orders for the size and balloon for the suprapubic catheter. The agency failed to include all DME and orders on the patient's POC including a reacher device and suprapubic catheter orders required by the patient. 3.Patient #5 had a start of care date of 12/3/24. Clinical record review revealed the following: a. The POC, dated 2/1/25 to 4/1/25, identified the patient had diagnoses of chronic obstructive pulmonary disease (COPD), hypertension and non-insulin dependent diabetes mellitus (NIDDM). The POC included orders for medications, treatments, and the following DME used by the patient: medication cassette, cane and diabetic supplies. b. The skilled nurse visit note, dated 2/5/25, completed by Staff D, Licensed Practical Nurse (LPN), identified the patient uses oxygen at 2 liters per nasal cannula as needed. c. Review of the medical record lacked orders for patient's use of oxygen. The agency failed to include all orders on the patient's POC including oxygen orders required 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 home visit observations, agency staff interview, clinical record reviews and agency policy review, the agency failed to follow physician orders for treatments for 4 of 7 sampled patients (Patients #2, #3, #4 and #5). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 3. Patient #3 had a start of care date of 10/8/2020. Clinical record review revealed the following: a. The POCs, dated 11/16/24 to 1/14/25 and 1/15/25 to 3/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nursing visits one time a week. b. The POCs included physician orders for medications and treatments, which included orders to assess the patient's use of glucose measuring and glucometer recordings. c. The skilled nurse visit notes, dated 12/17, 12/24/24, 1/21/25 and 2/6/25, lacked documentation of the patient's glucometer recordings. Agency staff failed to document the glucometer readings every visit. 4. Patient #4 had a start of care date of 12/18/23. Clinical record review revealed the following: a. The POCs, dated 10/13/24 to 12/11/24,12/12/24 to 2/9/25 and 2/10/25 to 4/10/25, identified the patient had a diagnosis of cerebral palsy and included orders for skilled nursing visits two times a week. The POCs included the order for vitamin D supplement 5,000 units daily. b. The POCs included physician orders for medications and treatments, which included orders for the skilled nurse to set up the patients medications every week. The POCs included the order for vitamin D supplement 5,000 units daily. c. The verbal order, dated 10/2/24, included physician's order to decrease the vitamin D3 from 50,000 units daily to 5,000 units daily. d. The verbal order, dated 1/20/25, identified physician notification the pharmacy continued to supply vitamin D3 50,000 units. The physician ordered vitamin D3 5,000 units and to draw a vitamin D3 level due to 6 weeks on the wrong vitamin D3 therapy. c. The verbal order, dated 1/30/25, identified physician notification the skilled nurse attempted the vitamin D3 level laboratory draw and unable due to patient not cooperating. The physician ordered the patient to have lab draw at the medical clinic. d. During an interview on 2/11/25 at 11:55 AM the Clinical Manager stated the patient had not gone to the medical clinic for a lab draw due to lack of transportation and weather caused the inability to use his/her motorized scooter. Agency staff failed to document the glucometer readings every visit. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager. According to the agency policy titled Plan of Care, dated 4/21/14, the plan of care developed in consultation with the physician and agency staff includes but is not limited to all pertinent diagnoses, types of services and equipment, medications and treatments, frequency of visits and functional limitations. Orders for each service must include specific procedures and modalities to be used and the frequency and duration of services. 1.Patient #2 had a start of care date of 1/24/25. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/24/25 to 3/24/25 identified the patient had diagnoses of paraplegia, new ostomy and hypertension and included orders for skilled nursing services three times a week. b. The POC included physician orders for medications and treatments, which included the following wound care orders: complete wound care three times a week, moisten dry gauze with 1/4 strength vashe or dakins, pack into wound leaving tail for easy removal. Cover with abdominal pad and skin friendly tape. c. During on home observation visit on 2/10/25 at 2:00 PM, surveyor observed Staff E, Registered Nurse (RN) performing the following wound care: Staff E, RN irrigated patient's wound with 6 cubic centimeters (cc) of normal saline, moistened gauze with vashe, applied calmoseptine, packed wound with dry gauze and left tail out, covered would with abdominal pad and secured with skin friendly tape. Agency staff failed to provide wound care only as ordered by the physician. 2.Patient #5 had a start of care date of 12/3/24. Clinical record review revealed the following: a. The POCs, dated 12/3/24 to 1/31/25 and 2/1/25 to 4/1/25 identified the patient had diagnoses of chronic obstructive pulmonary disease, hypertension and non-insulin dependent diabetes mellitus and included orders for skilled nursing visits two times a week. b. The POCs included physician orders for medications and treatments, which included orders to notify physician of systolic blood pressure greater than 140 or less than 100, diastolic blood pressure greater than 90 or less than 60 and blood glucose level greater than 145 or less than 70. c. The skilled nurse visit note, dated 12/9/24, completed by Staff D, Licensed Practical Nurse (LPN), included documentation the patient had a blood pressure (BP) of 142/80 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled visit note lacked documentation of the patient's blood glucose level. d. The skilled nurse visit notes, dated 12/12/24, 12/16/24 and 12/19/24, completed by Staff D, LPN, lacked documentation of the patient's blood glucose level. e. The skilled nurse visit note, dated 12/23/24, completed by Staff D, LPN, included documentation the patient had a BP of 142/82 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled nurse visit note lacked documentation of the patient's blood glucose level. f. The skilled nurse visit note, dated 12/26/24 completed by Staff C, Clinical Manager, included documentation the patient had a BP of 163/90 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled nurse visit note lacked documentation of the patient's blood glucose level. g. The skilled nurse visit notes, dated 12/30/24 and 1/2/25, completed by Staff D, LPN, lacked documentation of the patient's blood glucose level. h. The skilled nurse visit note, dated 1/5/25, completed by Staff D, LPN, included documentation the patient had a BP of 142/80 but lacked documentation the physician was notified of the BP that fell outside parameters set. The skilled nurse visit note lacked documentation of the patient's blood glucose level. i. The skilled nurse visit notes, dated 1/9/25, 1/13/25, 1/16/25, 1/20/25, 1/23/25, 1/27/25 and 2/3/25, completed by Staff D, LPN, lacked documentation of the patient's blood glucose level. The agency staff failed to notify the physician of vital sign readings that fell outside parameters set and failed to document patient's blood glucose levels each visit.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to assure nurses taking verbal orders from a physician documented the orders in the clinical record (signed, dated and timed) sending the orders to the physician for authentication, including signature and date of signature for 1 of 7 sampled patients (Patients #6). Failure to document physician orders taken into patient clinical records placed the patient at risk for inappropriate, inadequate care resulting in potential injury or harm. Findings include: According to the agency policy, titled Interim (Verbal Orders), dated 4/21/14, when verbal orders for care are given by the patient's physician, a record of the orders will be immediately written on the agency's physician interim order form. The original will be sent to the physician for signature within 30 days and a copy will remain in the active chart. When the order is returned, the copy is removed and the original filed in the chart. During an interview on 2/11/25 at 12:15 PM the Clinical Manager stated interim physician orders are printed and put in the patient's chart. If there is an update to the plan of care (POC), it is put in the computer on the POC, printed and put in the patient's chart. Patient #6 had a start of care date of 11/18/24 and discharged from the agency on 1/13/25. Clinical record review revealed: a. The POC, dated 11/18/24 to 1/16/25, identified the patient had a diagnosis of Diabetes Mellitus. The POC included orders for skilled nursing services. b. The skilled nurse visit note, dated 11/25/24, Staff E, Registered Nurse, identified the patient started a new medication Cefadroxil (antibacterial) 500 milligrams 2 times a day for 7 days. c. Review of the clinical record lacked documentation of a verbal order for the medication Cefadroxil. The agency failed to include verbal orders for all medications required by the patient. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager.

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 home visit observation, clinical record review and agency policy review, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 1 of 3 sampled patients (Patient #2) with home visits. Failure to follow accepted standards of practice for infection control may put the patient at risk for receiving unsafe care or care that allows the spread of infection. Findings include: According to the agency policy titled Control of Infection Sources, dated 4/21/14, staff place bags taken into the home on a barrier. Equipment is cleaned prior to patient use, before returning to bag after patient use and stored in Ziplock bags in the nursing bag. Patient #2 had a start of care date of 1/24/25 and received services from the Clarinda office. 1.The Plan of Care (POC), dated 1/24/25 to 3/24/25 identified the patient had diagnoses of paraplegia, new ostomy and hypertension and included orders for skilled nursing services three times a week. 2.During a home visit observation on 2/10/25 at 2:00 PM, with Staff E, Registered Nurse (RN), the surveyor observed equipment for vital signs assessment placed on a clean barrier. Staff E assessed the patients vital signs. After use, Staff E placed the contaminated equipment back on the barrier and placed the thermometer in her scrub shirt pocket. Staff E set up a clean workspace to provide wound care in patient's bedroom. Staff E utilized scissors to cut gauze, placed the scissors on clean barrier, used the scissors to cut another piece of gauze and placed scissors in her scrub shirt pocket. Staff E measured wound using a tape measure (not disposable) and placed tape measure in her scrub shirt pocket after use. At end of the visit, Staff E placed all blood pressure cuff, stethoscope, pulse oximeter (electronic device used to monitor blood oxygen saturation and heart rate) back in nursing bag without sanitizing the items. The tape measure, scissors and thermometer remained in Staff E's pocket. Staff E, RN, failed to sanitize all contaminated items prior to returning them to nursing bag. The above findings were reviewed with the Administrator, Assistant Administrator and Clinical Manager.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 1 of 2 sampled patients with transfers/ discharges (Patient #6). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy titled, Transfer of Home Health Patients, last revised 4/21/14, when the overall medical condition or living situation of the patient dictates that the agency's skills and services are no longer sufficient to provide the necessary care, the agency shall notify the attending physician of such. He and/or the responsible party shall make the final determination whether the patient should be transferred to a hospital or other home care facility. During an interview on 2/11/25 at 11:58 AM Staff C, Registered Nurse (RN) stated she generally filled out the transfer summary and it would be sent to the physician. She further stated she had not sent a transfer summary to the receiving facility. Patient #6 had a start of care date of 11/18/24 and discharged from the agency on 1/13/25. Clinical record review revealed: a. The POC, dated 11/18/24 to 1/16/25, identified the patient had a diagnosis of Diabetes Mellitus. The POC included orders for skilled nursing services. b. An interim physician's order, dated 1/13/25, ordered to transfer the patient to a higher level of care (nursing home). c. A home health transfer summary completed by the Staff C, RN, dated 1/13/25, included identification the patient transferred to the hospital and the summary sent to the primary care physician. The agency failed to send the transfer summary and discharge summary to the receiving nursing home. The above findings reviewed with the Administrator, Assistant Administrator and Clinical Manager.

The recertification survey, conducted from 6/27/22 through 6/29/22, identified the following standard level deficiencies 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 agency policy review 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 home health 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 clinic's failure to identify a hazard, complete a risk assessment, and develop strategies for addressing emergency events. Findings include: Review of the agency's Emergency Preparedness Plan and related policies, revealed the plan did not include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. During an interview on 6/29/22 at 8:50 AM, the Assistant Administrator reported the agency did not have documentation of a facility-based and community-based risk assessment. 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 above finding was reviewed with the Assistant Administrator. The agency provided no further information prior to the end of the survey

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and related policies and staff interview, the agency failed to ensure the emergency preparedness program addressed the continuity of operations including delegation of authority and succession plans. Failure to ensure the agency's emergency preparedness program addressed the continuity of operations including delegations of authority and succession plans placed agency staff at risk for not knowing how to address emergency situations and who to go to if immediate agency leadership was not available. Findings include: Review of the agency's Emergency Preparedness Plan and related policies, the agency failed to address the contingency of operations including delegations of authority and succession plans. During an interview on 6/29/22 at 8:50 AM, the Assistant Administrator stated she acknowledged the Emergency Preparedness Program failed to address the continuity of operations. The above finding was reviewed with the Assistant Administrator. No further information was received 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 emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan that included a process for cooperation and collaboration with local, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency's efforts to contact such officials and of its participation in collaborative and cooperative planning efforts. Failure to have a process for cooperation and collaboration with local, 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's Emergency Preparedness Plan and related policies, the agency failed to address the process for cooperation with state and federal emergency preparedness officials efforts to maintain an integrated response during a disaster or emergency situation. During an interview on 6/29/22 at 8:50 AM, the Assistant Administrator stated she acknowledged the Emergency Preparedness Program failed to address state and federal emergency preparedness officials. The agency failed to have a written policy and procedure for cooperation and collaboration with local, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or 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 the agency emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan that included procedures to inform State and local officials of any on duty staff 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 on duty staff they are unable to contact in the event of an interruption of services related to an emergency placed agency staff and 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 and related policies identified a lack of procedures 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. During agency staff interview on 6/29/22 at 8:50 AM, the Assistant Administrator verified an inability to find language in the plan to include procedures to inform State officials of on duty staff they are unable to contact and to inform both local and State officials of patients they are unable to contact in the event of an interruption of services related to an emergency. The above stated findings were reviewed with the agency Assistant Administrator and the agency provided no additional 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), §485.625(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):] 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 hospice failed to ensure the development of a policy and procedure for a medical documentation system that preserves patient information and confidentiality of patient information. Failure to have the development of a policy which outlines the procedures in place for preservation of patient information and confidentiality of patient information place patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the review of the Emergency Preparedness Plan and related policies revealed the home health 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 6/29/22 at 8:50 AM, the Assistant Administrator reported she was unable to find a policy for the above concern. The above stated findings were reported to the Assistant Administrator and the agency provided no further information prior to the end of the survey.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on agency policy review and staff interview, the home health agency failed to develop an Emergency Preparedness communication plan that includes name and contact information of staff and patient healthcare practitioners. Failure to ensure an EP communication plan is developed and implemented could lead staff failing to effectively communicate in the event of an emergency which could potentially place patients, staff and visitors in harm's way due to broken lines of communication. Findings include: Review of the review of the agency's Emergency Preparedness Plan and related policies revealed the agency did not have a written policy and procedure for communication plan that includes name and contact information of staff and patient healthcare practitioners. During an interview on 6/29/22 at 8:50 AM, the Assistant Administrator reported she was unable to find a policy for the above concern. The above stated findings were reported to the Assistant Administrator and the agency provided no further information prior to the end of the survey.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and related policies and staff interview, the agency's emergency preparedness communication plan failed to include contact information for state and federal official emergency staff. Failure to ensure the emergency preparedness communication plan included contact information for state and federal officials and other sources of assistance could lead to a lack of communication and poor patient outcomes in the event of an emergency/disaster. Findings include: Review of the agency's Emergency Preparedness Plan and related policies revealed the agency did not have a policy which included contact information for state and federal official emergency staff. During on 6/30/22 at 8:50 AM, the Assistant Administrator concurred the communication plan included contact information for local and regional emergency officials, but not for State and Federal emergency preparedness staff. The above finding was reviewed with the Assistant Administrator. No further information was received 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: Review of the agency's Emergency Plan and related policies the agency failed to include primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies. On 6/29/21 at 8:50 AM, the Assistant Administrator acknowledged the agency's communication plan failed to include 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 Assistant Administrator received the above stated findings. The agency provided no further information prior to the end of the 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), §485.625(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. Findings include: 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 6/30/21 at 8:50 AM, the Assistant 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 Assistant Administrator received the above stated findings. The agency provided no further information prior to the end of the survey.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. 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 communication plan that included a means of providing information about the agency's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Failure to develop and maintain an emergency preparedness communication plan that included a means of providing information about the agency's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, 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 means of providing information about the agency's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. On 6/30/21 at 8:50 AM, the Assistant Administrator acknowledged the agency's communication plan failed to include a means of providing information about the agency's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The Assistant Administrator received the above stated findings. 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 emergency preparedness plan policy review and review of emergency preparedness exercises conducted by the agency, the agency failed to ensure agency staff participated in at least one full scale community emergency preparedness exercise, or if a full scale community exercise was unavailable, then a facility based functional exercise in 2020 or 2021. Failure to conduct or participate in emergency preparedness exercises placed agency patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: Review of the agency's emergency preparedness plan revealed a lack of direction for the need and frequency to complete testing of the agency's plan. Review of agency's testing of the emergency preparedness plan for 2020 revealed a lack of documentation of a full-scale community wide exercise, facility wide, mock disaster or table top drill or documentation of an actual event. On 6/29/22 at 8:50 AM, during an interview, the Assistant Administrator reported did a facility wide table top exercise on 9/15/2020 with the local health department. She provided documentation of a training, titled Covid 19 and Emergency Preparedness, dated 9/15/2020. The training information provided did not include documentation of an actual exercise performed. The information provided lacked documentation of an after action report which evaluated the agency response to the exercise. The Assistant Administrator reported they did have an actual event which triggered the agency's full response to Covid 19, but did not complete an after action report. She reported the agency did complete a table top drill in 2021, and provided evidence of this. The agency failed to maintain documentation of an after action report to either a an actual event which triggered the activation of their emergency program or a community wide full-scale exercise, or facility wide if a community wide exercise was not available. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

The recertification survey for 42CFR 484 Home Health Conditions of Participation, conducted 6/27/22 through 6/29/22, found the agency operating out of compliance with the following standard level deficient practices. The agency reported a current census of 8 patients in the Atlantic parent office and 52 patients in the Clarinda branch office at the time of the recertification 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 , home visit observation, patient and staff interview, the agency failed to assess each patients medications for duplication, side effects, ineffectiveness, actual or potential interactions and non-compliance within the required time frames, identifying medication discrepancies, as part of the initial comprehensive assessment at admission and as part of the updates to the comprehensive assessment at the time of recertification, resumption of care and discharge for 3 of 7 sampled patients (Patients #1, #3 and #4). Failure to identify actual/ potential issues at the time of each comprehensive assessment increased the potential for unidentified medication interactions and side effect risks to the patient. Findings Include: According to the agency policy titled Drug Regimen Review, dated November, 1996, a drug regimen review will be completed by an RN at the time of each comprehensive assessment within the 5 day window. The RN will review medications for potential adverse side effects and dug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy with the patients every 60 days. During an interview on 6/29/22 at 10:40 AM, the Clinical Manager stated the Registered Nurse (RN) completes the drug regimen review (DRR) with comprehensive assessments and upon receipt of new medication orders. 1. Patient #4 had a start of care date of 10/22/18 and received agency services from the branch office. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 4/4/22 to 6/2/22 and 6/3/22 to 8/1/22, included physician orders for medications and skilled nursing services 1 time per week. b. A DRR completed with the update to the comprehensive assessment at the time of recertification, dated 6/3/22, included a review by the patient's nurse of the patient's medication regimen. On 6/28/22 at 11:30 AM, in an interview, during a home visit observation with the patient and Staff D, Licensed Practical Nurse, the patient reported staff set up the patient's medications. The patient reported the following medications discrepancies: a. The POC included an order for Tramadol (for pain) 50 milligrams (mg) 1 tab by mouth daily. The patient reported not taking Tramadol since at least 4 months prior. The DRR, dated 6/3/22, incorrectly included a review of this medication by the patient's nurse. b. The POC included an order for Methylprednisolone (for inflammation) per package instructions effective 5/28/22. The patient reported the medication completed and no longer taking. The DRR, dated 6/3/22, included Methylprednisolone 4 mg but failed to include the specific physicians orders. c. Staff D stated the medication included specific orders from the physician for tapering and had been completed. c. The POC included an order for Zofran 4 mg 1 tab by mouth every 4 hours as needed for nausea. The patient reported not taking the medication and did not recall ever taking it. The DRR, dated 6/3/22, incorrectly included a review of this medication by the patient's nurse. 2. Patient #1 had a start of care date of 1/14/21 and received agency services from the parent office. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 3/10/22 to 5/8/22 and 5/9/22 to 7/7/22, included physician orders for medications and skilled nursing services 2 times per week. b. A DRR completed with the update to the comprehensive assessment at the time of recertification, dated 5/6/22, included a review by the patient's nurse of the patient's medication regimen. On 6/29/22 at 11:15 AM, in an interview, during a home visit observation with the patient and Clinical Manager, the patient reported setting up and administering the patient's own medications. The patient reported the following medications discrepancies: a. The POC included an order for Potassium Chloride 8 milliequivalents 1 tab by mouth daily. The patient reported not taking Potassium since 3/24/22 per physician order. The DRR, dated 5/6/22, incorrectly included a review of this medication by the patient's nurse. b. The POC included an order for Fiber 3 capsules by mouth 2 times per day. The patient reported not taking the Fiber capsules for more than a year. The DRR, dated 5/6/22, incorrectly included a review of this medication by the patient's nurse. c. The POC included an order for Claritin 10 mg 1 tab by mouth daily for allergies. The patient reported not taking the Claritin for a couple years. The DRR, dated 5/6/22, incorrectly included a review of this medication by the patient's nurse. d. The POC included an order for Sucralfate 1000 mg 1 tab by mouth 4 times per day. The patient reported not taking the Sucralfate for the last couple months due to a side effect of coating the patient's throat and increasing swallowing difficulties. The DRR, dated 5/6/22, failed to identify the patient stopped taking this medication due to experiencing side effects and an adverse reaction to taking the medication. e. The patient reported taking Diphenhydramine 25 mg 1 tab daily by mouth for allergy symptoms and an extra dose as needed for symptoms relief for more than a year. The DRR, dated 5/6/22, failed to include a review of this medication by the nurse. f. The patient reported using a Duoneb solution via nebulizer treatment as needed up to 3 times per day per physician order since 3/24/22. The DRR, dated 5/6/22, failed to include a review of this medication by the nurse. 2. Patient #3 had a start of care date of 1/26/22 and received home health services from the branch office. Review of the clinical record revealed the following: a. The POCs, dated 3/27/22 to 5/22/22 and 5/26/22 to 7/24/22, included physician orders for medications and skilled nursing services 2 times per week. b. A DRR completed with the update to the comprehensive assessment at the time of recertification, dated 5/25/22, included a review by the patient's nurse of the patient's medication regimen. On 6/28/22 at 11:35 AM, during a home visit observation with the patient and Staff J, Clarinda Office RN, Staff J set up the patient's medications and both the patient and and Staff J reported the following medication discrepancies: 1) Staff J, Clarinda Office RN, set up Baclofen 10 mg 1 tab every morning and 2 tabs every evening and reported a prescription start date on the pill bottle, dated 3/25/22. The DRR, dated 5/25/22, failed to include a review of this medication by the nurse. 2) Staff J, Clarinda Office RN, set up Pantoprazole 40 mg 1 capsule by mouth daily and reported a start date for the medication of 2/22/22. The DRR, dated 5/25/22, failed to include a review of this medication by the nurse. 3) The patient reported using a Symbicort inhaler 2 puffs twice per day since 2009 and a Ventolin inhaler 2 puffs 4 times per day as needed for the last 3 years. The DRR, dated 5/6/22, failed to include a review of these medication by the nurse. The Assistant Administrator received the above findings and agency staff provided no further 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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #6 and #7). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. According to the agency policy titled Plan of Care, last revised 4/21/14, orders for each service must include the specific procedures and modalities to be used and the frequency and duration of services. During an interview on 6/29/22 at 10:40 AM the Clinical Manager stated office staff track missed visits on a sheet and will then write up an order to the Doctor to cancel the visits. The staff try to write the orders every couple of days. 1. Patient #1 had a start of care date of 4/19/22 and received agency services from the parent office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/19/22 to 6/17/22, included physician orders for skilled nursing services 2 times per week. b. The physicians order, dated5/12/22 included documentation the patient since admit, only allowed the skilled nurse to do visit 1 time on 4/28/22. c. The weeks of 5/15, 5/22, 5/29 and 6/5/22 lacked documentation of any skilled nurse visits. d. The clinical record lacked documentation of physician notification of the missed skilled nurse visits for the weeks of 5/15, 5/22, 5/29 and 6/5/22. 2. Patient #4 had a start of care date of 10/22/18 and received agency services from the branch office. Review of the clinical record revealed the following: a. The POC, dated 4/4/22 to 6/2/22 and 6/3/22 to 8/1/22, included physician orders for home health aide services 2 times per week. b. The week of 5/29/22 included documentation of only 1 home health aide visit on 6/3/22. c. The clinical record lacked documentation of physician notification of the missed home health aide visit for the weeks of 5/29/22 . 3. Patient #6 had a start of care date of 6/9/14 and received agency services from the branch office and had a discharge date of 3/25/22. Review of the clinical record revealed the following: a. The POC, dated 12/28/21 to 2/25/22 and 2/26/22 to 4/26/22, included physician orders for skilled nursing services 2 times per week and home health aid 4 to 5 times a week. b. The physicians order, dated 1/24/22 included orders to increase skilled nurse visits to 3 times a week through the remainder of the certification period b. The week of 1/23/22 included documentation of only 2 skilled nurse visits, 1/24 and 1/26/22. c. The clinical record included documentation of only 2 skilled nurse visits, 2/7 and 2/11/22. d. The clinical record lacked documentation of physician notification of the missed skilled nurse visits for the weeks of 1/23 and 2/6/22. 4. Patient #1 had a start of care date of 1/14/21 and received agency services from the parent office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/9/22 to 7/7/22, included physician orders for home health aide services 2 times per week. b. The week of 6/5/22 included documentation of only one home health aide visit, dated 6/6/22. c. The clinical record lacked documentation of physician notification of the missed home health aide visit for the week of 6/5/22. 5. Patient #3 had a start of care date of 1/26/22 and received agency services from the branch office. Review of the clinical record revealed the following: a. The POC, dated 3/27/22 to 5/22/22, included physician orders for home health aide services five times per week. b. The week of 5/1/22 included documentation of 3 completed home health aide visits, dated 5/4, 5/5 and 5/6/22, and one canceled home health aide visit, dated 5/2/22. The clinical record lacked documentation of another provided or canceled visit for the week of 5/1/22. The clinical record lacked documentation of physician notification of a second missed home health aide visit for the week of 5/1/22. 6. Patient #7 had a start of care date of 9/4/12, received home health services from the branch office and discharged from agency services on 1/8/22. Review of the clinical record revealed the following: a. The POC, dated 11/16/21 to 1/14/22, included physician orders for skilled nursing visits 3 times per week. b. The week of 11/21/21 included documentation of only one skilled nursing visit, dated 11/24/21. c. The clinical record lacked documentation of physician notification of the 2 missed skilled nursing visits the week of 11/21/21. On 6/28/22 at 2:50 PM, during an interview, the Assistant Administrator reported agency staff notified the physician of missed visits weekly. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used to meet the needs of the patient for 4 of 7 sampled patients (Patients #1, #3 and #7). 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: According to the agency policy titled Plan of Care, last revised 4/21/14, the plan of care developed in consultation with the physician and agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognoses, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral and any other appropriate items. 1. Patient #2 had a start of care date of 4/19/22 and received services from the parent office. Clinical record review revealed the following: a. The Plan of Care (POC), dated 4/19/22 to 6/17/22, identified the following as medical equipment and supplies used by the patient: cane, walker and grab bars. b. The comprehensive assessment at the start of care, dated 4/19/22 included documentation the patient utilized the following medical equipment and supplies: glucometer, diabetic supplies, urinal oxygen sensor, wheelchair, tub/shower chair and ace wraps. The POC lacked inclusion of the glucometer, diabetic supplies, urinal oxygen sensor, wheelchair, tub/shower chair and ace wraps as equipment used by the patient to meet his/her needs. 2. Patient #1 had a start of care date of 1/14/21 and received agency services from the parent office. Review of the clinical record revealed the following: The Plan of Care (POC), dated 5/9/22 to 7/7/22, included physician orders for medications and skilled nursing services 2 times per week. On 6/29/22 at 11:15 AM, in an interview, during a home visit observation with the patient and Clinical Manager, the patient reported setting up and administering the patient's own medications. The patient reported the following medication discrepancies: a. The POC included an order for Potassium Chloride 8 milliequivalents (meq) 1 tab by mouth daily. The patient reported not taking Potassium since 3/24/22 per physician order. b. The patient reported taking Magnesium 400 milligrams (mg) 1 tab by mouth daily since 3/24/22 per physician order. The POC failed to include an order for the Magnesium. c. The POC included an order for Fiber 3 capsules by mouth 2 times per day. The patient reported not taking the Fiber capsules for more than a year. d. The POC included an order for Claritin 10 mg 1 tab by mouth daily for allergies. The patient reported not taking the Claritin for a couple years. e. The POC included an order for Vitamin D 1 tab by mouth daily. The order failed to specify a dosage amount. The patient reported taking Vitamin D3 5000 units one cap daily by mouth. f. The POC included an order for Sucralfate 1000 mg 1 tab by mouth 4 times per day. The patient reported not taking the Sucralfate for the last couple months due to a side effect of coating the patient's throat and increasing swallowing difficulties. g. The patient reported taking Diphenhydramine 25 mg 1 tab daily by mouth for allergy symptoms and an extra dose as needed for symptoms relief for more than a year. The POC failed to include an order for this medication. h. The patient reported using a Duoneb solution via nebulizer treatment as needed up to 3 times per day per physician order since 3/24/22. The POC failed to include an order for this medication or identify the patient used a nebulizer for medical equipment. i. The POC included an order for Ferrous Sulfate 625 mg orally 2 times per day. The patient reported taking Ferruos Sulfate 325 mg 1 tab by mouth daily for the last 3 to 4 months. The POC failed to include accurate information. 3. Patient #3 had a start of care date of 1/26/22. Review of the clinical record revealed the following: a. The patient had a POC, dated 3/27/22 to 5/22/22, and a subsequent POC, dated 5/26/22 to 7/24/22. The patient received a skilled nursing visit, dated 5/25/22 without an order for services to cover the visit due to the POC, dated 3/27/22 to 5/22/22, ending 3 days early. On 6/28/22 at 2:50 PM, during an interview, the Assistant Administrator acknowledged the POC, dated 3/27/22 to 5/22/22, had an incorrect ending date for the certification period. b. The POCs, dated 1/26/22 to 3/26/22, 3/27/22 to 5/22/22 and 5/26/22 to 7/24/22, identified the patient used a CPAP (Continuous Positive Airway Pressure) Machine. The POCs identified the had oxygen safety precautions in place, but lacked an order for oxygen. 1) The comprehensive assessment completed by the RN, dated 1/26/22, identified the patient used a CPAP machine with 4 liters of oxygen at night. 2) The skilled nursing visits, dated 4/7 and 6/16/22, identified the patient used a BiPAP (machine that delivers airway pressure on inhale and exhale) with 4 liters of oxygen at night. On 6/28/22 at 11:35 AM, in an interview, during a home visit observation with Staff J, Clarinda Office RN, the patient reported using a BiPAP machine with 4 liters of oxygen at night. The POCs failed to include an order for the oxygen use and failed to correctly identify the medical equipment used by the patient. c. The POC, dated 5/26/22 to 7/24/22, included physician orders for medications and skilled nursing services 2 times per week. On 6/28/22 at 11:35 AM, during a home visit observation with the patient and Staff J, Clarinda Office RN, Staff J set up the patient's medications and both the patient and and Staff J reported the following medication discrepancies: 1) Staff J, Clarinda Office RN, set up Abilify 15 mg 1 tab by mouth daily and reported the patient's prescription changed from 20 mg to 15 mg daily on 3/29/22 according to the label on the pill bottle. The POC had an order for 20 mg 1 tab by mouth daily. 2) Staff J, Clarinda Office RN, set up Tylenol 500 mg 2 tabs twice per day scheduled. The POC included orders for Tylenol 500 mg 2 tabs 3 times per day as needed. The patient reported taking Tylenol 500 mg 2 tabs scheduled daily and not as needed. 3) Staff J, Clarinda Office RN, set up Linzess 290mg 1 tab daily scheduled. The POC included orders for Linzess 290 mg 1 tab daily as needed. The patient confirmed taking this medication as a daily scheduled medication and not as needed. 4) Staff J, Clarinda Office RN, set up Baclofen 10 mg 1 tab every morning and 2 tabs every evening and reported a prescription start date on the pill bottle, dated 3/25/22. The POC failed to include an order for the Baclofen. 5) Staff J, Clarinda Office RN, set up Pantoprazole 40 mg 1 capsule by mouth daily and reported a start date for the medication of 2/22/22. The POC failed to include an order for the Pantoprazole. 6) The patient reported using a Symbicort inhaler 2 puffs twice per day since 2009 and a Ventolin inhaler 2 puffs 4 times per day as needed for the last 3 years. The POC lacked orders for the inhalers. 7) The patient administering a self injection of Trulicity 3mg 1 time per week on Sundays. Staff J, Clarinda Office RN, confirmed the 3mg dosage and a start date on the medication prescription of 4/19/22. The POC included an order for Trulicity 1.5 mg injection subcutaneously one time per week. 4. Patient #7 had a start of care date of 9/4/12, received home health services from the branch office and discharged from agency services on 1/8/22. Review of the clinical record revealed the following: The POC, dated 11/16/21 to 1/14/22, included physician orders for oxygen via nasal cannula and titrate oxygen to keep blood oxygen saturation levels above 92 percent. The orders failed to identify a specific liter amount or range of liter amount to use. On 6/28/22 at 2:50 PM, during an interview, the Assistant Administrator confirmed the POC should have included a liter per minute amount or range of liters per minute. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

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, patient and staff interview, the agency failed to ensure staff provide services, medications and treatments only as ordered by the physician and per the Plan of Care for 3 of 7 sampled patients (Patients #1, #3 and #7). Failure to ensure staff obtain/follow physician orders for services, administration of medications and treatments placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency policy, titled Plan of Care, dated 4/21/14, identified agency staff develop the Plan of Care in consultation with the physician and includes the patient's medications and treatments. On 6/29/22 at 10:40 AM, during an interview, the Clinical Manager reported if she observed the patient was using oxygen at a rate not ordered by the physician, she would found out why the patient was using the oxygen at a different rate, educate the patient on the proper use and contact the physician to determine if the ordered rate needed to be adjusted. She was unaware of the need to have a physician order to set up patient medications. 1. Patient #1 had a start of care date of 1/14/21 and received agency services from the parent office. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 3/10/22 to 5/8/22 and 5/9/22 to 7/7/22, identified diagnoses of chronic obstructive pulmonary disease and hypertension (high blood pressure). The POCs included an order for oxygen at 3 liters per minute continuously via nasal cannula and the following physician orders for the skilled nurse: monitor the patient's respiratory status and report systolic blood pressure measuring above 160. b. A skilled nursing visit note, dated 4/15/22, included documentation the patient used oxygen at 4 liters per minute and up to 6 liters per minute while bathing. c. A skilled nursing visit note, dated 4/18/22, included documentation the patient used oxygen at 4 liters per minute. d. The skilled nursing visit notes, dated 4/19, 4/25, 4/28, 5/3, 5/6, 5/10, 5/12 and 5/17/22, included documentation the patient used oxygen at a rate of 3 to 4 liters per minute. e. A communication note, dated 5/17/22, included documentation the nurse notified the patient's physician the patient had an increased cough the last 2 days, diminished lung sounds, low blood pressure, blood oxygen saturation level of 94 percent and was using oxygen at 4 liters per nasal cannula. The clinical record lacked documentation the physician gave a return order based on the information provided. The clinical record lacked documentation the nurse educated the patient on following the physician orders for oxygen use or attempted to contact the physician prior to 5/17/22 to notify the physician of the patient's use of oxygen at a higher rate. f. The skilled nursing visit, dated 6/6/22, included documentation the patient used oxygen at 4 liters per minute constantly and up to 6 liters per minute with exertion. The visit note lacked documentation the nurse contacted the patient's physician about the increase in use of oxygen or provided the patient with education on following physician orders. The visit note included documentation the nurse assessed the patient had a systolic blood pressure of 168, but lacked documentation of physician notification per the patient's POC. On 6/29/22 at 11:15 AM, in an interview, during a home visit observation with the Clinical Manager, the patient reported use of oxygen at 4 liters per minute. 2. Patient #3 had a start of care date of 1/26/22 and received agency services from the branch office. Review of the clinical record revealed the following: The POCs, dated 3/27/22 to 5/22/22 and 5/26/22 to 7/24/22, identified the patient was a hospital risk due to a diagnosis of congestive heart failure (condition associated with fluid retention and weight gain) and included physician orders for skilled nursing services 2 times per week. The POCs included orders for the skilled nurse to report variations in the patient's weight of 3 pounds in 1 day and 5 pounds in a week. 1) A skilled nursing visit, dated 4/28/22, included documentation the patient weighed 352 pounds. A skilled nursing visit, dated 5/5/22, included documentation the patient weighed 357.8 pounds. The patient gained 5.8 pounds in one week. The clinical record lacked documentation the nurse notified the patient's physician of the weight gain. 2) A skilled nursing visit, dated 5/5/22, included documentation the patient weighed 357.8 pounds. The subsequent skilled nursing visit, dated 5/10/22, included documentation the patient weighed 367.1 pounds. The patient gained 9.3 pounds in 5 days. The clinical record lacked documentation the nurse notified the patient's physician of the weight gain. 3) A skilled nursing visit, dated 5/10/22, included documentation the patient weighed 367.1 pounds. The subsequent skilled nursing visit, dated 5/12/22, included documentation the patient weighed 358 pounds. The patient lost 9.1 pounds in 2 days. The clinical record lacked documentation the nurse notified the patient's physician of the weight loss. 4) A skilled nursing visit, dated 5/12/22, included documentation the patient weighed 358 pounds. The subsequent skilled nursing visit, dated 5/17/22, included documentation the patient weighed 352.6 pounds. The patient lost 5.4 pounds in 5 days. The clinical record lacked documentation the nurse notified the patient's physician of the weight loss. 5) A skilled nursing visit, dated 5/25/22, included documentation the patient weighed 358.8 pounds. A skilled nursing visit, dated 5/26/22, included documentation the patient weighed 355 pounds. The patient lost 3.8 pounds in one day. The clinical record lacked documentation the nurse notified the patient's physician of the weight loss. 6) A skilled nursing visit, dated 5/26/22, included documentation the patient weighed 355 pounds. The subsequent skilled nursing visit, dated 5/31/22, included documentation the patient weighed 345 pounds. The patient lost 10 pounds in 5 days. The clinical record lacked documentation the nurse notified the patient's physician of the weight lost. 7) A skilled nursing visit, dated 6/2/22, included documentation the patient weighed 347.6 pounds. The subsequent skilled nursing visit, dated 6/7/22, included documentation the patient weighed 357.8 pounds. The patient gained 10.2 pounds in 5 days. The clinical record lacked documentation the nurse notified the patient's physician of the weight gain. b. The POCs lacked an order for the skilled nurse to set up the patient's medications. A skilled nursing visit note, dated 5/3/22, included documentation the skilled nurse set up the patient's medications. On 6/28/22 at 11:35 AM, during a home visit observation with Staff J, Clarinda office RN, set up the patient's medications per the patient's request without contacting the physician to obtain an order. c. The clinical record lacked an order for wound care. On 6/28/22 at 11:35 AM, during a home visit observation with Staff J, Clarinda office RN, measured a wound on the patient's right lower anterior leg. Staff J, Clarinda office RN, then applied Bacitracin to the wound. The wound had a scab over the wound bed and the skin around the wound was reddened. Staff J, Clarinda office RN, also measured and applied Bacitracin (antibiotic ointment) to a wound on top of the left upper foot per the patient's request and without contacting the physician to obtain an order for wound care. In an interview, during the same home visit observation, the patient reported having had the wound on the right lower anterior leg wound for 2 weeks and the physician was aware of the wound. The wound had become infected and the patient was currently taking an antibiotic. The patient reported the physician told the patient to cleanse the wound with soap and water and apply Bacitracin. The patient and Staff J, Clarinda office RN, reported the wound on the top of the left upper foot was new wound. The nurse completed wound care on the right lower leg and left upper foot without physician orders. 3. Patient #7 had a start of care date of 9/4/12, received home health services from the branch office and discharged from agency services on 1/8/22. Review of the clinical record revealed the following: a. The POC, dated 11/16/21 to 1/14/22, included physician orders for medications and orders for the nurse to assess the patient's vital signs, body systems, neurological status, level of consciousness, communication skills, pain , diabetic status and skin integrity. b. The skilled nursing visit notes, dated 11/17, 11/24, 12/1, 12/8, 12/15, 12/22 and 12/29/21, included documentation the nurse set up the patient's medications. The POC lacked an order for the skilled nurse to set up the patient's medications. c. A skilled nursing visit, dated 11/24/22, included documentation the nurse set up the medications. The nurse did not complete any of the physician ordered assessment and lacked documentation the nurse contacted the physician to alert the physician for the need to alter the POC. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

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, patient 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 #3). 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 Control of Infection Sources, dated 4/21/14, revealed staff must wash or sanitize their hands before and after reaching into the nursing bag and after removing or when changing gloves. On 6/29/22 at 10:40 AM, during an interview, the Clinical Manager reported staff are to sanitize hands after removing gloves and in between wounds when providing wound care. Patient #3 had a start of care date of 1/26/22 and received agency services from the branch office. Review of the clinical record revealed the following: The Plan of Care (POC), dated 5/26/22 to 7/24/22, included a physician order for skilled nursing services. The POC and clinical record lacked any orders for wound care. On 6/28/22 at 11:35 AM, during a home visit observation, Staff J, Clarinda Office Registered Nurse (RN), sanitized her hands and gloved prior to setting up the patient's medications. After setting up medications, Staff J, Clarinda Office RN, sanitized her hands prior to reaching in her bag to take out equipment to assess the patient's vitals. She placed a wrist cuff on the patient to obtain a blood pressure reading, used a pulse oximeter to measure the patient's blood oxygen saturation level and pulse and used forehead thermometer to measure the patient's temperature. She touched the patient during the process of assessing the patient's vitals and viewing a new wound on the top of the patient's left foot. Staff J, Clarinda Office RN, then reached into a bag that had held the vitals equipment and got out a reusable tape measure. She measured a wound on the patient's lower right anterior leg (lower shin). The wound was not open, had a scab with redness around the scab site. Staff J, Clarinda Office RN, then reached into her nursing bag and pulled out a bag with gloves. She reached into the nursing bag and into the bag with gloves without sanitizing or washing her hands. She donned the gloves without sanitizing or washing her hands and applied an antibiotic ointment to the wound on the right lower leg. She then removed the gloves without sanitizing after removing them. Staff J, Clarinda Office RN, assisted with weighing the patient. She then pulled a stethoscope from around her neck and used it to listen to the patient's heart and lungs. She palpated the patient's ankles and top of the feet. She then used the same reusable measuring tape (used from measuring the right lower leg wound) without sanitizing it to measure the wound on the top of the left foot. Staff J, Clarinda Office RN, reported the patient had a blister that had opened on the top of the left foot. The area was scabbed over. Staff J, Clarinda Office RN, then removed a pair of gloves from the glove bag and donned them without sanitizing her hands. She applied antibiotic ointment to the wound on the top of the left foot. She removed the gloves and then sanitized her hands. The RN failed to follow the agency infection control policy when providing patient care. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, agency policy review and staff interview, the agency failed to ensure the home health aides successfully completed competencies in all basic home health aide 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 with a home health aide or pseudo patient for 5 of 5 sampled home health aides (Staff E, F, G, H and I) hired or contracted since the last recertification survey (7/29/19). Failure to ensure home health aides were competent in any assigned skill which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: According to the agency policy titled Home Health Aide Competency Evaluation, dated November, 1996 the home health aide must satisfactorily demonstrate competence in basis skills to include personal hygiene and grooming that include bed bath, sponge, tub or shower bath, shampoo in sink, tub or bath. During an interview on 6/29/22 at 10:40 AM the Clinical Manager stated she did not complete competency testing on a tub bath or tub shampoo. 1. Staff E, Home Health Aide, began providing care to agency patients on 5/16/22. a. The agency provided a skills demonstration checklist which was not dated and included sponge, tub or shower bath on one line. It was unclear which type of bath the registered nurse (RN) observed for competency testing. b. The checklist included sink shampoo, tub shampoo and bed shampoo on the same line, making it unclear which type of shampoo the RN observed for competency testing. c. The undated written competency test lacked documentation the test check by a qualified Registered Nurse. d. The checklist lacked documentation of competency testing for all of the required basic skills. 2. Staff F, Home Health Aide, began providing care to agency patients on 2/21/22. a. The agency provided a skills demonstration checklist which included sponge, tub or shower bath on one line. It was unclear which type of bath the registered nurse (RN) observed for competency testing. b. The checklist included sink shampoo, tub shampoo and bed shampoo on the same line, making it unclear which type of shampoo the RN observed for competency testing. c. The checklist lacked documentation of competency testing for all of the required basic skills. 3. Staff G, Home Health Aide, began providing care to agency patients on 11/2/19. a. The agency provided a skills demonstration checklist which included sponge, tub or shower bath on one line. It was unclear which type of bath the registered nurse (RN) observed for competency testing. b. The checklist included sink shampoo, tub shampoo and bed shampoo on the same line, making it unclear which type of shampoo the RN observed for competency testing. c. The checklist lacked documentation of competency testing for all of the required basic skills. 4. Staff H, Home Health Aide, began providing care to agency patients on 3/29/22. a. The agency provided a skills demonstration checklist which included sponge, tub or shower bath on one line. It was unclear which type of bath the registered nurse (RN) observed for competency testing. b. The checklist included sink shampoo, tub shampoo and bed shampoo on the same line, making it unclear which type of shampoo the RN observed for competency testing. c. The checklist lacked documentation of competency testing for all of the required basic skills. 5. Staff I, Home Health Aide, began providing care to agency patients on 1/6/21. a. The agency provided a skills demonstration checklist which included sponge, tub or shower bath on one line. It was unclear which type of bath the registered nurse (RN) observed for competency testing. b. The checklist included sink shampoo, tub shampoo and bed shampoo on the same line, making it unclear which type of shampoo the RN observed for competency testing. c. The checklist lacked documentation of competency testing for all of the required basic skills. The Assistant Administrator received the above findings and agency staff provided no further information 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, patient 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 4 of 6 sampled patients receiving home health aide services (Patients #1, #3, #6 and #7). The agency reported 39 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 include: According to the agency policy titled Home Health Aide Program Information, dated November, 1996, home health aides are assigned by, and function under the direct supervision of the staff nurse (and her supervisor) in charge of the family situation. Home health aides may not accept or carry out medical orders; these must be referred to the professional nurse or her supervisor by the patient's home. A home health aide care plan, defining written instructions for patient care shall be prepared and signed by a registered nurse or therapist, as appropriate. The home health aide shall also sign that he or she understands the instructions a written prior to or during the first patient visit, and shall retain a copy of the home health aide care plan. During an interview on 6/29/22 at 10:40 AM the Clinical Manager stated the Registered Nurse (RN) writes the home health aide care plan according to the patients wants and needs. The home health aide expected to complete the tasks as written on the care plan and document a task may be omitted for example a patient refused. 1. Patient #6 had a start of care date of 6/9/14 and received agency services from the branch office. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 12/28/21 to 2/25/22 and 2/26/22 to 4/26/22, included physician orders for home health aide services 4 to 5 times per week. b. The Home Health Aide Care Plan, dated 8/6/21, included RN instructions to the home health aide to complete the tasks of hair care, skin care, perineal care, assist with dressing and linen change. c. The home health aide visit notes, dated 3/8 and 3/15/22, lacked documentation the home health aide completed the assigned task of assist with dressing and linen change if time permits. The visit note lacked documentation to indicate whether or not the home health aide offered the task of assist with dressing and linen change and lacked a reason why the home health failed to complete the assigned task. 2. Patient #1 had a start of care date of 1/14/21 and received agency services from the parent office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/9/22 to 7/7/22, included physician orders for home health aide services two times per week. b. The Home Health Aide Care Plan, dated 3/31/22, included RN instructions to the home health aide to complete the tasks of shower, sponge bath per patient request, hair care per patient request and skin care to include lotion to arms, back and legs. c. The home health aide visit note, dated 4/28/22, lacked documentation the home health aide completed the assigned task of skin care and lacked a reason why the home health aide failed to complete the assigned task. d. The home health aide visit notes, dated 5/10 and 6/2/22, lacked documentation the home health aide completed the assigned task of hair care. The visit note lacked documentation to indicate whether or not the home health aide offered the task of hair care and lacked a reason why the home health failed to complete the assigned task. e. The home health aide visit note, dated 6/16/22, lacked documentation the home health aide completed the assigned tasks of skin care and hair care and lacked a reason why the home health aide failed to complete the assigned tasks. 3. Patient #3 had a start of care date of 1/26/22 and received agency services from the branch office. Review of the clinical record revealed the following: a. The POCs, dated 3/27/22 to 5/22/22 and 5/26/22 to 7/24/22, included physician orders for home health aide services five times per week. b. The Home Health Aide Care Plan, dated 1/26/22, included RN instructions to the home health aide to complete the tasks of shower, sponge bath per patient request, assist with upper and lower body dressing, apply lotion for skin care, apply lotion to feet and to assist with hair care including washing and drying. c. The home health aide visit notes, dated 5/4, 5/6, 6/7, 6/8, 6/10, 6/12, 6/13, 6/14, 6/15 and 6/17/22, lacked documentation the home health aide completed the assigned task of hair care. The visit note lacked documentation to indicate whether or not the home health aide offered the task of hair care and lacked a reason why the home health failed to complete the assigned task. d. A skilled nursing visit note, dated 5/5/22, included documentation the home health aide had applied Calmoseptine cream on the patient. e. The home health aide visit note, dated 5/23/22, lacked documentation the home health aide completed the assigned tasks of hair care, skin care and foot care and lacked a reason why she she failed to complete the assigned tasks. On 6/28/22 at 11:35 AM, in an interview, during a home visit observation with Staff J, Clarinda office RN, the patient reported the home health aide put Calmoseptine (type of topical moisture barrier) on the skin folds of the patient after bathing. Staff J, Clarinda office RN, reported being aware the home health aide had been doing this. The home health aide care plan lacked RN instructions for the home health aide to apply Calmoseptine and the home health aide visit notes lacked documentation the home health aide completed this unassigned task. 4. Patient #7 had a start of care date of 9/4/12, received agency services from the branch office and discharged from agency services on 1/8/22. Review of the clinical record revealed the following: a. The POC, dated 11/16/21 to 1/14/22, included physician orders for home health aide services three times per week. b. The Home Health Aide Care Plan, dated 4/5/21, included RN instructions to the home health aide to complete the tasks of shower, sponge bath per patient request, skin care including washing, drying and lotion, apply lotion to legs and feet per patient request, assist with drying per patient request, personal hygiene per patient request, perineal care by assisting with hard to reach places, assist with dressing, hair care including wash and dry per patient request. c. The home health aide visit note, dated 11/17/21, lacked documentation the home health aide completed the tasks of a assisting the patient with dressing, hair care or personal hygiene. The visit note lacked documentation to indicate whether or not the home health aide offered the tasks per patient request and lacked a reason why the home health failed to complete the assigned tasks. d. The home health aide visit notes, dated 11/29, 12/1, 12/3, 12/6, 12/8, 12/10, 12/13, 12/15, 12/17, 12/20, 12/22, 12/23, 12/27, 12/29 and 12/31/21 and 1/3/22, lacked documentation the home health aide completed the assigned tasks of apply lotion to legs and feet, assist with personal hygiene and hair care. The visit notes lacked documentation to indicate whether or not the home health aide offered the tasks per patient request and lacked a reason why the home health failed to complete the assigned tasks. On 6/28/22 at 2:50 PM, during an interview, the Assistant Administrator explained the nurses used to use "PRN" (as needed) when assigning tasks for the home health to complete, but changed it to "per patient request". The home health aide completes the task if the patient requests it. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff completed and sent a discharge summary within 5 business days of knowledge of a patient discharge for 2 of 2 patients requiring a discharge summary and a transfer summary to the health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of the planned transfer for 2 of 2 sampled patients requiring transmission of a transfer summary (Patient #4, #6 & #7). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up and care. Findings include: According to the agency policy titled Discharge From Home Care, dated November, 1996, each patient's record will include a discharge summary written by each discipline involved with he patient. A copy of the completed discharge summary will be sent to the attending physician. 1. Patient #4 had a start of care date of 10/22/18, received agency services from the branch office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 6/3/22 to 8/1/22, identified a diagnosis of congestive heart chronic obstructive lung disease and included orders for skilled nursing and home health aide services. b. A physician's order, dated 6/7/22, included documentation which identified the patient transferred to the hospital on 6/7/22. c. A physician's order, dated 6/10/22, included documentation which identified the agency canceled home care aide and skilled nursing services due to the patient hospitalization. d. The clinical record lacked documentation of agency staff sending a transfer summary to the hospital receiving the patient care. 2. Patient #6 had a start of care date of 6/9/14, received agency services from the branch office and discharged from agency services on 3/25/22. Review of the clinical record revealed the following: a. The Plans of Care, dated 12/28/21 to 2/25/22 and 2/26/22 to 4/26/22, identified a diagnosis of chronic obstructive lung disease and included orders for skilled nursing and home health aide services. b. A transfer assessment form, dated 1/8/22, included documentation which identified the hospital admitted the patient. c. An interim physician order, dated 1/9/22, included an order notifying the patient transfer to an inpatient facility for scheduled right knee replacement and to cancel all visits until resumption of care. d. The clinical record lacked documentation of agency staff sending a transfer summary to the hospital receiving the patient care. e. A discharge summary, dated 3/25/22, included documentation the patient discharged from the agency due to a move out of the agency's geographical area. d. The clinical record lacked documentation of agency staff sending a discharge summary until 4/1/22 ( 1 day late). 3. Patient #7 had a start of care date of 9/4/12, received agency services from the branch office and discharged from agency services on 1/8/22. Review of the clinical record revealed the following: a. The Plan of Care, dated 11/16/21 to 1/14/22, identified a diagnosis of congestive heart failure and included orders for skilled nursing and home health aide services. b. A transfer assessment form, dated 1/8/22, included documentation which identified the hospital admitted the patient. c. An interim physician order, dated 1/8/22, included an order to discharge the patient from agency services due to admission to the hospital. d. The clinical record lacked documentation of agency staff sending a discharge summary until 1/18/22 ( 4 days late). On 6/28/22 at 2:50 PM, during an interview, the Assistant Administrator confirmed agency staff sent the discharge summary late. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on patient clinical record review and staff interview the agency failed to ensure all clinical entry notes included a date and time and staff signature with title for 6 of 7 sampled patients (Patients #1, #3, #4, #5, #6 and #7). Failure to ensure all clinical record documentation was dated, timed and signed with staff title, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: During an interview on 6/28/22 at 4:15 PM the Assistant Administrator stated the agency had not required Home Health Aides to included their title with signatures. 1. Patient #4 had a start of care date of 10/22/18. Review of the clinical record revealed the following: a. The home health aide visit notes, dated 4/26, 4/29, 5/2, 5/6, 5/10, 5/13, 5/16, 5/20, 5/23, 5/27, 6/3, 6/6, 6/13, 6/17, 6/20, 6/24/22, included a signature of completion of the visit note by the home health aide and a date, but lacked documentation of a title with the signature. 2. Patient #6 had a start of care date of 6/9/14. Review of the clinical record revealed the following: a. The Home Health Aide Care Plan, dated 8/6/21, included a signature of understanding by the home health aide and a date with the signature, but lacked documentation of a title with the signature. b. The home health aide visit notes, dated 1/24, 2/1, 2/2, 2/3, 2/4, 2/7, 2/8, 2/11, 2/14, 2/15, 2/16, 2/17, 2/18, 2/21, 2/22, 2/23, 2/24, 2/25, 3/1, 3/2, 3/3, 3/4, 3/7, 3/8, 3/9, 3/14, 3/15, 3/16, 3/17, 3/18, 3/21, 3/22, 3/23, 3/24, 3/25, included a signature of completion of the visit note by the home health aid and a date, but lacked documentation of a title with the signature. 3. Patient #1 had a start of care date of 1/14/21 and received agency services from the parent office. Review of the clinical record revealed the following: a. The Home Health Aide Care Plan, dated 3/21/22, included a signature of understanding by the home health aide and a date with the signature, but lacked documentation of a title with the signature. b. The home health aide visit notes, dated 4/25, 4/28, 5/2, 5/10, 6/2, 6/6 and 6/16/22, included a signature of completion of the visit note by the home health aide and a date, but lacked documentation of a title with the signature. 4. Patient #3 had a start of care date of 1/26/22 and received agency services from the branch office. Review of the clinical record revealed the following: a. The Home Health Aide Care Plan, dated 1/26/22, included a signature of understanding by the home health aide and a date with the signature, but lacked documentation of a title with the signature. b. The home health aide visit notes, dated 5/4, 5/5, 5/6, 5/23, 6/6, 6/7,6/8, 6/9, 6/10, 6/13, 6/14, 6/15, 6/16 and 6/17/22, included a signature of completion of the visit note by the home health aide and a date, but lacked documentation of a title with the signature. 5. Patient #5 had a start of care date of 4/22/22 and received agency services from the branch office. Review of the clinical record revealed the following: a. The Home Health Aide Care Plan, dated 4/22/22, included a signature of understanding by the home health aide and a date with the signature, but lacked documentation of a title with the signature. b. The home health aide visit notes, dated 5/18, 5/25, 6/1, 6/8, 6/15 and 6/22/22, included a signature of completion of the visit note by the home health aide and a date, but lacked documentation of a title with the signature. 6. Patient #7 had a start of care date of 9/4/12, received agency services from the branch office and discharged from agency services on 1/8/22. Review of the clinical record revealed the following: a. The Home Health Aide Care Plan, dated 4/5/21, included a signature of understanding by the home health aide and a date with the signature, but lacked documentation of a title with the signature. b. The home health aide visit notes, dated 11/17, 11/29, 12/1, 12/3, 12/6, 12/8, 12/10, 12/13, 12/15, 12/17, 12/20, 12/22, 12/23, 12/27, 12/29 and 12/31/21, included a signature of completion of the visit note by the home health aide and a date, but lacked documentation of a title with the signature. The Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.