Every finding on record at Horn Memorial Hospital

A Recertification Survey was conducted by the Department of Inspections and Appeals from 4/29/24 through 5/1/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections and Appeals conducted a Recertification Survey from 4/29/24 through 5/1/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a census of 29 current patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, patient interview, and agency staff interview, the agency failed to ensure accurate and thorough completion of pertinent components of the initial comprehensive assessment for 1 of 2 sampled patients with wound care. (Patient #4) Failure to accurately and thoroughly complete the comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition. Findings include: According to agency policy, titled , dated April 2023, Wound/Surgical Incision Assessment, dated 7/24, wound/surgical incision will be assessed and documented by the nurse with admission, follow-up, resumption of care and with every nursing visit. During an interview on 4/29/24 at the Clinical Manager stated wounds are expected to be measured on admit and weekly, unless the provider wants something else. The measurements are length, width and depth. Patient #1 had a start of care date of 4/22/24. Clinical record review revealed the following: a. The plan of care, dated 4/23/24 to 6/21/24, included orders for skilled nurse services to assess pressure ulcer status including signs and symptoms of healing and complications. b. The comprehensive assessment, dated 4/23/24, contained documentation the patient had a wound on the left lower medial leg on the calf. The note also included a wound to the right outer leg on the calf. The wound assessments failed to include measurements of the wounds. b. The skilled nurse visit notes dated, 4/26/24, included documentation the patient had a right leg calf blister. The wound assessment failed to include measurements of the wound. Agency failed to document wound measurements. The above stated findings were reviewed with the agency Director, Clinical Manager, Staff E, Registered Nurse and Staff C, Licensed Practical Nurse. The agency provided no additional information prior to the end of the survey.

The recertification survey, conducted from 5/3/21 through 5/5/21, identified the following standard level deficiencies in the area of emergency preparedness.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on agency policy review and staff interview, the hospice failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The agency reported a current census of 20 patients at the time of the survey. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: During an interview on 5/3/21 at 11:35 AM, the surveyor notified the Administrator, of an inability to find a written policy and procedure for notification of appropriate agencies and officials of homebound patients in need of evacuation due to an emergency situation. The Administrator revealed in 2019 after their hospice survey, they altered there plan and identified the agency will notify local Emergency Management Agency about hospice patients in need for evacuation from their residences, but did not include homebound home health patients in this change. The agency provided no further information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 5/3/21 through 5/5/21 . The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey found the agency operating out of compliance with multiple standard level regulatory requirements.

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 clinical record review, agency policy review and agency staff interview, the agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment within the allowed time frames for 2 of 8 sampled patients (Patients #3 and #7). The agency reported a census of 20 patients at the time of the survey. Failure to ensure medications were reviewed at the time of each comprehensive assessment, using a current and accurate list of medications taken by the patient at the time of the assessment, increased the potential for unidentified medication interactions, patient non-compliance, ineffective medication therapy and side effect risks to the patient. Findings include: According to the agency policy, titled Drug Regimen Review, Home Health and Hospice, dated 1/2020, to be in compliance with Medicare Conditions of Participation, assuring that all Home Health and Hospice patients receive a Drug Regimen Review at the specified and appropriate times. The review for home health will be completed with all comprehensive assessments, including Start of Care, Recertification/Follow Up, Resumption of Care, Discharge, and Significant Change in Condition to identify any potential side effects, drug interactions, ineffective drug therapies, duplicate drug therapies, or non-compliance. During interview on 5/3/21 at 3:12 PM, the Clinical Manager revealed the Drug Regimen Review (DRR) is obtained from the doctor and completed the by nurses and is to be completed at start of care, recertification assessments, resumption of care assessments, and at discharge. 1. Patient #3 had a start of care date of 11/12/2020. Clinical record review revealed: a. An update to the comprehensive assessment for recertification, dated 1/7/21, documented see medication profile for DRR per agency policy. b. The medication profile lacked documentation of completion of a drug regimen review with the 1/7/21 recertification assessment. 2. Patient #7 had a start of care date of 2/4/21 and was discharged from agency on 3/30/21. Clinical record review revealed: a. A skilled nurse narrative note, dated 3/30/21, documented the patient's spouse would provide the cares for the patient as the patient wanted a sponge bath only and would not get in the shower. The patient discharged from private pay services and spouse would call again if services needed. b. A physician's order, dated 3/30/21, included orders to discharge the patient from the private home health program and patient's spouse would provide care. Interview on 5/5/21 at 8:29 AM with the Clinical Manager revealed the agency did not perform a discharge assessment, drug regimen review, or discharge summary at the time of the discharge since the patient was private pay. The above findings for Patients #3 and #7 were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 2 sampled patients requiring a resumption of care assessment (Patient #3). The agency provided services to 20 patients at the time of the survey and performed 2 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Outcome And Assessment Information Set (OASIS) Policy, Home Health, dated 2/2020, all home care patients, age 18 and older and non-obstetrical, shall receive a completed OASIS assessment, upon resumption of care by the home health agency after discharge from an inpatient facility, within 2 days of the facility discharge date or knowledge of the patient's return home. Patient #3 had a start of care date of 11/12/2020. Clinical record review revealed: a. The transfer assessment, dated 12/21/2020, documented the patient was hospitalized for a surgical repair of a fractured left shoulder/arm b. The update to the comprehensive assessment at the time of resumption of care, dated 12/24/2020, documented the patient was discharged from the hospital on 12/23/2020. The nurse initiated the update to the assessment on 12/24/2020 but did not complete the assessment until 12/28/2020, 5 days after the patient's return home from the inpatient stay. The assessment was completed 3 days late as required by regulation and the agency's own policy. The above stated findings for Patient #3 were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on agency policy and clinical record review, the agency failed to ensure completion of all required components of the discharge comprehensive assessments within 2 calendar days of identification of the need to discharge a patient for 1 of 2 sampled patients requiring a discharge comprehensive assessment (Patient #7). The agency reported a census of 20 patients at the time of the survey and discharged 30 patients in the previous 6 months. Failure to accurately and thoroughly complete discharge comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Outcome And Assessment Information Set (OASIS) Policy, Home Health, dated 2/2020, all home care patients, age 18 and older and non-obstetrical, shall receive a completed OASIS assessment, upon discharge from the home health agency within 2 calendar days of the discharge date. Patient #7 had a start of care date of 2/4/21 and a discharge date of 3/30/21. Clinical record revealed: a. A skilled nurse narrative note, dated 3/30/21, documented the patient's spouse would provide the cares for the patient as the patient wanted a sponge bath only and would not get in the shower. The patient discharged from private pay services and spouse would call again if services needed. b. A physician's order, dated 3/30/21, included orders to discharge the patient from the private home health program and patient's spouse would provide care. Interview on 5/5/21 at 8:29 AM with the Clinical Manager revealed the agency did not perform a discharge assessment, drug regimen review, or discharge summary at the time of the discharge since the patient was private pay. The above findings were reviewed with the Administrator and Clinical Manager. 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 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 8 sampled patients (Patients #1, #2, #3, #5, #6 and #8). The agency reported a census of 20 patients at the time of the survey. 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. Findings include: During agency staff interview on 5/3/2021 at 10:15 PM, the Administrator reported if the plan of care cannot be followed, the agency notifies the physician. If visit frequency differs from the Plan of Care, the physician is notified of missed visits and an order is obtained for extra visits or interventions. 1. Patient #1 had a start of care date of 4/13/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/13/2021 to 6/11/2021, included physician orders for skilled nursing visits to the patient's home once weekly to assess vital signs (temperature, pulse, respirations, blood pressure and pulse oxygen saturation), assess medication compliance, assess symptoms of hypertension, assess pain control, perform physical assessment of the patient's skin, edema, lungs, bowel patterns, nutrition and mobility/safety. The Plan also included physician reporting parameters including reporting: 1. systolic blood pressure readings less than 80 or greater than 160 2. diastolic blood pressure readings less than 50 or greater than 90 3. apical pulse less than 50 or greater than 110 4. respirations greater than 30 per minute 5. temperature greater than 101 6. any weight gain of 5 pounds or more in one week or 3 pounds in 24 hours 7. pulse oxygen saturation below 90 % 8. significant increase in edema b. The skilled nurse visit note, dated 4/28/2021, lacked documentation of the nurse monitoring the patient's pulse oxygen saturation level as directed by the physician. The notes also lacked documentation of the nurse monitoring the patient's weight to determine weight gain as directed by the reporting parameters. c. The skilled nurse visit note, dated 4/19/2021, documented the patient's diastolic blood pressure reading was 39. The reading exceeded the physician ordered parameters on the Plan of Care, thereby requiring reporting to the physician. The clinical record lacked documentation indicating the nurse contacted the physician to report the low diastolic blood pressure reading. 2. Patient #2 had a start of care date of 4/27/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/27/2021 to 6/19/2021, included physician orders for skilled nursing visits to the patient's home twice weekly to assess vital signs (temperature, pulse, respirations, blood pressure and pulse oxygen saturation), assess medication compliance, perform physical assessment of the patient's skin, edema, lungs, bowel patterns, nutrition and mobility/safety. The same Plan of Care directed the nurse to perform a dressing change to the patient's lower legs (unna boots) each visit, weigh the patient once weekly and assess compliance with diabetes protocol, including use of glucometer and reporting blood glucose readings greater than 300 and less than 70. The Plan also included physician reporting parameters including reporting: 1. systolic blood pressure readings less than 80 or greater than 160 2. diastolic blood pressure readings less than 50 or greater than 90 3. apical pulse less than 50 or greater than 110 4. respirations greater than 30 per minute 5. temperature greater than 101 6. any weight gain of 5 pounds or more in one week or 3 pounds in 24 hours 7. pulse oxygen saturation below 90 % 8. significant increase in edema 9. blood glucose patterns less than 70 or greater than 300 b. The skilled nurse visit note, dated 4/30/2021, documented the patient's pulse oxygen saturation was 88% on 3.5 liters of oxygen per nasal cannula. The reading exceeded the physician ordered parameters on the Plan of Care, thereby requiring reporting to the physician. The clinical record lacked documentation indicating the nurse contacted the physician to report the low pulse oxygen saturation. 3. Patient #3 had a start of care date of 11/12/2020. Clinical record review revealed: a. The Plans of Care, dated 1/11/21 to 3/11/21 and 3/12/21 to 5/10/21, included physician orders for skilled nursing visits to the patient's home two to three times per month to assess vital signs (temperature, pulse, respirations, blood pressure and pulse oxygen saturation), assess medication compliance, assess symptoms of hypertension, assess pain control, perform physical assessment of the patient's skin, edema, lungs, bowel patterns, nutrition and mobility/safety. The Plan also included physician reporting parameters including reporting: 1. systolic blood pressure readings less than 80 or greater than 160 2. diastolic blood pressure readings less than 50 or greater than 90 3. apical pulse less than 50 or greater than 110 4. respirations greater than 30 per minute 5. temperature greater than 101 6. any weight gain of 5 pounds or more in one week or 3 pounds in 24 hours 7. pulse oxygen saturation below 90 % 8. significant increase in edema b. The skilled nurse visit notes, dated 3/2, 3/23, 4/7, and 4/20/21, lacked documentation of the nurse monitoring the patient's weight to determine weight gain as directed by the reporting parameters. c. The updates to the comprehensive assessments for recertification, dated 1/7/21 and 3/9/21, lacked documentation of the nurse monitoring the patient's pulse oxygen saturation level as directed by the physician. Interview with the Administrator on 5/5/21 at 11:42 AM, revealed the OASIS forms used for the comprehensive assessments do not include an area to document the pulse ox. The nurse does perform pulse ox and faxes readings to the the doctor for recertification, but the readings are not documented in the actual assessment as completed. 4. Patient #5 had a start of care date of 4/23/21. Clinical record review revealed: a. The Plan of Care, dated 4/23/21 to 6/12/21, included physician orders for skilled nursing visits to the patient's home one to two times per week to assess vital signs (temperature, pulse, respirations, blood pressure and pulse oxygen saturation), assess medication compliance, assess symptoms of hypertension, assess pain control, perform physical assessment of the patient's skin, edema, lungs, bowel patterns, nutrition and mobility/safety. The Plan also included physician reporting parameters including reporting: 1. systolic blood pressure readings less than 80 or greater than 160 2. diastolic blood pressure readings less than 50 or greater than 90 3. apical pulse less than 50 or greater than 110 4. respirations greater than 30 per minute 5. temperature greater than 101 6. any weight gain of 5 pounds or more in one week or 3 pounds in 24 hours 7. pulse oxygen saturation below 90 % 8. significant increase in edema b. The skilled nurse visit notes, dated 4/26/21 and 4/29/21, lacked documentation of the nurse monitoring the patient's weight to determine weight gain as directed by the reporting parameters. c. The updates to the comprehensive assessments for discharge dated 5/3/21, lacked documentation of the nurse monitoring the patient's pulse oxygen saturation level as directed by the physician. Interview with the Administrator on 5/5/21 at 11:42 AM, revealed the OASIS forms used for the comprehensive assessments do not include an area to document the pulse ox. The nurse does perform pulse ox and faxes readings to the the doctor for recertification, but the readings are not documented in the actual assessment as completed. 5. Patient #6 had a start of care date of 10/11/16. Clinical record review revealed: a. The Plans of Care, dated 11/19/2020 to 1/17/21 and 1/18/21 to 3/18/21, included physician orders for skilled nursing visits to the patient's home two to three times per month to assess vital signs (temperature, pulse, respirations, blood pressure and pulse oxygen saturation), assess medication compliance, assess symptoms of hypertension, assess pain control, perform physical assessment of the patient's skin, edema, lungs, bowel patterns, nutrition and mobility/safety. The Plan also included physician reporting parameters including reporting: 1. systolic blood pressure readings less than 80 or greater than 160 2. diastolic blood pressure readings less than 50 or greater than 90 3. apical pulse less than 50 or greater than 110 4. respirations greater than 30 per minute 5. temperature greater than 101 6. pulse oxygen saturation below 88 % 7. significant increase in edema b. The updates to the comprehensive assessments for recertification, dated 1/13/21 and 3/16/21, lacked documentation of the nurse monitoring the patient's pulse oxygen saturation level as directed by the physician. Interview with the Administrator on 5/5/21 at 11:42 AM, revealed the OASIS forms used for the comprehensive assessments do not include an area to document the pulse ox. The nurse does perform pulse ox and faxes readings to the the doctor for recertification, but the readings are not documented in the actual assessment as completed. 6. Patient #8 had a start of care date of 8/20/13. Clinical record review revealed: a. The Plans of Care, dated 11/19/2020 to 1/17/21 and 1/18/21 to 3/18/21, included physician orders for skilled nursing visits to the patient's home two to three times per month to assess vital signs (temperature, pulse, respirations, blood pressure and pulse oxygen saturation), assess medication compliance, assess symptoms of hypertension, assess pain control, perform physical assessment of the patient's skin, edema, lungs, bowel patterns, nutrition and mobility/safety. The Plan also included physician reporting parameters including reporting: 1. systolic blood pressure readings less than 80 or greater than 160 2. diastolic blood pressure readings less than 50 or greater than 90 3. apical pulse less than 50 or greater than 110 4. respirations greater than 30 per minute 5. temperature greater than 101 6. pulse oxygen saturation below 90 % 7. significant increase in edema b. The skilled nurse visit notes, dated 3/16/21, lacked documentation of the nurse monitoring the patient's edema to report a significant increase as directed by the reporting parameters. c. The updates to the comprehensive assessments for recertification, dated 1/5/21 and 3/9/21, lacked documentation of the nurse monitoring the patient's pulse oxygen saturation level as directed by the physician. Interview with the Administrator on 5/5/21 at 11:42 AM, revealed the OASIS forms used for the comprehensive assessments do not include an area to document the pulse ox. The nurse does perform pulse ox and faxes readings to the the doctor for recertification, but the readings are not documented in the actual assessment as completed. The above findings for Patients #1, #2, #3, #5, #6, and #8 were reviewed with the Administrator and the Clinical Manager. 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 and patient/caregiver interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient, accurate medication orders and physician approved staff interventions for 6 of 8 sampled patients (Patients #1, #2, #3, #5, #6 and #7). The agency reported a current census of 20 patients at the time of the survey. 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 agency policy, titled 485 Physician's orders/Plan of Care and dated as revised in 3/2020, the individualized plan of care must include the following: all pertinent diagnoses, orders for discipline frequency/duration/treatments, the patient's mental status, supplies and equipment required, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, all medications and treatments used by the patient, safety measures to protect against injury, a description of the patient's risk for emergency hospitalization and hospital readmission, discharge planning, patient-specific interventions and education and measurable outcomes and goals and information related to advance directives. 1. Patient #1 had a start of care date of 4/13/2021. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The physical therapy visit note, dated 4/19/2021, documented the patient used a transfer strap to use on the car door handle when getting in and out of the car. b. The occupational therapy visit note, dated 4/20/2021, documented the patient continued using a pivot cushion for transfers in and out of the chair and a gel cushion in the chair to relieve pressure to the patient's buttocks area when sitting. c. The Home Care Aide Plan of Care, undated, directed the aides to use a gait belt with ambulation and transfers every visit. d. On 5/3/2021 at 1:00 PM, the surveyor accompanied Staff D, Physical Therapy Assistant (PTA), to Patient #1's home. During the home visit, the physical therapy assistant used a gait belt when working with the patient on transfers and ambulation. Patient caregiver interview during the home visit revealed the caregiver used the gait belt for all transfers and ambulation. The caregiver reported the gait belt was left around the patient's trunk at all times except when in bed. e. During the same home visit, the surveyor observed: 1. a pressure relieving mattress on the hospital bed 2. a gel pressure relieving chair cushion 3. a stool riser with hand rails 4. incontinence briefs 5. a wheelchair ramp 6. a pivot cushion in the dining room chair During the home visit, the patient's caregiver removed the gel pressure relieving chair cushion from the dining room chair where the patient was initially sitting to the lift recliner when the patient decided to rest in the chair. The caregiver reported the patient used the incontinence briefs at night due to his/her inability to get to and from the toilet independently. f. The Plan of Care, dated 4/13/2021 to 6/11/2021, lacked inclusion of the gait belt, pressure relieving mattress, gel pressure relieving chair cushion, stool riser with hand rails, incontinence briefs, transfer strap, wheelchair ramp or the pivot cushion as used by the patient to meet the patient's needs. g. The same Plan of Care included the patient's use of Ketoconazole 2% shampoo twice a week with shower. The Home Care Aide Plan of Care, undated, directed the aide to shampoo the patient's head/hair every visit. On 5/3/2021 at 1:00 PM, the surveyor accompanied Staff D, PTA, to Patient #1's home. During the home visit, the patient's caregiver interview revealed the home health aide had been applying Ketoconazole 2% medicated shampoo to the patient's head and face when showering Patient #1. The Plan of Care as stated above included physician orders for the use of Ketoconazole 2%; however, lacked physician orders or direction for the aide to apply the medicated shampoo as an extension of nursing services. The Plan lacked inclusion of the intervention. h. The Home Care Aide Plan of Care, undated, directed the aides to shave the patient as requested by the patient. The Plan of Care as stated above lacked inclusion of shaving by the home health aide as an extension of nursing services was approved by the physician. i. During the 5/3/2021 home visit, the patient's caregiver interview revealed the home health aide had been applying Zeosorb medicated powder (antifungal) to the patient's feet every aide visit. The Plan of Care as stated above lacked inclusion of Zeosorb antifungal powder as a topical medication used by the patient. The same Plan of Care lacked physician orders or direction for the aide to apply the medicated powder as an extension of nursing services. The Plan lacked inclusion of the medication used by the patient and lacked inclusion of the intervention. 2. Patient #2 had a start of care date of 4/27/2021. Clinical record review, home visit observation and patient interview revealed the following: a. The Plan of Care, dated 4/27/2021 to 6/19/2021, included physician orders for skilled nursing visits to the patient's home twice weekly to assess vital signs (temperature, pulse, respirations, blood pressure and pulse oxygen saturation), assess medication compliance, perform physical assessment of the patient's skin, edema, lungs, bowel patterns, nutrition and mobility/safety. The same Plan of Care directed the nurse to perform a dressing change to the patient's lower legs (unna boots) each visit, weigh the patient once weekly and assess compliance with diabetes protocol, including use of glucometer and reporting blood glucose readings greater than 300 and less than 70. On 5/4/2021 at 9:45 AM, the surveyor accompanied Staff F, Registered Nurse (RN), to Patient #2's home. During the home visit, patient interview revealed the patient did not have a glucometer for monitoring blood sugars and had never been monitoring blood sugars in the home. The Plan of Care task to assess use of glucometer and reporting parameters was not individualized to Patient #2. b. The same Plan of Care included a medication order for Metformin. The Plan documented the patient took Metformin 850 milligrams twice daily in the morning and afternoon. During the home visit, patient interview revealed the patient had taken Metformin 850 milligrams once daily in the morning for approximately one year. The Plan of Care did not include an accurate frequency of administration of the Metformin. 3. Patient #3 had a start of care date of 11/12/2020. Clinical record review revealed: a. The Plans of Care, dated 11/12/2020 to 1/10/11, 1/11/21 to 3/11/21, identified the following equipment and supplies as used by the patient: hand held shower, grab bars, pill planner, life alert, shower bench, walker, and added on 1/11/21, arm splint. b. The initial comprehensive assessment completed for start of care, dated 11/12/2020, documented the patient is suppose to have left arm in sling, however, does not wear the sling. c. The update to the comprehensive assessment completed for resumption of care, dated 12/24/2020, documented the patient's left arm is in a sling. d. The update to the comprehensive assessment completed for recertification dated 1/7/21, documented the arm sling as supplies used by the patient. During findings on 5/5/21 at 10:30 AM, the Clinical Manager revealed the patient did use both an arm sling and a splint while receiving care from the agency. The Plans of Care, dated 11/12/2020 to 1/10/11 and 1/11/21 to 3/11/21, lacked inclusion of the arm sling as equipment used by the patient to meet the patient's needs. 4. Patient #5 had a start of care date of 4/23/21. Clinical record review revealed: a. The Plan of Care, dated 4/23/21 to 6/21/21, identified the following equipment and supplies as used by the patient: ace wraps, briefs/attends, cane, compression stockings/TEDS, glasses, gowns, high rise toilet, incentive spirometer, linens, sheets, med box/planner, scale, shower chair/bench, stool riser, thermometer, and wheeled walker. b. The initial comprehensive assessment completed for start of care, dated 4/23/21, documented the patient was sitting in a recliner with feet elevated and an ice machine on the left knee. c. The skilled nurse visit note, dated 4/26/21, documented the patient does have an ice machine on the left knee add day that is removed at night. The Plan of Care, dated 4/23/21 to 6/21/21, lacked inclusion of the ice machine as equipment used by the patient to meet the patient's needs. 5. Patient #6 had a start of care date of 10/11/16. Clinical record review revealed: a. The Plan of Care, dated 3/19/21 to 5/17/21, identified the following equipment and supplies as used by the patient: medication organizers, scale, single point cane, shower chair, hand held shower, stool riser with grab bars, front wheeled walker, grab bars, lifeline, wheelchair, walker, and nebulizer. b. The skilled nurse visit notes, dated 3/30, 4/2, 4/16, and 4/20/21, documented the patient's use of incontinence briefs The Plan of Care, dated 3/19/21 to 5/17/21, lacked inclusion of incontinence supplies as equipment used by the patient to meet the patient's needs. c. The Home Care Aide Plan of Care, undated, directed the aides to shave the patient as requested by the patient. The Plans of Care as stated above lacked inclusion of shaving by the home health aide as an extension of nursing services was approved by the physician. 6. Patient #7 had a start of care date of 2/4/21 and a discharge date of 3/30/21. Clinical record review revealed: a. The Plan of Care, dated 2/4/21 5 to 4/4/21, ordered skilled nursing visits every 55 to 60 days and as needed. The Plan of Care did not specify the number of as needed visits for the nurse. b. The Plan of Care, dated 2/4/21 to 4/4/21, ordered home care aide visits two times per week. The Plan of Care did not specify the duration of visits for the home care aide. The above findings for Patients #1, #2, #3, #5, #6, and #7 were reviewed with the Administrator and the Clinical Manager. Agency staff provided no further information prior to the end of the survey.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on personnel file review and staff interview, the agency failed to document the home health aide successfully completed a training and competency evaluation program as specified per regulatory requirements 1 of 1 sampled home health aides hired since the last survey(Staff E). The agency provided home health aide services to 9 patients at the time of the survey and employed 3 home health aides. Failure to document the home health aide's successful completion of a training and competency evaluation program increased patient risk of injury and/or inadequate care during care provision. Findings include: On 5/5/21, the surveyor reviewed the home health aide personnel files. Staff E, was hired on 3/2/21. No information regarding verification of completion of a course or training and testing completed at the agency was provided for the aide. Interview with the Administrator on 5/5/21 at 12:15 PM, revealed the agency contacted Staff E and the agency is working with the aide to obtain a copy of the certificate received after completion of the course. The Administrator stated "I know Staff E completed the certified nurse aide (CNA) course as she is currently in nursing school." The agency failed to have documentation of Staff E completion of a state administered program, including Staff E's certificate, or documentation of verification with the state's registry that Staff E is on the registry. The Administrator received the above findings and no further information was provided prior to the end of the survey.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on personnel file review and staff interview, the agency failed to document whether extra skills competencies were evaluated in a laboratory setting using a pseudo patient or in a home setting while being performed on an actual patient for 2 of 3 sampled home health aides (Staff F and G). The agency provided home health aide services to 9 patients at the time of the survey and employed 3 home health aides. Failure to document how extra skills competencies were evaluated increased patient risk of injury and/or inadequate care during care provision if the skills taught in a laboratory setting would not transfer successfully to the patient's home. Findings include: a. Staff F, Home Health Aide, had a hire date of 12/1/93. The aide's personnel file failed to include documentation of skills testing for the tasks assigned for Patient#1 application of a medicated powder and medicated shampoo. b. Staff G, Home Health Aide, had a hire date of 5/6/05. The aide's personnel file failed to include documentation of skills testing for the tasks assigned for Patient #1 application of a medicated powder and medicated shampoo. Interview on 5/5/21 at 12:15 with the Administrator revealed the aides were trained in shampooing the patient's hair, but no documentation was found on application of medicated powder or medicated shampoo. The above stated findings were reviewed with the Administrator. No further information was received prior to the end of the survey.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and staff interview, the agency failed to ensure the patient's clinical record included accurate and complete documentation of interventions in the patient record for 1 of 2 sampled patients with wounds/surgical incisions (Patient #5). The agency reported a census of 20 patients at the time of the survey, including 2 patients receiving wound care. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patient's at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's policy, titled Wound/Surgical Incision Assessment, dated 5/2018, identified the wound/surgical incision will be assessed and documented by the RN with the admission, follow up, resumption of care OASIS and with every nursing visit. The surgical incision should be accessed at each skilled nursing visit and photographed if deterioration or a significant change is present. Initial documenation should include incision location, measurement (length and width), drainage, and treatment. Interview on 5/3/21 at 10:45 with the Administrator revealed wound assessment and measurements should be completed every visit and include a length, width, and depth, along with weekly photos. Patient #5 had a start of care date of 4/23/21 and was discharged from the agency on 5/3/21. Clinical record review revealed: a. The Plan of Care (POCs), dated 4/23/21 to 6/21/21, included orders for the nurse to visit 1 to 2 times per week to monitor incision for infection, teach pain management, assess vitals, and provide medication education.. b. The initial comprehensive assessment completed at start of care, dated 4/23/21, documented the patient's wound was covered with a bandage/occlusive dressing and the doctor will remove the dressing at an appointment the next week. c. The skilled nurse visit, dated 4/26/21, documented the adhesive dressing was still intact and the patient would see the surgeon on 4/28/21. d. The skilled nurse visit, dated 4/29/21, documented the patient's left knee surgical incision had no drainage and steristrips in place. The agency failed to document the surgical incision's measurements once the dressing was removed. The above findings were reviewed with the Administrator and Clinical Manager. 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 and agency staff interview, the agency failed to send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 1 sampled patients with a discharge where a summary should have been sent (Patient #7). The agency reported discharging 30 patients in the past 6 months. 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: Patient #7 had a start of care date of 2/4/21 and a discharge date of 3/30/21. Clinical record revealed: a. The Plan of Care, dated 2/4/21 to 4/4/21, documented the patient's diagnoses as chronic renal failure. b. A skilled nurse narrative note, dated 3/30/21, documented the patient's spouse would provide the cares for the patient as the patient wanted a sponge bath only and would not get in the shower. The patient discharged from private pay services. c. A physician's order, dated 3/30/21, included orders to discharge the patient from the private home health program and patient's spouse would provide care. Interview on 5/5/21 at 8:29 AM with the Clinical Manager revealed the agency did not perform a discharge assessment, drug regimen review, or discharge summary at the time of the discharge since the patient was private pay. The agency did not send the transfer and discharge summaries as required by regulation. The above findings were reviewed with the Administrator and Clinical Manager. 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 agency policy review, clinical record review and agency staff interview, the agency failed to ensure authentication of staff documentation in each patient's clinical record included the date and time of the employee signature for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, and #8). The agency reported a current census of 20 patients at the time of the survey. Failure to maintain appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: According to the agency policy, titled Timely Documentation (Skilled Nursing Notes/Therapy Notes) and dated 1/2018, all documentation must be completed and in the patient clinical record within 72 hours following each home visit. 1. Patient #1 had a start of care date of 4/13/2021. The Plan of Care, dated 4/13/2021 to 6/11/2021, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. The patient's clinical record included the following: a. The initial comprehensive assessment completed at admission to home health services, dated 4/13/2021, was hand signed by the registered nurse lacked a time of signature. b. The skilled nursing visit note, dated 4/28/2021, were hand signed by the RN completing the visit. The notes lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. c. The home health aide visit notes, dated 4/14/2021, 4/16/2021, 4/19/2021, 4/22/2021, 4/26/2021 and 4/29/2021, were hand signed by the home health aide completing the visit. The notes lacked a date and time of the aide's signature signifying completion of the documentation of the visit. 2. Patient #2 had a start of care date of 4/27/2021. The Plan of Care, dated 4/27/2021 to 6/19/2021, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. The patient's clinical record included the following: a. The home health aide visit note, dated 4/29/2021, was hand signed by the home health aide completing the visit. The note lacked a date and time of the aide's signature signifying completion of the documentation of the visit. b. On 5/4/2021 at 9:45 AM, the surveyor accompanied Staff C, Registered Nurse (RN), to Patient #2's home. During the home visit, the surveyor observed Staff C perform a physical assessment and changed the unna boot dressings to the patient's lower legs; however, the surveyor did not observe the RN document any of the visit findings in the patient's chart prior to exit from the patient's home. 3. Patient #3 had a start of care date of 11/12/2020. The Plans of Care, dated 11/12/2020 to 1/10/2020, 1/11/21 to 3/11/21 and 3/12/21 to 5/10/21, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. Clinical record review revealed: a. The initial comprehensive assessment completed at admission to home health services, dated 11/12/2020, was hand signed by the registered nurse (RN) lacked a time of signature. b. The update to the comprehensive assessment completed at transfer, dated 12/21/2020, was hand signed by the registered nurse lacked a time of signature. c. The update to the comprehensive assessment completed at resumption of care, dated 12/24/21, was hand signed by the registered nurse lacked a time of signature. d. The updates to the comprehensive assessment completed at recertification, dated 1/7/21 and 3/9/21, were hand signed by the registered nurse lacked a time of signature.. e. The skilled nursing visit notes, dated 3/2/21, 3/23/21, 4/7/21, were hand signed by the RN completing the visit. The notes lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. c. The home health aide visit notes, dated 3/1/21, 3/4/21, 3/8/21, 3/11/21, 3/15/21, 3/18/21, 3/22/21, 3/25/21, 3/29/21, 4/1/21, 4/5/21, 4/8/21, 4/12/21, 4/15/21, 4/19/21, 4/22/21, 4/26/21, and 4/29/21, were hand signed by the home health aide completing the visit. The notes lacked a date and time of the aide's signature signifying completion of the documentation of the visit. 4. Patient #4 had a start of care date of 3/31/21. The Plan of Care, dated 3/31/21 to 5/29/21, included orders for skilled nursing services. Clinical record review revealed: a. The initial comprehensive assessment completed at admission to home health services, dated 3/31/21, was hand signed by the registered nurse lacked a time of signature. b. The skilled nursing visit notes, dated 4/2/21, 4/7/21, 4/9/21, 4/12/21, 4/14/21, 4/16/21, 4/19/21, 4/21/21, 4/23/21, 4/26/21, 4/28/21, and 5/3/21, were hand signed by the RN completing the visit. The notes lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. 5. Patient #5 had a start of care date of 4/23/21 and discharged from the agency on 5/3/21. The Plan of Care, dated 4/23/21 to 6/21/21, included orders for skilled nursing, physical therapy, and occupational therapy services. Clinical record review revealed: a. The initial comprehensive assessment completed at admission to home health services, dated 4/23/21, was hand signed by the registered nurse lacked a time of signature. b. The skilled nursing visit notes, dated 4/26/21 and 4/29/21, were hand signed by the RN completing the visit. The notes lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. c. The update to the comprehensive assessment completed at discharge, dated 5/3/21, was hand signed by the registered nurse lacked a time of signature. 6. Patient #6 had a start of care date of 10/11/2016 and was discharged from the agency on 4/24/21. The Plans of Care, dated 11/11/2020 to 1/17/2020, 1/18/21 to 3/18/21 and 3/19/21 to 5/17/21, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. Clinical record review revealed: a. The updates to the comprehensive assessment completed for recertification, dated 11/17/2020, 1/13/21, and 3/16/21, were hand signed by the registered nurse lacked a time of signature. b. The updates to the comprehensive assessment completed for transfer 3/18/2020, was hand signed by the registered nurse lacked a time of signature. c. The update to the comprehensive assessment completed at resumption of care, dated 3/25/21, was hand signed by the registered nurse lacked a time of signature. d. The updates to the comprehensive assessment completed for transfer to inpatient facility, dated 4/26/21, were hand signed by the registered nurse lacked a time of signature. e. The skilled nursing visit notes, dated 3/2/21, 3/30/21, 4/2/21, 4/6/21, 4/9/21, 4/13/21, 4/16/21, 4/20/21, 4/23/21, were hand signed by the RN completing the visit. The notes lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. f. The home health aide visit notes, dated 3/26/21, 3/29/21, 4/1/21, 4/5/21, 4/8/21, 4/12/21, 4/15/21, 4/19/21, and 4/22/21, were hand signed by the home health aide completing the visit. The notes lacked a date and time of the aide's signature signifying completion of the documentation of the visit. 7. Patient #7 had a start of care date of 2/4/21 and was discharged from the agency on 3/30/21. The Plan of Care, dated 2/4/21 to 4/4/21, included orders for skilled nursing and home health aide services. Clinical record review revealed: a. The initial comprehensive assessment completed at admission to home health services, dated 2/4/21, was hand signed by the registered nurse (RN) lacked a time of signature. b. The home health aide visit notes, dated 2/9/21, 2/16/21, 2/23/21, 3/5/21, 3/9/21, 3/12/21, 3/16/21, 3/23/21, 3/30/21, were hand signed by the home health aide completing the visit. The notes lacked a date and time of the aide's signature signifying completion of the documentation of the visit. 8. Patient #8 had a start of care date of 8/20/13. The Plans of Care, dated 11/11/2020 to 1/9/21, 1/10/21 to 3/10/21 and 3/11/21 to 5/9/21, included orders for skilled nursing and home health aide services. Clinical record review revealed: a. The updates to the comprehensive assessment completed for recertification, dated 11/10/2020, 1/5/21, and 3/9/21, were hand signed by the registered nurse lacked a time of signature. b. The skilled nursing visit notes, dated 3/16/21, 3/30/21, 4/13/21, and 4/27/21, were hand signed by the RN completing the visit. The notes lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. c. The home health aide visit notes, dated 3/1/21, 3/3/21, 3/5/21, 3/8/21, 3/10/21, 3/12/21, 3/15/21, 3/17/21, 3/19/21, 3/22/21, 3/24/21, 3/26/21, 3/29/21, 3/31/21, 4/2/21, 4/5/21, 4/7/21, 4/9/21, 4/12/21, 4/14/21, 4/16/21, 4/19/21, 4/21/21, 4/23/21, 4/26/21, 4/28/21, and 4/30/21, were hand signed by the home health aide completing the visit. The notes lacked a date and time of the aide's signature signifying completion of the documentation of the visit. The above findings for Patients #1, #2, #3, #4, #5, #6, #7, and #8 were reviewed with the Administrator and the Clinical Manager. Agency staff provided no further information prior to the end of the survey.