Every finding on record at Iowa Home Care, LLC

The Iowa Department of Inspections, Appeals and Licensing conducted a complaint investigation for complaint #2727754-C from 2/2/26 to 2/4/26. The complaint survey identified the following: Condition of Participation 42 CFR 484.54 Patient Rights, was investigated and no condition level deficiency was identified. Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services, was investigated and no condition level on one standard level deficiency was identified. The home health agency reported a current census of 571 patients including 444 patients in the West Des Moines parent office and 127 patients in the Marshalltown branch office.

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 agency policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 1 sampled patients with orders for wound assessments (Patient #3). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Care Planning Proscess, dated November 2024, the patient-specific clinical plan of care (POC) includes: all patient care orders including verbal orders. According to the undated agency policy, titled Skin and Wound Care-Assessment: Wound, wounds and patients change therefore wounds need to be re-assessed regularly and treated according to the changing needs of the patient and the wound. In home care, a professional reassessment of most wounds is usually indicated at least once a week. Basic wound assessment for all wounds, dimensions: length, width, and depth, presence of tunneling or undermining, shape, wound bed tissue, wound edges, surrounding skin, drainage and pain. During an interview on 2/5/26 at 9:10 AM, Staff C, Corporate Clinical stated the agency did not have documentation of wound assessment on 1/22/26. Patient #4 had a start of care date of 9/4/25. Review of the clinical record revealed the following: a. The POC, dated 1/2/26 to 3/2/26, identified the patient had diagnosis that included Amyotrophic lateral sclerosis (ALS) and included orders for skilled nursing services 1 time a week to observe and assess wuonds. Assessment to include wound location, wound measurements (width/length/depth). Change dressing to pressure ulcer on right buttock: remove old dressing, cleanse with soap and water, apply thin layer of triple antibiotic ointment and bandaid, change 2 to 3 times a week and when soiled. b. The skilled nurse visit note, dated 1/22/26, Staff H, Licensed practical nurse (LPN), documented the dressing changed to the right buttock per orders. The note lacked documentation of an assessment of the patients wound, or assessment of wound measurements. c. The wound assessment form, dated 11/6/25 through 1/30/26, identified the patient had a stage 2 pressure area to the right buttock. The assessment form lacked documentation of a wound assessment or assessment of the wound measurements on 1/22/26. The clinical record lacked completion of the physician orders per the patient's POC. The above findings were reviewed with the agency Administrator, Chief of Organizational Performance, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead, RN.

The Department of Inspections, Appeals & Licensing conducted a complaint survey from 9/29/25 to 10/1/25 for complaint #2607198-C and complaint #2628057-C. The complaint 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 610 patients at the time of the survey, including 469 patients who received services through the West Des Moines office and 136 patients who received services through the Marshalltown branch office. The end date of the survey was adjusted to the date that the CMS 2567 is issued to the provider based on the Federal Government shutdown.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on staff interview, clinical record review and agency policy review, the agency failed to promptly notify the physician of changes in the patient condition or needs that suggest an alteration to the plan of care for 1 of 5 sampled patients receiving catheter cares (Patient #4). Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: According to the agency policy, titled Incident Reporting, dated October 2024, an incident is an unusual event involving organizational personnel, a patient, and family/caregiver. An incident is any happening that is not consistent with the routine operation of the organization or the routine care of a patient. When an incident occurs, an incident report form should be completed within 24 hours of the knowledge of the incident, supervisor should be notified immediately, preferably within 24 hours, and there should be follow up with the patient and family/caregiver, and/or patient's physician. During an interview on 9/30/25, Staff B, Clinical Manager, stated incidents should be documented within 24 hours of the occurrence and the physician should be notified. Patient #4 had a start of care date of 7/9/21. Clinical record review revealed: a. The Plan of Care, dated 8/17/25 to 10/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nursing services 1 time a week. b. The skilled nurse visit note, dated 9/1/25, completed by Staff C, Registered Nurse (RN), identified Staff C changed Patient #4's catheter and the patient tolerated well. c. An incident report form, dated 9/5/25 (3 days late according to agency policy), completed by Staff C, RN, detailed an incident that occurred on 9/1/25 during Patient #4's catheter change. d. During an interview on 9/30/25, a Patient Care Technician from Patient #4's physician's office, denied seeing any information in Patient's #4's clinical record identifying the home care agency notified the physician of the incident that occurred during Patient #4's catheter change on 9/1/25. The Patient Care Tech identified the physician was made aware of the issue when the patient presented to the clinic on 9/4/25 to have catheter checked and to make sure there was no infection due to incident on 9/1/25. The home health agency failed to promptly notify the physician when Patient's #4's catheter change didn't follow routine procedure. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on agency staff interview, patient and family interview, agency policy review and clinical record review, the agency clinician's failed to communicate with other staff, the patient and the caregiver regarding missing scheduled visits as identified by agency policy for 1 of 6 sampled patients. Failure to communicate with other staff, patient and caregiver placed the patient in a position to not receive needed cares and interventions as ordered in the plan of care. Findings include: According to agency policy, titled Care/Service Coordination, dated 11/24, identified it is the responsibility of the Registered Nurse Case Manager to facilitate communication about changes in the patient status among assigned personnel. Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. According to agency policy, titled Care Planning Process, dated 11/24, identified changes in the plan of care will be noted with the following documentation: assessment, plan of care with clinical outcome goals, care plan with specific services/actions to be taken, clinical notes and verbal orders. During an interview on 9/30/25 at 2:30 PM, Staff A, Agency President, reported agency expectation is for staff to call into the office 2-4 hours in advance of missing work. Staff are to talk with scheduler, scheduler should ask nurses what visits can be moved and what visits need covered for the day. Care coordination department is responsible for notifying patients of schedule change. Some nurses prefer to call patients themselves as well as following above process. Patient #1 had a start of care date of 7/15/25. Clinical record review revealed the following: 1. Plans of Care, dated 7/15/25 to 9/12/25 and 9/13/25 to 11/11/25, included diagnosis of Amyotrophic Lateral Sclerosis (ALS) and orders for skilled nursing services 5 visits per week. 2. Care coordination note, dated 8/14/25, identified coordination meeting with home care staff, private nursing staff and family. 3. Missed visit notes, dated 8/18/25 and 8/19/25, identified nurse unable to go at requested time for visit so family/patient declined need for skilled nurse visit today. 4. Care coordination note, dated 8/19/25 at 9:06 AM, identified RN clinical manager left message for patient after RN case manager started receiving text messages from patient and caregiver wondering where nurse was at, as nurse was scheduled to arrive at 8:00 AM. Nurse scheduled was out ill and supervisor had covered visit later in the day, unaware that visit needed to be from 8:00 AM to 8:30 AM due to private care staff in the home at other time later in the day. 5. Care coordination note, dated 8/20/25, identified summary of new patient cares, reasons for home care, outcome of meeting on 8/14/25 was for home care to provide skilled nurse services 5 days per week, Monday through Friday from 8:00 AM to 8:30 AM. 6. Missed visit note, dated 9/10/25, identified nurse out ill today and patient/caregiver declined need for skilled nurse visit today. 7. Missed visit note, dated 9/22/25, identified regular nurse unavailable at regularly scheduled visit time, cares will resume on 9/23/25. 8. Missed visit note, dated 9/29/25, identified no service needed for today. During an interview on 9/29/25 at 1:50 PM, Staff A, Agency President, reported Patient #1 has another payor source in the home. Patient/family came to home health agency asking to provide skilled nursing for patient 5 days per week from 8:00 AM to approximately 9:00 AM, this would allow patient to continue to receive other payor source services due to a recent changes and patient’s need to utilize a home care service to the full extent before other payor source would cover the services. During an interview on 9/29/25 at 2:05 PM, Staff A, Agency President, reported the scheduled nurse for 9/29/25 was not aware the visit needed to be made at 8:00 AM, nurse had not made visit and had not contacted patient or family at time of interview. Office staff contacted family and 9/29/25's visit was declined. During a home observation visit on 9/30/25 at 7:55 AM, Patient #1 reported problem is the agency staff don't show up. Patient #1 has his/her mom or other people as back up when agency staff don't show up as scheduled. During an interview on 9/30/25 at 10:01 AM, Patient #1's mother reported problems with home health staff not showing up, staff don't call or cancel visit. When no one shows up, mother calls office but no one is in the office until 8:00 AM. Mother working with agency staff to figure this out. Skilled nurses and agency staff failed to notify patient and family timely of not making visits at requested scheduled timeframe as agreed upon. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on patient interview, agency staff interview, clinical record reviews and agency policy review, the agency failed to ensure clinicians followed agency policies and procedures when inserting an indwelling catheter for 1 of 5 sampled patients (Patient #4). Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. Findings include: According to the agency policy titled Genitourinary System-Indwelling Catheter Insertion for Female, in pertinent part, adhere to standard precautions and explain procedure to patient. To perform catheterization, lubricate the catheter with water soluble lubricant to minimize urethra trauma. During an interview on 9/30/25 at 10:14 AM, Staff B, Clinical Manager reported skilled nurses are expected to follow the agency catheterization policy and to notify the physician immediately regarding any deviation to the policy. Patient #4 had a start of care date of 7/9/21. Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/17/25 to 10/25/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nursing services. b. The skilled nurse visit note, dated 9/1/25, completed by Staff C, Registered Nurse (RN), identified catheter changed and patient tolerated well. c. An incident report, dated 9/5/25, completed by Staff C, RN, detailed the catheterization stating at one point the catheter tip became dry and the tip of the catheter kept sliding toward the opening of the vagina. Skilled nurse took another sterile, clean catch catheter, got olive oil from the kitchen, put it in a clean cup from the dishwasher, used the clean catch catheter tip to point to the opening of the vagina for mapping purposes, lubricated the tip of the other catheter for insertion with olive oil and inserted the catheter. Skilled nurse noted clear, yellow urine in bag and no bleeding. d. During an interview on 9/30/25 at 1:30 PM, Staff C, RN confirmed the above information from the incident report. e. During an interview on 9/30/25 at 8:59 AM, Patient #4 identified a nurse came to her home on 9/1/25 to change her catheter and struggled with insertion. The nurse used all of the lubricant on one catheter and then brought in another catheter. Patient reported instead of the nurse taking out the catheter she couldn't get in, she left it in while putting a second catheter in. The nurse needed more lubricant and patient told her she didn't have any in the home so she used cooking oil from the kitchen. After the nurse got the second catheter in, she took the first one out. Patient reported feeling sore and had blood clots in the catheter tubing. The skilled nurse failed to follow agency procedure for insertion of an indwelling catheter. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on agency staff interview, agency job description review and clinical record review, the agency failed to ensure a registered nurse (RN) completed licensed practical nurse (LPN) supervision for 1 of 3 sampled patients with LPN services. (Patient #1) Failure to supervise licensed practical nurse services, increased the risk that patients received unsatisfactory or inappropriate care from licensed practical nurses. Findings include: According to agency job description, titled Registered Nurse Case Manager, dated 5/18, Registered Nurse Case Manager directs, supervises and educates LPNs, personal care and support service staff, patients/consumers and family members. During an interview on 9/30/25 at 2:30 PM with Staff A, Agency President, reported LPN supervision is completed at a minimum at the time of recertification. Patient #1 had a start of care date of 7/15/25. Clinical record review revealed the following: 1. Plans of Care, dated 7/15/25 to 9/12/25 and 9/13/25 to 11/11/25, included diagnosis of Amyotrophic Lateral Sclerosis (ALS) and orders for skilled nursing services 5 visits per week. 2. Skilled nurse visit notes, dated 8/26/25, 8/28/25, 9/2/25 and 9/4/25, completed by LPNs, identified services were provided. 3. Recertification comprehensive assessment, dated 9/8/25, identified supervision was not applicable. During an interview on 9/30/25 at 2:40 PM, Staff A, Agency President, confirmed no LPN supervision had been completed at recertification time point for Patient #1. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.

The Department of Inspections, Appeals and Licensing conducted a complaint investigation for complaint #107757-C from 7/8/24 to 7/10/24. The allegation related to 42 CFR 484.80 Home Health Aide Services was investigated and no condition level deficiencies were identified and one standard level deficiency was identified. The allegation related to 42 CFR 484.50 Patient Rights was investigated and no condition level deficiencies were identified and no standard level deficiencies was identified. The agency reported a census of 523 patients at the time 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 clinical record review, the agency failed to ensure home health aides provided care to agency patients 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 1 of 6 sampled patients (Patient #5). Failure to ensure 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 increased the risk that patient's personal care needs were not safely and/or adequately met. Findings include: Patient #5 had a start of care date of 3/23/23. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/17/24 to 3/16/24, included physician orders for home health aide services to assist with personal cares and transfers using Hoyer lift. b. On 3/8/24, Staff G, Home Care Aide, reported an incident where she was transferring Patient #5 in the Hoyer lift. Documentation revealed Staff G closed the legs of the Hoyer lift to get under Patient #5's bed better and the Hoyer lift tilted, causing Patient #5 to fall to the floor. The home health aide failed to utilize the Hoyer lift per agency guidelines and training.

A Recertification Survey was conducted by the Department of Inspections and Appeals from 10/30/23 through 11/1/23 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections and Appeals conducted a Recertification Survey from 10/30/23 through 11/1/23. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a census of 788 patients at the time of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record, agency policy, and staff interview, the agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 4 sampled patients with wounds (Patient #4 and #16). Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. Findings include: 2. Patient #4 had a start of care date of 9/9/21. Clinical record review revealed the following: a. Resumption of Care comprehensive assessment, dated 9/21/23, included documentation the patient had 2 stage 3 pressure ulcers and 1 stage 4 pressure ulcer but lacked documentation of wound measurements for the 3 wounds. b. Skilled nursing visit note, dated 9/22/23, included documentation the Registered Nurse reported wound measurements and pictures were obtained on the 9/21/23 resumption of care comprehensive assessment visit. No new skin issues noted. During an interview on 11/1/23 at 2:45 PM, the Clinical Manager reported she had reviewed the clinical record and did not find wound measurements for the comprehensive assessment on 9/21/23 but did identify wound pictures taken on 9/21/23 and uploaded in the electronic medical record on 9/23/23. The clinical record lacked documentation of wound measurements with every comprehensive assessment. The surveyor reviewed the above findings with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. According to agency policy titled, Initial and Comprehensive Assessment, dated September 2023 revealed in pertinent part that during a comprehensive patient assessment, a physical assessment including skin and other relevant data related to pertinent physical findings of skin breakdown. According to agency policy titled, Skin and Wound Care - Assessment: Wound, last revised January 2022 revealed in pertinent part that in home care, a professional reassessment of most wounds is usually indicated at least once a week. 1. Patient #16 had a start of care date of 3/6/23 and received services from the agency. Clinical record review revealed the following: M1311 - Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage revealed the patient had 1 stage 3 wound and 2 wounds at stage 4. The Discharge Assessment, dated 5/3/23, lacked assessment of the patient’s wounds. In an interview on 11/1/23 at 11:15 AM, the Clinical Manager reported that she expected wound measurements to be part of the comprehensive discharge assessment.

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, clinical record review, and staff interview, 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 2 of 3 sampled patients requiring a resumption of care assessment (Patient #13 and #10). 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: 2. Patient #10 had a start of care date of 1/24/2020. Clinical record review revealed the following: a. The patient's clinical record included hospital stay from 9/12/23 to 9/16/23 for complaints of headaches. b. The physicians order, dated 9/18/23, included an order due to staffing and patient's schedule, resumption of care visit unable to be completed until 9/1/23. The OASIS resumption of care, dated 9/19/23, included documentation of resumption of care. The agency failed to complete the resumption of care within 48 hours after hospital discharge. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. According to the agency policy, Reassessment/Recertification, last revised February 2022 revealed in pertinent part: OASIS assessments for resumption of care will be completed within the mandated time frames. Each patient will be reassessed when the patient returns home after an inpatient admission lasting 24 hours or longer for any purpose other than diagnostic testing. 1. Patient #13 had a start of care date of 5/5/17. Clinical record review revealed the following: The patient's clinical record included hospital discharge documentation, dated 3/24/2020, and dated as received by the agency by facsimile on 11/1/22. The hospital documentation indicated the patient was admitted to the inpatient facility on 10/21/22 under a mental health court order. The patient remained hospitalized and was discharged to home on 10/28/22 with home health resumption of care on 10/31/22. The Care Coordination note on 10/28/22 at 3:31 PM revealed that the client will be discharging today and that the inpatient facility was informed the agency won’t be able to resume services until Monday (10/31/22). In an interview on 11/1/23 at 11:15 PM, the Clinical Manager reported that there was a note in the patient’s chart that reads the agency would not be able to resume services until 10/31/22. The Clinical Manager then shrugged her shoulders and reported that this note would not help meet the 48 hour requirement for resumption of care to be completed.

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 observation, clinical record, agency policy, patient interview, and staff interview, the agency failed to include all medications in Plans of Care for 4 of 7 patients with home visits (Patient #2, #3, #5, and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. Findings include: 4. Patient #3 had a start of care date of 6/15/23. Clinical record review revealed the Plans of Care, dated 6/15/23 to 8/13/23, 8/14/23 to 10/12/23 and 10/13/23 to 12/11/23, included physician order for Sucralfate 1 gram tablet orally twice daily. On 10/31/23 at 11:00 AM, in an interview, during a home visit observation with Staff D, Physical Therapy Assistant (PTA), the patient reported that the patient has not taken Sucralfate 1 gram oral tablets for a year. The patient explained the medication might have been in the patient’s home when the patient started home health agency services, but the patient was not taking the medication. The Plans of Care failed to identify accurate medications the patient was taking. The surveyor sreviewed the above findings with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. 2. Patient #2 had a start of care date of 10/1/2015. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 8/20/23 to 10/18/23 and 10/19/23 to 12/17/23, included physician orders for skilled nursing services 1 time per week and daily home health aide services. The POCs included instructions for the home health aide to assist in apply a light dusting of Nystatin powder in reddened skin areas as needed to the groin, breasts and armpits. The POCs did not include a dosage amount or frequency of application (such as daily or twice a day). The POC, dated 8/20/23 to 10/18/23, did not include an order for the use of Triad cream (Zinc Oxide- based hydrophilic paste). The POC, dated 10/19/23 to 12/17/23, included the following order: "Wound #1 TREATMENT: SN or HHA to change dressing to right groin/peri area wound: Cleanse with soap and water, apply Triad cream and change every day." The POC, dated 10/19/23 to 12/17/23, did not include an order for Calmoseptine. b. The home health aide care plan, dated 6/21/23 and 10/19/23, included the following instructions to the home health aides: "Apply Nystatin powder in redden skin areas as needed to groin, breasts, armpits and neck. Apply Triad cream to peri area wound after bathing." The home health aide care plan, dated 10/19/23, included the following additional instructions to the home health aides: "Cleanse both sides of groin and peri area with antibacterial soap and water daily, drying skin well. Reapply Calmoseptine cream to peri area skin break down along left side and to left groin." c. A physician order, dated 10/5/23, included orders from the wound care center health practitioner as follows: bath aide to cleanse bilateral groin area daily with antibacterial soap and water, dry the skin well. Reapply Calmoseptine cream to peri skin breakdown along left side and to left groin. Apply clean incontinence brief daily. Easter Seals staff to apply Calmoseptine cream to left groin and peri area nightly; unfasten brief and remove if soiled to allow air flow at night with sleeping. Discontinue use of Nystatin Powder." d. A wound picture, dated 10/18/23, identified the patient's wound was located on the left groin area, and not the right as identified on the POC (dated 10/19/23 to 12/17/23) order. On 10/31/23 at 8:25 AM, during a home visit observation, the surveyor observed the patient lying supine in the patient’s bed. Staff C, RN, sanitized their hands at the start of the visit, set up a clean field, sanitized their hands again and removed vitals equipment from Staff C’s nursing bag. After assessing the patient's vital signs, Staff C, RN, assisted the patient with rolling over to the left side and then cleansed the patient’s peri area with wet wipes. The surveyor observed the patient had a copious amount of a white powdery substance located in the groin folds. Staff C, RN, and the surveyor observed a small indentation on the left peri area near the labia. Staff C, RN, stated that the wound was “about the size of the head of an eraser” and reported they observed a small open area. Staff C, RN, removed the gloves, sanitized their hands, donned gloves and assessed the wound by using a disposable measuring tape and taking pictures with Staff C’s phone. Staff C, RN, asked the patient if staff were using Triad cream on the patient’s wound area. The patient reported that staff were using the Triad cream. Staff C, RN, applied Triad cream to the tip of their gloved finger and applied the Triad cream to the patient’s wound and surrounding area. In an interview during the same home visit observation, Staff C, RN, reported they had been Patient #2’s nurse for approximately 6 weeks, and the wound located in the perineal area was fairly new at that time. Staff C, RN, reported the patient starting going to the Wound Center for treatment almost immediately, and the home health aides have been applying Triad cream. Patient #2 reported the patient has been using Calmoseptine cream on the wound per recommendation from the Wound Center, and would switch back to the Triad cream once the wound healed. Staff C, RN, then told the patient that they had misunderstood the patient when Staff C, applied the Triad cream. Staff C, RN, reported the home health aide would be coming to shower the patient at 9:00 AM and apply the appropriate cream at that time. Staff C, RN, then pulled the physician orders up on the computer from the Wound Center. Staff C, RN, and the surveyor observed wound care orders, dated 10/5/23, and Staff C reported that 10/5/23 were the most recent orders. Both Staff C, RN, and the surveyor noted that the orders included direction for the application of Calmoseptine, not Triad cream. Staff C, RN, then pulled up the home health aide care plan on the computer and identified that the home health aide had direction to apply Calmoseptine. Staff C, RN, reported that when orders come into the office, office staff usually update the POC. Staff C, RN, reported that they had just completed a recertification assessment on the patient the week of 10/19/23. Staff C, RN, reported the home health aides provide services 7 days a week, but only assist the patient with a shower on Mondays, Wednesdays and Fridays. The patient reported the home health aide had not provided services yet on 10/31/23 (a Tuesday), but was due to show up after Staff C’s, RN, visit. On 11/1/23 at 12:17 PM, during an interview, Staff H, Home Health Aide (HHA), reported that they had applied Calmoseptine to the groin area when they provided services to the patient on 10/30/23. Staff H, Home Health Aide, explained they did not apply Nystatin powder to the groin due to the powder becoming a cottage cheese consistency when they applied it with the Calmoseptine. Staff H, Home Health Aide, thought that maybe the patient’s Consumer Directed Care Attendant staff applied the Nystatin powder to the groin during the overnight shift on 10/30 to 10/31/23. Staff H, Home Health Aide explained that if it looked like they had documented that they had applied either the Nystatin powder, or Triad cream on 10/30/23, that the documentation was not correct and Staff H had not applied either one. On 11/1/23 at 2:55 PM, during an interview, Staff P, Corporate RN, reported that the wound care orders from the wound care center, dated 10/5/23, should have been added to the POC, dated 10/19/23 to 12/17/23. The staff should have been applying Calmoseptine and not the Triad cream and Nystatin powder. 11/1/23 at 3:10 PM, during an interview, Staff Q, HHA, reported they had been applying Calmoseptine, not Triad cream or Nystatin. Staff Q, HHA, reported they had completed a home health aide visit on 10/31/23. Staff Q, HHA, reported they wiped the patient’s perineal area with baby wipes and applied Calmoseptine (neither Staff C, RN, or Staff Q, HHA, washed the patient's perineal/groin area with antibacterial soap and water per the physician orders, dated 10/5/23). On 11/1/23 at 3:30 PM, during an interview, Staff C, RN, reported that they did say during the visit that the patient had a small open wound, but upon further inspection, Staff realized the patient did not have an open area and the wound was healed. Staff C, RN, reported they had contacted the patient’s physician and got an order to discontinue the Calmoseptine and change to Triad cream. 3. Patient #5 had a start of care date of 3/21/19. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 10/26/23 to 12/24/23, included orders for Lysine (amino acid) 500 milligrams (mg) with instructions for the patient to take 1 tablet daily. The POC also included the order for Polyethylene glycol (laxative) 3350 1 scoop daily. b. The undated Client Medication Report included orders for Lysine 500 mg with instructions for the patient to take 1 tablet daily. The medication report also included the order for Polyethylene glycol 3350 1 scoop daily. c. During a home visit observation on 10/31/21 at 9:12 am, with Staff G, Registered Nurse, RN, filled the patient medication planner with Lysine 1000 mg tablet daily. The bottle that contained Lysine 1000 mg only had approximately 20 tablets that remained. The patient reported to Staff G, he/she had more bottles of Lysine. Staff G identified she had been the only nurse to set up the patient's medication planners. Staff G removed the Lysine 1000 mg tablets and placed the 500 mg tablets in the patient's medication planners. d. During the same home visit observation, patient interview revealed he/hse no longer took Polyethylene glycol and had not taken it for a long time. He/she now takes a stool softener if anything needed. He/she could not find the bottle and did not know the name of the medications. The POC failed to include the correct medications the patient had been taking. 1. Patient #7 had a start of care date of 3/13/15 and received services from the agency. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 7/29/23 to 9/26/23 and 9/27/23 to 11/25/23 lacked Pepto Bismol and Walgreens Smooth medications. b. During a home visit observation on 10/31/23 at 1:00 PM, with Staff I, Registered Nurse (RN), the 2 medications were observed to be on a side table next to the patient’s couch. The patient reported that she started taking the 2 medications prior to Labor Day to treat diarrhea and took them regularly. c. In an interview with Staff I, she reported that she knew the medications were in the patient’s home and that she would prefer the patient to take Immodium AD to treat her diarrhea, but she was unable to contact the patient’s physician to obtain an order. d. In an interview on 11/1/23 at 11:15 PM, the Clinical Manager agreed that all medications should be listed on the patient’s Plan of Care.

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 observation, clinical record review, agency policy review and agency staff interview, the agency failed to obtain physician orders for the addition of over-the-counter medications to the patient's medication regimen and changes in wound care for 2 of 17 sampled patients (Patient's #4 and #10). Failure to ensure staff obtain physician orders for administration of medications provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 2. Patient #10 had a start of care date of 1/24/23. Review of the clinical record revealed the following: a. The Plans of Care, dated 5/24/23 to 7/22/23, 7/23/23 to 9/20/23 and 9/21/23 to 11/19/23, included diagnosis of suicidal ideations. The Plans of Care included an order for the skilled nurse to instruct regarding management of disease process anxiety to include treatment and medication regimen, signs/symptoms of exacerbation, complications to report and consequences of non-compliance. b. The skilled nurse visit note, dated 6/2/23, lacked documentation of an assessment of the patient's emotional status. Agency staff failed to follow orders on the Plan of Care. Findings include: According to the agency policy, titled Verification of Provider Orders, dated February 2023, all telephone orders or verbal orders will be “read back” to the physician or designee to assure accuracy. Orders will be documented dated and signed by the professional receiving the order. Signed verbal and original provider orders will be in the clinical record within a timely manner. According to the agency procedure, titled Skin and Wound Care – Assessment: Wound, dated January 2022, staff will discuss wound assessment with patient’s physician and obtain orders for care. 1.Patient #4 had a start of care date of 9/9/21. Clinical record review revealed the following: a. Plans of Care, dated 8/30/23 to 10/28/23 and 10/29/23 to 12/27/23, included physician orders for wound care to right knee, skilled nurse to change dressing 3 times weekly as follows: cleanse with Vashe (wound cleansing solution) moistened gauze for 3-5 minutes and pat dry. Discontinue use of Vashe on knee once Santyl (debriding ointment) is initiated and just cleanse with normal saline. Apply nickel thick layer of Santyl to wound bed, top with saline moistened gauze, and cover with an ABD pad (abdominal gauze pad) and secure with gauze roll. Perform daily or as able per home health care. b. Resumption of Care order, dated 10/16/23, included physician order to resume Plan of Care, dated 8/30/23 to 10/28/23 with the following changes: patient is full code, skilled nurse frequency 5 times weekly, aide frequency 9 visits per week, and social worker frequency 1 time weekly. On 10/31/23 at 2:00 PM, during a home visit observation, the surveyor observed Staff F, LPN, wash their hands prior to patient contact. Staff F, LPN, washed their hands, gloved, pulled back the patient’s covers and removed the wound dressing covering the patient’s knee. The surveyor observed Staff F, LPN, remove a Mepilex dressing (type of adhesive foam dressing) and gauze covering the right knee. Staff F, LPN, removed their gloves, washed their hands, applied Santyl to the wound bed, covered the wound with saline moistened gauze and with a Mepilex dressing. In an interview, during the same home visit observation, Staff F, LPN, confirmed that they removed and applied a Mepilex dressing to the right knee. 11/1/23 at 2:07 PM, during an interview, Staff F, LPN, confirmed Staff F performed wound care on 10/17-10/20/23,10/23/23, 10/24/23, 10/26/23, 10/27/23. Staff F, RN, reported the ABD pads and rolled gauze had never been delivered to the patient’s home, and they have always used the foam Mepilex dressing to cover the right knee wound. Staff F, LPN was aware of the discrepancy in the physician order for wound care and what they were using for wound care. Staff F, LPN, believed the RN Case Manager for the patient notified the wound care center of the discrepancy with the wound care dressing, but the wound care center would not change the order without seeing the patient. 11/1/23 at 2:00 PM, during an interview, Staff O, RN, reported that Staff O had performed wound care to the right knee on 10/25/23 with the update to the comprehensive assessment due at the time of recertification. Staff O, RN, reported Staff O soaked gauze with Vasche, applied Santyl and covered the right knee wound with a foam dressing. Staff O reported the patient discharged from the hospital with a foam dressing on the right knee and nursing staff have been applying a foam dressing to the right knee wound since the patient came home from hospital (last hospital discharge date was 10/16/23). Staff O, RN, reported the patient has not been to the wound care center since the patient got out of the hospital. On 11/1/23 at 4:12 PM, during an interview, Staff P, Corporate RN, reported that the wound care order from the wound clinic, dated 8/23/23, included physician orders for wound care to be completed daily or as able per home health care. Staff P, Corporate RN, reported the order for 3 days a week was a minimum, but the nursing staff were doing wound care to the right knee 5 days a week. On 11/1/23 at 4:35 PM, during an interview, Staff P, Corporate RN, and Staff E, Clinical Manager, reported that the patient’s provider has been in the home weekly when staff have been performing wound care, and is aware of what the staff are doing for wound care. Staff P, Corporate RN, and Staff E, Clinical Manager, confirmed that they did not have a written physician order for wound care which specified the use of a foam dressing rather than an ABD pad and roll gauze. The agency failed to obtain a change in wound care orders when the ordered wound care supplies were not available.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 14 sampled patients receiving home health aide services (Patients #2, #14 and #13). The agency reported 373 patients who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: 3. 1. Patient #13 had a start of care date of 5/5/17. The Plan of Care, dated 6/3/23 to 8/1/23, included physician orders for home health aide 7 visits per week starting from 06/03/2023, 7 visits per week starting from 07/01/2023. Clinical record review revealed in pertinent part: Home Health Aide to assist with personal cares (lotion included), check skin, level of assistance with mobility- stand by assist, weigh client and notify nurse of weight loss or gain greater than 3 pounds in 24 hours or greater than 5 pounds in a week, encourage fluids, incidental housekeeping. Home health aide to use calm and approachable body language, communicate cares prior to performing the cares and if client refuses the cares home health aide to disengage with client and reattempt to offer cares 10 minutes later, if client continues to refuse home health aide to notify RN case manager and relay to patient that we want to help you with your personal cares and your next home health aide visit will be tomorrow and we will try again at that point, have a good day and then the home health aide is to dismiss themselves. The Home Health Aide Visit Note on 6/24/23 revealed the patient weighed 152 pounds (lbs.). The Home Health Aide Visit Note on 6/25/23 revealed the patient weighed 157 lbs. which was a 5 lbs. The Clinical Record lacked that the home health aide reported the increase in the patient’s weight to a nurse. Staff M, Certified Nurse Assistant (CNA), visited the patient for home health aide care. Staff N, Certified Nurse Assistant (CNA), visited the patient for home health aide care. Staff M visited the patient a total of 28 times. Staff M did not weigh the patient 25 times. Staff N visited the patient 5 times. Staff N did not weigh the patient at any of the visits and did not apply lotion to the patient 3 times. The Clinical Record lacked that Staff M or Staff N reported that the patient refused to be weighed or have lotion applied to a nurse. The above findings were reviewed with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. According to the agency policy titled Home Health Aide Plan of Care, dated November 2023, the home health aide plan of care will be individualized to the specific patient and will include at least type of services/procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications ordinarily self-administered. Home health aides are members of the interdisciplinary team and shall report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and shall complete appropriate documentation in compliance with organizational policies and procedures. During an interview on 10/31/23 at 2:00 PM the Clinical Manager stated unassigned tasks not on the aide care plan, the aide will contact the Registered Nurse by text or by phone to approve. 1. Patient #2 had a start of care date of 10/1/15. The Plans of Care, dated 8/20/23 to 10/18/23 and 10/19/23 to 10/17/23, included physician orders for skilled nursing services for assessment 1 time a week and home health aide services 7 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan, dated 6/21/23, included direction to the aide to apply lotion to torso/extremities, assist using Nystatin powder in redden skin areas as needed to groin, breasts, armpits, neck. Apply triad cream to peri area wound after bathing. b. The physician's order, dated 10/5/23, included orders for the home health aide to assist patient with cleansing peri area and goin daily with antibacterial soap and dry well. Re-apply calmoseptine cream to peri area skin break down along left side and to left groin. Apply clean brief daily. The order also included to discontinue use of Nystatin powder. c. The home health aide care plan, dated 10/19/23, included the task of cleanse both sides of the groin and peri area with antibacterial soap and water daily, drying skin well. Reapply calmoseptine cream to peri area along left side and to the left groin. d. The home health aide visit notes, dated 10/7, 10/8, 10/9, 10/10, 10/13, 10/16, 10/18, 10/20, 10/21, 10/22, 10/24/23, included documentation the home health aide applied lotion, Nystatin powder and triad cream to the groin along with calmoseptine cream to the peri area. 11/1/23 at 3:10 PM, during an interview, Staff Q, HHA, reported they had been applying Calmoseptine, not Triad cream or Nystatin. Staff Q, HHA, reported they had completed a home health aide visit on 10/31/23. Staff Q reported they wiped the patient’s perineal area with baby wipes and applied Calmoseptine. When asked how an individual could tell what tasks had been completed, as 3 of the tasks, applying lotion, applying Triad cream and applying Nystatin powder, were all on the same task line, Staff Q reported they did not know how someone could tell which specific tasks they had completed. Staff Q confirmed they only made one entry in the box labeled “performed”, and did not make a separate entry for the 3 tasks that were lumped together on the form. The home health aide failed to follow the aide care plan and documented the Nystatin powder and triad continued along with the task of applying calmoseptine cream. 2. Patient #14 had a start of care date of 6/22/23 and discharge date of 7/14/23. The Plans of Care, dated 6/21/23 t0 8/20/23, included physician orders for skilled nursing services for assessment 1 time a week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The home health aide plan of care, dated 6/21/23, included the task to complete a shower every visit. b. The home health aide visit note, dated 7/6/23, included documentation the aide completed a partial bath given. No documentation of the Registered Nurse notified and directed the change in the home health aide care plan noted. The home health aide failed to follow the aide care plan as written.