Every finding on record at Iowa Home Care, LLC

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 3/2/26 through 3/4/26 and the home health agency was found to be operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 3/2/26 through 3/4/26. 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 current census of 71 patients.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home observation visits, patient interview, clinical record review, and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care (POC), including all medical supplies/equipment and all medication for used by the patient for 3 of 3 home visits (Patients #1, #2, and #3). Failure to maintain complete and accurate POCs with current orders placed patient at risk to not receive services, supplies, and/or medication according to assessed needs and physician orders. Findings include: 3. Patient #3 had a start of care date of 4/21/23. Clinical record review revealed: a. The POCs, dated 12/6/25 to 2/3/26 and 2/4/26 to 4/4/26, identified the patient had a primary diagnosis of Hypertensive heart disease with kidney disease and included physician orders for medications and medical supplies/equipment used by the patient including: cane, grab bars, hand-held shower, nebulizer, oxygen, oxygen concentrator, oxygen tubing, pill splitter, shower chair, urinal, walker, medication planner, humidifier, nonsterile gloves and personal protective equipment. b. During a home observation visit on 3/3/26 at 10:00 AM with Staff G, Registered Nurse (RN), the surveyor identified the patient had a incentive spirometer (device to help with strengthening the lungs) located on the dining table. The patient stated the incentive spirometer used since hospitalization in January, 2026. c. During the same home observation visit, the surveyor identified the patient had the medication polyethylene glycol (laxative) and took 17 grams daily as needed for constipation. The patient stated the medication used for greater than 2 months. The agency failed to include all medical supplies/equipment on the patient's POC, including an incentive spirometer and the medication polyethylene glycol. The above findings reviewed with the Administrator/Clinical Manager, Chief of Organizational Performance and Office Manager. According to the agency policy titled Care Planning Process, last revised October 2024, the patient specific clinical plan of care includes: supplies and equipment required and medications including dose/frequency/route/purpose. 1.Patient #1 had a start of care date of 12/27/24. Clinical record review revealed: a.The POC, dated 12/22/25 to 2/19/26, identified the patient had a primary diagnosis of lymphedema (swelling in the body) and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: grab bars, hand held shower, incontinent supplies, lymphedema pumps, pill splitter, scale, sock slider, compression hose, TENS unit (transcutaneous electrical nerve stimulation), wound care supplies, wood shelf in tub to sit on. The POC identified the patient receives skilled nursing visits every other week. b.During a home observation visit on 3/2/26 at 3:00 PM with Staff G, Registered Nurse (RN), a walker was present in the home. The patient reported that he uses the walker in the home and started using the walker 1 month ago. The patient patient reported that he received two therapeutic seat cushions (used to prevent pressure ulcers and/or skin breakdown) 2 years ago and placed them in the chairs he uses daily. The agency failed to include all medical supplies/equipment on the patient's POC, including a walker and therapeutic seat cushions. 2.Patient #2 had a start of care date of 5/16/22. Clinical record review revealed: a.The POC, dated 2/24/26 to 4/24/26, identified the patient had a primary diagnosis of essential hypertension (high blood pressure) and included physician orders for medication used by the patient. The POC included albuterol sulfate (to treat or prevent sudden breathing problems) 90 micrograms/actuation aerosol inhaler 2 puffs every 4 hours as needed for shortness of breath. b.During a home observation visit on 3/3/26 at 10:00 AM, with Staff B, Licensed Practical Nurse (LPN), the patient reported that she has never used albuterol. The agency failed to include current medications used by the patient.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on home observation visit, clinical record review, staff and patient interview and agency policy review, the agency failed to provide services only as ordered by the physician for 3 of 3 home visit observations (Patients #1, #2. and #3). Failure to ensure staff follow physician orders for treatments provided by agency staff placed patient at risk for inconsistent care/treatment and possible harm. Finding include: 3. Patient #3 had a start of care date of 3/21/23. Clinical record review revealed the following: a. The POC, dated 2/4/26 to 4/4/26, included primary diagnosis of Hypertensive heart disease with kidney disease and physician orders for skilled nurse and medications including: Varenicline (smoking cessation) 1 milligram (mg) 2 times a day, Finasteride (5 alpha reductase inhibitor) 5 mg daily, Iron (supplement) 325 mg daily and Tamsulosin (alpha blocker) 0.4 mg 2 times a day. b. During a home observation visit on 3/3/26 at 10:00 AM with Staff G, RN, set up the patients medications in a medication planner. The surveyor noted the following medications not set up in the planner: Varenicline, Fenasteride, Iron and Tamsulosin. c. During an interview at the same home visit the patient stated Varenicline discontinued after approximately 30 days (start date 1/19/26). The clinical record failed to include orders to discontinue the medication. d. During an interview at the same home visit, Staff G, RN, stated the medications Fenasteride, Iron and Tamsulosin not added to the patient's medication planner due to the primary physician will not order until the patient seen at the urology clinic. Staff G stated the medications not taken for 2 weeks and the urology appointment not scheduled. Agency staff failed to discontiue medications and/or place medications on hold when no longer administered. The above stated findings were reviewed with Administrator/Clinical Manager, Chief of Organizational Performance and Office Manager. According to agency policy, titled Care Planning Process, last revised October 2024, the Plan of Care (POC) will be based upon the physician's orders and will encompass the services required to meet the patient's needs and any other pertinent instruction related to the patient's care and treatments that the organization will provide, specific to the patient's care needs. 1.Patient #1 had a start of care date of 12/27/24. Clinical record review revealed: a.The POC, dated 12/22/25 to 2/19/26, identified the patient had a diagnosis of lymphedema (swelling of the body) and failed to include orders for physical therapy (PT). b.A clinical record document titled Medical Documentation, dated 12/11/25, included a new order for in home PT to evaluate and treat for 2 visits per week for 6 weeks. The Clinical Record failed to reveal that PT performed home visits or why the PT did not perform home visits. 2.Patient #2 had a start of care date of 5/16/22. Clinical record review revealed: a.The POC, dated 2/24/26 to 4/24/26, identified the patient had a diagnosis of essential hypertension (high blood pressure)and included skilled nurse orders of no blood pressure to left arm due to lymph node removal. b.During a home observation visit on 3/3/26 at 10:00 AM, Staff B, Licensed Practical Nurse (LPN) performed a blood pressure procedure on the patient's left arm. Agency staff failed to follow physician's orders to not use the patient's left arm to obtain blood pressure.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, staff interview, and agency policy, the agency failed to ensure the home health aides successfully completed competencies in home health aide skills that exceed basic skills, which require a registered nurse (RN), or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 3 of 4 sampled home health aides (Staff C, D, and E). Failure to ensure home health aides were competent in a skill which exceed the level of basic home health aide skills placed agency patient at risk to receive inadequate or unsafe home health aide services. Findings include: According to agency policy titled Home Health Training, last revised January 2014, the competency evaluation program is conducted at the time of orientation prior to delivery of services and annually. The program includes observation of performance of the following skills: taking and recording temperature, pulse, and respiration; appropriate and safe techniques in personal hygiene and grooming that include bed bath, sponge, tub, or shower bath, shampoo in sink, tub or bed, nail and skin care, oral hygiene, toileting and elimination; safe transfer techniques and ambulation assistance; normal range of motion and positioning. Additional training will be provided and documented when clients are receiving high technology or complex services. Home health aide personnel files must contain competency training and /or evaluation and competency skills checklist. In an interview on 3/4/26 at 9:56 AM, when asked about Staff E’s competency testing for simple dressing changes, the Administrator reported that she was not employed at the agency during Staff E’s employment period and was not aware of why the competency testing was not performed. In an interview on 3/4/26 at 10:13 AM, the Chief of Organizational Performance reported that the agency did not start skills testing for feeding until after Staff C was hired. 1.Patient #1 had a start of care date of 12/27/24. Clinical record review revealed the following: a.The Plan of Care (POC), dated 12/22/25 to 2/19/26, directed the aide to shave the patient's face at the direction of the client. The clinical record identified that Staff C provided care to the patient. b.Staff C had a hire date of 3/1/24. Staff C's personnel file lacked documentation of competency testing to ensure competency evaluation was completed for shaving the patient's face. 2. Patient #4 had a start of care date of 8/19/25. Clinical record review revealed the following: a.Home health aide care plan, dated 2/15/26, directed the aide to apply orthotic braces to feet and assist with feeding. The clinical record identified that Staff C provided care to the patient. b.Staff C had a hire date of 3/1/24. Staff C's personnel file lacked documentation of competency testing to ensure competency evaluation was completed to apply orthotic braces to feet and assist with feeding. In an interview on 3/4/26 at 10:13 AM, the Chief of Organizational Performance reported that the agency did not start skills testing for feeding until after Staff C was hired. 3.Patient #7 had a start of care date of 3/29/25. Clinical record review revealed the following: a.The POC, dated 7/27/25 to 9/24/25, directed the aides to perform a simple dressing change every visit to the patient's right shin and to the patient's sacral (base of spine) wound. The clinical record identified that Staff D and E provided care to the patient. b.Staff D had a hire date of 7/16/24. Staff D's personnel filed lacked documentation of competency testing to ensure competency evaluation was completed for simple dressing changes. c.Staff E had a hire date of 4/10/25. Staff E's personnel file lacked documentation of competency testing to ensure competency evaluation was completed for simple dressing changes. The above findings were reviewed with the Chief of Organizational Performance, Administrator/Clinical Manager, and Office Manager

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, policy review and agency staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 6 sampled patients receiving home health aide services (Patients #4). The agency reported 49 patients received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: According to the policy, titled Plan of Care, dated October, 2024, the patinet's Registered Nurse (RN) Case Manager or other appropriate skilled professional, upon initialization of aide services, will develop the written home health aide plan of care, consistent with the comprehensive plan of care and physician orders. The home health aide care plan will be individualized to the specific patient and will include safety measures, including use of specific equipment. During an interview on 3/3/26 at 3:15 PM, The Administrator/Clinical Manager stated the aide documentation was completed on the aide documentation visit and If a task not completed, the aide informs the RN. Patient #4 had a start of care date of 12/4/2020. Clinical record review revealed the following: a. The Plans of Care (POC), dated 12/17/25 to 2/14/26 and 2/15/26 to 4/15/26, included primary diagnosis of Chromosomal abnormality and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 2/15/26, identified the following home health aide tasks: two person assist with transfers or use mechanical lift. c. Aide visit notes, dated 2/17/26, 2/18/26, 2/19/26, 2/20/26 and 2/23/26, completed by Staff H, Home Care Aide (HCA), included documentation transfer completed but failed to identify the transfer completed by a 2 person transfer or use of a mechanical lift. The agency failed to document the actudal type of transfer completed using 2 person assist or mechanical lift. The above stated findings were reviewed with the Administrator/Clinical Manager, Chief of Organizational Performance and Office Manager.

The Department of Inspections and Appeals conducted a Recertification Survey from 4/17/23 through 4/19/23, and found the home health agency operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 4/17/23 to 4/19/23. The survey identified the following standard level deficient practices. The agency reported a census of 37 patients at the time of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 3 of 7 sampled patients (Patients #3, #6 and #7). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: Review of the agency policy, titled Care Planning Process, dated 1/2022, revealed each patient's care and services will follow a patient-specific plan of care (POC). The comprehensive assessment is the basis for patient specific orders identified on the POC. Agency clinicians will inform the patient's physician of any changes that suggest a need to alter the POC. On 4/17/23 at 11:10 AM, during an interview, the Administrator/Clinical Manager reported if agency staff are unable to follow the visit frequency on the POC, agency staff write an order to notify the physician. 3. Patient #3 had a start of care date of 10/8/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/30/23 to 3/30/23, included orders for skilled nursing services one time a week, every other week. b. The clinical record included documentation of a skilled nursing visit on a Friday, dated 3/10/23, and then the next subsequent skilled nursing visit on a Monday, dated 3/27/23, 2 weeks and 3 days later. The clinical record lacked documentation of missed visit notification to the physician. On 4/18/23 at 3:36 PM, during an interview, the Chief of Organizational Performance agreed the patient went more than 2 weeks without a visit. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. 1. Patient #6 had a start of care date of 10/20/20. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 10/10/22 to 12/8/22 and 12/9/22 to 2/6/23, included orders for skilled nursing services one time every other week, every other week and home care aide 8 hours a week. b. The physician's order dated 11/29/22, included orders to resume the POC dated 10/10/22 to 12/8/22. c. The clinical record failed to include documentation of a home care aide visit the week of 11/29/23 through 12/3/23. The clinical record lacked documentation of missed visit notification to the physician. On 4/18/23 at 10:40 AM, during an interview, the Administrator stated the agency did not have an order to delay the home care aide visits. 2. Patient #7 had a start of care date of 1/24/19. Review of the clinical record revealed the following: a. The POC, dated 11/4/23 to 1/2/23, included orders for skilled nursing services one time every other week, every other week and home care aide 6 hours a week. b. The physician's order dated 12/16/22, included orders to resume the POC dated 11/4/22 to 1/2/23. c. The clinical record failed to include documentation of a home care aide visit the week of 12/16/22 through 12/3/23. The clinical record lacked documentation of missed visit notification to the physician.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including frequency and duration of all disciplines and all supplies/equipment and medications used by the patient for 3 of 7 sampled patients (Patients #1, #3 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: Review of the agency policy, titled Care Planning Process, dated 1/2022, revealed each patient's care and services will follow a patient-specific plan of care (POC). The POC will include equipment, supplies and specific services required to meet the needs of the patient. The POC will identify the type, frequency and duration of services. 2. Patient #1 had a start of care date of 7/8/21. On 4/18/23 at 10:10 AM, during a home visit observation with Staff B, Registered Nurse (RN), the surveyor observed the patient was wearing an emergency response button on the front of the patient’s shirt. In an interview, during the same home visit observation, the patient confirmed the patient used the emergency response button in the event the patient fell and no one was around. The patient discussed the last fall the patient had resulted in an emergency room visit. Both the patient and the patient’s spouse reported the patient had the emergency response button for several years. Review of the clinical record revealed the following: The POCs, dated 12/30/22 to 2/27/23 and 2/28/23 to 4/28/23, failed to identify the patient used an emergency response button. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. Patient #6 had a start of care date of 10/20/20 and discharge date of 12/23/22. a. The plan of care (POC), dated 11/3/22 to 1/2/23, included orders for skilled nursing services every other week and home care aide services up to 6 hours a week of home care aide or homemaker services. b. The POC failed to include orders specific to the home care aide and homemaker services.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 2 of 7 sampled patients (Patients #3 and #4). Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to not receive safe, individualized and consistent care designed to meet each patients' health care needs. Findings include: Review of the agency policy, titled Care Planning Process, dated 1/2022, revealed each patient's care and services will follow a patient-specific plan of care (POC). The comprehensive assessment is the basis for patient specific orders identified on the POC. On 4/18/23 at 3:36 PM, during an interview, the Administrator/Clinical Manager reported that medical monitoring and assessment of the urinary output for this patient would include totaling the number of wet/soiled diapers for the shift. 1. Patient #4, a pediatric patient, had a start of care date of 8/14/17. Review of the clinical record revealed the following: a. The POCs, dated 1/14/23 to 3/14/23 and 3/15/23 to 5/13/23, identified a diagnosis of chronic respiratory failure and included orders for skilled nursing (SN) 10 to 16 hours per day and 5 to 7 days per week. The POCs included orders for the SN to obtain vital signs at least every 4 hours and may obtain more at a more frequent rate as assessment warrants. The POC specified vitals signs included temperature, pulse, respirations and pulse oximetry. The POCs included orders for the skilled nurse to medically monitor and assess the patient’s urine output. b. The SN visit, dated 2/13/23, included documentation that the nurse worked a 10 hour shift from 6:50 AM to 4:01 PM. The nurse documented a temperature reading at 7:00 AM and 11:00 AM, but lacked documentation of a temperature reading after 11:00 AM. c. The SN visit, dated 2/14/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. d. The SN visit, dated 2/15/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 9:00 AM, but lacked documentation of a temperature reading before or after 9:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. e. The SN visit, dated 2/16/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:55 PM. The nurse documented a temperature reading at 7:00 AM and 11:00 AM, but lacked documentation of a temperature reading after 11:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. f. The SN visit, dated 2/17/23, included documentation that the nurse worked a 10 hour shift from 6:52 AM to 4:52 PM. The nurse documented that a temperature reading at 7:00 AM, 3:00 PM and 4:30 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. g. The SN visit, dated 2/23/23, included documentation that the nurse worked an 8 hour shift from 6:51 AM to 2:51 PM. The nurse documented a temperature reading at 7:00 AM and 2:45 PM, but lacked documentation of a temperature reading between 7:00 AM and 2:45 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. h. The SN visit, dated 2/24/23, included documentation that the nurse worked a 9.25 hour shift from 6:48 AM to 4:02 PM. The nurse documented a temperature reading at 7:20 AM and 11:00 AM, but lacked documentation of a temperature reading after 11:00 AM. i. The SN visit, dated 3/1/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:52 PM. The nurse documented a temperature reading at 7:00 AM, 3:00 PM and 4:30 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. j. The SN visit, dated 3/2/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 8:45 AM and 3:00 PM, but lacked documentation of a temperature reading between 8:45 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. k. The SN visit, dated 3/3/23, included documentation that the nurse worked a 10 hour shift from 6:49 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. l. The SN visit, dated 3/6/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM and 3:00 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. m. The SN visit, dated 3/7/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. n. The SN visit, dated 3/9/23, included documentation that the nurse worked a 9.5 hour shift from 6:53 AM to 4:30 PM. The nurse documented a temperature reading at 7:00 AM and 3:00 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. o. The SN visit, dated 3/10/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM and 4:30 PM, but lacked documentation of a temperature reading between 7:00 AM and 4:30 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. p. The clinical record included documentation of 2 skilled nursing visits, dated 3/13/23. One SN visit included documentation the nurse worked a 10 hour shift from 6:53 AM to 4:53 PM, and did not document a temperature reading or urine output. The second SN visit, included documentation the nurse completed an update to the comprehensive assessment due at the time of recertification from 11:04 PM to 12:45 PM. The update to the comprehensive assessment included documentation of a temperature taken during the time frame of the visit and an average urine output of 6 to 8 wet diapers per day. The nurses failed to ensure the assessment of the patient’s temperature reading every 4 hours. q. The SN visit, dated 3/14/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM and 11:00 AM, but lacked documentation of a temperature reading after 11:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. r. The SN visit, dated 3/16/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM and 3:00 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. s. The SN visit, dated 3/17/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:56 PM. The nurse documented a temperature reading at 7:00 AM and 11:00 AM, but lacked documentation of a temperature reading after 11:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. t. The SN visit, dated 3/20/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:53 PM. The nurse documented a temperature reading at 7:00 AM and 3:00 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. u. The SN visit, dated 3/21/23, included documentation that the nurse worked a 10 hour shift from 6:55 AM to 4:55 PM. The nurse documented a temperature reading at 7:00 AM and 3:00 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. v. The SN visit, dated 3/23/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. w. The SN visit, dated 3/24/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. x. The SN visit, dated 3/27/23, included documentation that the nurse worked a 9.25 hour shift from 6:50 AM to 4:06 PM. The nurse documented a temperature reading at 7:05 AM and 11:00 AM, but lacked documentation of a temperature reading after 11:00 AM. y. The SN visit, dated 3/28/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:56 PM. The nurse documented a temperature reading at 7:00 AM and 3:00 PM, but lacked documentation of a temperature reading between 7:00 AM and 3:00 PM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. z. The SN visit, dated 3/29/23, included documentation that the nurse worked an 8 hour shift from 6:51 AM to 2:52 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. aa. The SN visit, dated 3/30/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:52 PM. The nurse documented a temperature reading at 7:00 AM and 11:00 AM, but lacked documentation of a temperature reading after 11:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. bb. The SN visit, dated 3/31/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. cc. The SN visit, dated 4/3/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:52 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. dd. The SN visit, dated 4/4/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:52 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. ee. The SN visit, dated 4/5/23, included documentation that the nurse worked a 10 hour shift from 6:48 AM to 4:48 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. ff. The SN visit, dated 4/6/23, included documentation that the nurse worked a 10 hour shift from 6:52 AM to 4:53 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. gg. The SN visit, dated 4/7/23, included documentation that the nurse worked a 10 hour shift from 6:54 AM to 4:56 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. hh. The SN visit, dated 4/10/23, included documentation that the nurse worked a 10 hour shift from 6:55 AM to 4:55 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. ii. The SN visit, dated 4/11/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. jj. The SN visit, dated 4/12/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:54 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. kk. The SN visit, dated 4/13/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:51 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. The visit note lacked documentation the nurse assessed the patient’s urine output amount based on the number of diapers the patient used. ll. The SN visit, dated 4/14/23, included documentation that the nurse worked a 10 hour shift from 6:51 AM to 4:45 PM. The nurse documented a temperature reading at 7:00 AM, but lacked documentation of a temperature reading after 7:00 AM. 2. Patient #3 had a start of care date of 10/8/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/30/23 to 3/30/23, included an order for SN services and an order for the SN to assess the arteriovenous (AV) fistula (used for dialysis treatment) blood flow and patency by palpating for thrill (rumbling sensation) and auscultate for bruit (rumbling sound). b. The skilled nursing visit, dated 2/24/23, lacked documentation the nurse assessed the patient's AV fistula per the POC orders. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

The State Agency conducted a complaint investigation for complaint #61200-C, from 12/14/21 to 12/15/21. The allegation related to 42 CFR 484.50 Patient Rights: substantiated with related deficiencies. The allegation related to 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care: substantiated with related deficiency. The allegation related to 42 CFR 484.80 Home Health Aide Services: substantiated with no related deficiency. The recertification survey, conducted 10/22/18 through 10/24/18, found the agency operating out of compliance with the following: The survey also found the agency operating out of compliance with multiple other standard level regulatory requirements.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency complaint log, patient and staff interview, the agency failed to ensure the patient was informed about changes in the care to be furnished for 1 of 3 sampled patients (Patient #2). The agency reported a census of 50 patients at the time of the survey. Failure to notify the patient of changes in the care to be furnished and document the patient was informed of and agreed to the changes puts the patient at risk of not receiving the needed services. Findings include: The agency policy, titled Care Planning Process, dated April 2019, indicated the patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conferences/summary forms, and discharge/clinical summaries. Patient-specific clinical plan of care includes orders for patient-specific home health service needs identified in the comprehensive assessment and the responsible discipline(s), treatments and procedures, including amount/frequency/duration. 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. Patient #2 had a start of care date of 9/26/14. The Plans of Care, dated 8/20/21 to 10/18/21 and 10/19/21 to 12/17/21, included the diagnosis of quadriplegia and physician orders for skilled nursing and home health aide services. During a phone interview on 12/14/21 at 7:32 PM, Patient #2 reported receiving home health aide services Monday through Friday every morning. Patient was notified the aide schedule had changed and the aide would no longer be able to provide this service. The last day of services was provided on 10/22/21. Patient reported calling agency office around 11/9/21 and spoke with receptionist, inquiring when aide services would start again and was told agency was working on finding staff. Patient called office three times in a week and was told each time, agency was working on finding staff. Patient received one call from agency Interim Administrator around 11/12/21 and was informed agency working on finding staff. Patient reported calling the corporate complaint line and received a call back the next day from an individual who asked questions and requested names of previous staff that the agency could possibly contact to provide services. Patient received a call from Interim Administrator on 11/29/21 and was offered twice a week aide services. Clinical record reviewed on 12/14/21 revealed: a. Home health aide visit notes in electric medical record, dated 9/7, 9/8, 9/9, 9/10, 9/13, 9/14, 9/15, 9/16, 9/17, 9/20, 9/21, 9/22, 9/23, 9/24, 9/29, 9/30, 10/4, 10/5, 10/6, 10/7, 10/8, 10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19, 10/ 20, 10/ 21,10/ 22; 12/6, 12/8 and 12/13/21. b. Care coordination note in electronic medical record, dated 9/27/21, documenting no staff to provide aide service on 9/28/21. c. Hand written paper care coordination note, dated 10/25/21, identified phone call to patient caregiver reported agency unable to provide services, caregiver will assume cares, and agency will contact patient when staff available to provide services. Documentation provided to surveyor on 12/15/21 at 9:21 AM by Interim Administrator who reported she had checked the hard chart for documentation. During an interview on 12/15/21 at 10:03 AM, Staff C, administrative support/scheduler/aide, reported phone call to patient caregiver on 10/25/21 regarding aide no longer available to provide services, caregiver agreeable to providing care. Staff C reported Patient #2 called office a couple of weeks ago, unable to remember the date of the call. Staff C was out of the office providing services to other patients. The office phone is rolled to Staff C’s cell phone when out of the office. Staff C unable to remember if this phone call was documented in the patient’s clinical record. Staff C unable to remember any contact with patient or caregiver between 10/25/21 and 2 weeks ago. During an interview on 12/14/21 at 3:25 PM, Interim Administrator reported agency having problems covering aide services. Paper complaint form provided for Patient #2, Interim Administrator had on her desk and forgot to provide to surveyor when complaint log was requested at time of surveyor entrance on 12/13/21. During an interview on 12/14/21 at 4:08 PM, Staff D, Registered Nurse, reported Staff C had contacted Staff D, requesting Staff D contact the physician regarding placing aide services on hold due to staffing issues. Staff D obtained an interim order from the physician and entered this in the electronic medical record. Staff D reported Staff C contacted the patient and caregiver regarding the aide services being on hold. Staff D did not contact the patient or caregiver and received no phone calls or contact from them between 10/25/21 through 12/13/21. During an interview on 12/15/21 at 9:21 AM, Interim Administrator reported Staff C, administrative support/scheduler/aide, had contacted Patient #2's caregiver regarding aide no longer available to provide services and the caregiver agreeable to providing care. Patient Interim Administrator reported he/she had no contact with patient until 11/29/21 after receiving a voice mail that was forwarded to Interim Administrator from Chief of Organizational Performance. Interim Administrator reported after receiving voice mail she immediately called the caregiver to discuss concerns. Interim Administrator worked with Staff C to adjust aide schedules and provide aide services 2 days a week for patient. The clinical record review revealed a lack of documentation regarding the multiple phone calls made by the patient to the agency regarding aide services. Agency failed to inform patient of how long aide services would be on hold and when aide services would be provided. Interim administrator and Chief of Organizational Performance received the above findings and agency staff provided no further information prior to the end of the survey.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency complaint log, review of patient’s rights in in the admission packet, patient and staff interview, the agency failed to ensure the documentation of complaint and the resolution of complaint made by an agency patient for 1 of 3 sampled patients (Patient #2). The agency reported a census of 50 patients at the time of the survey. Failure to document and maintain evidence of complaints and the resolution of the complaints allows the problems to persist without being addressed and prevents the home health agency from critically evaluating the nature of the complaints, the investigation, and the resolution of the complaints. Findings include: The agency policy, titled Complaint/Grievance Process, dated June 2018, indicated the agency will consider any difference of opinion, dispute or controversy between a patient or family/caregiver or patient representative and the agency concerning any aspect of services or the application of policies and procedures will be considered a grievance. The agency staff receiving the complaint will immediately discuss, verbally and/or in writing, the grievance with a supervisor within 24 hours of the alleged grievance. The supervisor will investigate the grievance after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction in a timely manner. Complaints and any action taken will be documented on a complaint form. Resolution information will be communicated to the Patient and his/her representative filing the complaint. All complaints will be logged, tracked, trended, and filed in the performance improvement office. The Patients' Rights and Responsibilities, located in the agency admission packet, indicated the patient has the right to lodge complaints and have the complaints as well as your family’s or your representative’s complaints heard, investigated and if possible resolved. Patient #2 had a start of care date of 9/26/14. The Plans of Care, dated 8/20/21 to 10/18/21 and 10/19/21 to 12/17/21, included the diagnosis of quadriplegia and physician orders for skilled nursing and home health aide services. During a phone interview on 12/14/21 at 7:32 PM, Patient #2 reported receiving home health aide services Monday through Friday every morning. Patient was notified the aide schedule had changed and the aide would no longer be able to provide this service. The last day of services was provided on 10/22/21. Patient reported calling agency office around 11/9/21 and spoke with receptionist, inquiring when aide services would start again and was told agency was working on finding staff. Patient called office three times in a week and was told each time, agency was working on finding staff. Patient received one call from agency Interim Administrator around 11/12/21 and was informed agency working on finding staff. The clinical record review revealed a lack of documentation regarding the multiple phone calls made by the patient to the agency regarding aide services. The complaint log provided on 12/14/21 included documentation of a complaint from Patient #2, dated 7/16/21. The complaint log lacked documentation of complaints filed by Patient #2 between 10/22/21 to 12/14/21. During an interview on 12/14/21 at 3:25 PM, Interim Administrator reported agency having problems covering aide services. Paper complaint form provided for Patient #2, Interim Administrator had on her desk and forgot to provide to surveyor when complaint log was requested at time of surveyor entrance on 12/13/21. During an interview on 12/15/21 at 9:21 AM, Interim Administrator reported Staff C, administrative support/scheduler/aide, notified Patient #2 caregiver regarding home health aide services being on hold. Interim Administrator had no contact with patient until 11/29/21 after receiving a voice mail that was forwarded to Interim Administrator from Chief of Organizational Performance. Interim Administrator reported after receiving voice mail she immediately called the caregiver to discuss concerns. Interim Administrator worked with Staff C to adjust aide schedules and provide aide services 2 days a week for patient. During an interview on 12/15/21 at 10:03 AM, Staff C, administrative support/scheduler/aide, reported phone call to Patient # 2's caregiver on 10/25/21 regarding aide no longer available to provide services, caregiver agreeable to providing care. Staff c reported Patient #2 called office a couple of weeks ago, unable to remember the date of the call. Staff C was out of the office providing services to other patients. The office phone is rolled to Staff C’s cell phone when out of the office. Staff C unable to remember if this phone call was documented in the patient’s clinical record. Staff C unable to remember any contact with patient or caregiver between 10/25/21 and 2 weeks ago. The clinical record review revealed a lack of documentation regarding the multiple phone calls made by the patient to the agency regarding aide services. Agency failed to document both the existence of the complaint and the resolution of the complaint. Interim administrator and Chief of Organizational Performance received the above findings and agency staff provided no further information prior to the end of the survey.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of patient’s rights in in the admission packet, patient and staff interview, the agency failed to ensure the revision to the plan of care was communicated to the patient, representative (if any) and the caregiver for 1 of 3 sampled patients (Patient #2). The agency reported a census of 50 patients at the time of the survey. Failure to document and maintain evidence of communication to the patient, representative and caregiver regarding the change in the plan of care and how the change will impact the care delivered by the agency puts the patient at risk of not receiving the appropriate cares to meet the patient needs. Findings include: The agency policy, titled Care Planning Process, dated April 2019, identified the patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. The patient-specific clinical plan of care includes orders for patient-specific home health service needs identified in the comprehensive assessment and the responsible discipline(s), treatments and procedures, including amount/frequency/duration. The Patients' Rights and Responsibilities, located in the agency admission packet, indicated the patient has the right to participate in, consent to or refuse care in advance of and during treatment and be fully informed in advance about your care/service, where appropriate, including the care, treatments and services to be provided, based on the comprehensive assessment; establishing and revising your plan of care; the discipline that will provide the care; the frequency of visits; and the scope of services the agency will provide, specific limitations on services and barriers to treatment. Patient #2 had a start of care date of 9/26/14. The Plans of Care, dated 8/20/21 to 10/18/21 and 10/19/21 to 12/17/21, included the diagnosis of quadriplegia and physician orders for skilled nursing and home health aide services. During a phone interview on 12/14/21 at 7:32 PM, Patient #2 reported receiving home health aide services Monday through Friday every morning. Patient was notified the aide schedule had changed and the aide would no longer be able to provide this service. The last day of services was provided on 10/22/21. Patient reported calling agency office around 11/9/21 and spoke with receptionist, inquiring when aide services would start again and was told agency was working on finding staff. Patient called office three times in a week and was told each time, agency was working on finding staff. Patient received one call from agency Interim Administrator around 11/12/21 and was informed agency working on finding staff. Clinical record review revealed: Hand written paper care coordination note, dated 10/25/21, identified phone call to Patient #2's caregiver reported agency unable to provide services, caregiver will assume cares, and agency will contact patient when staff available to provide services. Documentation provided to surveyor on 12/15/21 at 9:21 AM by Interim Administrator who reported she had checked the hard chart for documentation. During an interview on 12/15/21 at 9:21 AM, Interim Administrator reported Staff C, administrative support/scheduler/aide, notified Patient #2 caregiver regarding home health aide services being on hold. Interim Administrator reported had no contact with patient or patient's caregiver until 11/29/21 after receiving a voice mail that was forwarded to Interim Administrator from Chief of Organizational Performance. Interim Administrator reported after receiving voice mail she immediately called the caregiver to discuss concerns. Interim Administrator worked with Staff C to adjust aide schedules and provide aide services 2 days a week for patient. During an interview on 12/14/21 at 4:08 PM, Staff D, Registered Nurse, reported Staff C had contacted Staff D, requesting Staff D contact the physician regarding placing aide services on hold due to staffing issues. Staff D obtained an interim order from the physician and entered this in the electronic medical record. Staff D reported Staff C contacted the patient and caregiver regarding the aide services being on hold. Staff D did not contact the patient or caregiver and received no phone calls or contact from them between 10/25/21 through 12/13/21. The clinical record review revealed a lack of documentation regarding the multiple phone calls made by the patient to the agency regarding aide services and lack of documentation the agency kept the patient informed of the time frame the aide services would remain on hold, impacting the patient care needs. Interim administrator and Chief of Organizational Performance received the above findings and agency staff provided no further information prior to the end of the survey.

The recertification survey, conducted 6/14/2021 through 6/16/2021 found the agency operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

A Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 6/14/21 through 6/16/21 . The recertification survey found the agency operating out of compliance with the following Condition of Participation: Condition of Participation 42 CFR 484.60 Care Planning, Coordination and Quality of Care (G570, G572, G574, G580, G590 and G606) The survey also found the agency operating out of compliance with multiple other standard level regulatory requirements. The survey found the agency operating in substantial compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency, its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 6/16/21 and ending on 6/16/23.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on review of the agency's complaint logs, review of the agency's incident investigation files, agency policy review and agency staff interview, the agency failed to report suspected allegations of dependent adult abuse (exploitation by theft) as required by agency policy and federal regulations for 1 of 1 patient reviewed with allegations of abuse. (Patient #6) The agency reported a current census of 61 patients at the time of the survey. The agency reported only one allegation of abuse since the last survey on 9/6/2018. Failure to report suspected exploitation by theft to the appropriate authorities, increased the risk of continued exploitation by the alleged perpetrator with patients of the agency and any other health care entity employing the alleged perpetrator. Findings include: During agency staff interview on 6/14/2021 at 9:55 AM, the Administrator reported if an allegation of abuse was made against an agency staff person the alleged perpetrator would be immediately suspended from all direct patient care until the investigation was complete. The Administrator would investigate the allegations by meeting with the patient and others involved, notify Department of Human Services and inform the managed care organization if applicable. According to the policy, titled Assessment of Possible Abuse/Neglect and dated as revised in April 2019, the agency will report all suspected cases of abuse, neglect or exploitation in compliance with appropriate state statutes to the appropriate protection organizations. The policy defined abuse as physical, sexual injury, emotional/mental distress, abandonment, neglect and exploitation as types of abuse. The policy defined exploitation as unexplained loss of social security or pension checks, any evidence material goods are being taken in exchange for care, any evidence that personal belongings (house, jewelry,car), money misuse and money theft are being taken without consent or approval of the patient. The policy defined caregiver as an individual or facility responsible for all or some of the care voluntarily or by agreement, such as a relative, friend or organization personnel. The policy directed any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to the immediate supervisor via incident report. The clinician will then submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with Iowa law by calling the Department of Human Services Hotline and complete a suspected abuse/neglect investigation report within 24 hours of the incident. If the reported incident involves an employee of the agency, the agency will follow the same policy, notifying the Administrator who will immediately remove the staff member from direct patient care as the investigation is initiated. The follow-up will include, as applicable, all required reporting to the appropriate protection organizations. The policy defined report as meaning a verbal or written statement of the abuse/neglect including what, when, who, where to the local welfare office, police department, county sheriff or any licensing organization. The policy defined an individual person mandated to report as any professional or professional assistant who is engaged in the care of the patient or in social services who has reasonable cause to believe that a patient sustained physical injury that is not reasonably explained by the history of the injuries. The policy identified property theft as financial abuse (exploitation). Any staff person who discovers any suspected abuse and/or neglect will immediately report such occurrences to the immediate supervisor. The clinician will call Adult or Child Protective Services in the Department of Human Services to make an oral report within 24 hours followed by completion of a written report within 48 hours. Upon review of the agencies complaint logs, the surveyor identified documentation of a complaint from a neighbor/caregiver of Patient #6, dated 5/18/2021. The complaint alleged Staff F, Licensed Practical Nurse (LPN), a current employee of the home health agency, stole $60.00 from the patient's safe while in the patient's home providing care to the patient. The patient requested discharge from the agency. The agency placed Staff F, LPN, on suspension removing the nurse from all direct patient care. The agency initiated an investigation, interviewing Staff F, LPN, Patient #6 and multiple other patients receiving care from Staff F, LPN. The patient verified $60.00 was missing from the safe. Staff F, LPN, was in the home caring for the patient on the day the money was taken. Staff F, LPN, was not the only person in the patient's home on the day the money was taken. Other patients cared for by Staff F, LPN, did not have any complaints regarding missing items or cares the nurse provided. The agency ended the investigation, removed Staff F, LPN's suspension, allowing her to return to direct patient care, instructed the patient to contact the police if he/she wished and discharged the patient from services as requested by Patient #6. The agency did not report the allegation of exploitation (theft of money) to the Department of Human Services, Department of Inspections and Appeals (oversight agency of the home health) or to the local police either verbally or by written report as directed by the agency policy. On 10/14/15 at approximately 11:00 AM, the above stated findings were reviewed with Staff A, Clinical Manager.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral, within 48 hours of known inpatient facility discharge date, or on the physician ordered start of care date for 5 of 9 sampled patients (Patients #1, #2, #5, #6, and #9). At the time of the survey, the agency reported providing services to 61 patients. Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: According to the agency policy titled, Initial and Comprehensive Assessment and dated 5/2018, a registered nurse, physical therapist, or speech therapist must conduct the initial assessment. The initial assessment must be held within 48 hours of the patient's return home, on the physician ordered start of care date, or at the patient/family request with approval of the physician. During agency staff entrance interviews with the Administrator on 6/14/2021 at 9:55 AM, the Administrator reported Staff J, Home Health Aide/Administrative Assistant was responsible for tracking completion of initial visits for timeliness. The Administrator reported Staff K, Scheduler, does all scheduling of the nurses based on competency and geographic location. During agency staff interview on 6/15/2021 at 2:50 PM, the Clinical Manager reported she and the Administrator were responsible for tracking initial visit timeliness. If the agency receives a referral for home health care and cannot make the initial visit within 48 hours, agency staff notify the physician of the inability to meet the regulation and obtain an order to make the initial visit on a different date. 1. Patient #1 was admitted to the agency on 6/1/2020. Clinical record review revealed: a. The profile page of the electronic health record, documented a referral date of 5/21/2020. b. A fax from the hospital referring the patient to the agency, dated 5/29/2020, on the date of hospital discharge. c. The patient's admission date was 6/1/2020 and included a verbal order from the physician dated 6/1/2020 to evaluate the patient for home care services and perform admission if applicable. The verbal order was received one day after the 48 hours of patient's return home. The clinical record lacked documentation/communication with the physician of the inability to perform initial assessment within 48 hours of referral as required by regulation. 2. Patient #2 was admitted to the agency on 10/20/2020. Clinical record review revealed: a. The profile page of the electronic health record, documented a referral date of 9/23/2020. b. A fax from the hospital referring the patient to the agency, dated 9/23/2020, on the date of hospital discharge. c. The patient's admission date was 10/20/2020 and included a verbal order from the physician dated 9/23/2020 to evaluate the patient for home care services and perform admission if applicable. The clinical record lacked documentation/communication with the physician of the inability to perform initial assessment within 48 hours of referral as required by regulation and the patient was not admitted until 10/20/2020, 27 days after the hospital discharge date. 3. Patient #6 was admitted to the agency on 11/5/2020 and discharged from services on 5/21/21. Clinical record review revealed: a. The profile page of the electronic health record, documented a referral date of 10/19/2020. b. A fax from the hospital referring the patient to the agency, dated 10/9/2020, documented start date of 10/19/2020. c. The patient's admission date was 11/5/2020, 17 days after the documented start date. The clinical record lacked documentation/communication with the physician of the inability to perform initial assessment within 48 hours of referral as required by regulation and the patient was not admitted until 11/5/2020. 4. Patient #5 had a start of care date of 11/11/2020. Clinical record review revealed the following: a. The physician's initial referral order, dated 10/26/2020 and sent to the agency by facsimile on 11/3/2020, ordered home health services for nursing care, social work services, home health aide for personal care assistance, and evaluation of physical therapy, occupational therapy and speech therapy services. The referral did not specify an ordered start of care date. b. The initial comprehensive assessment at the time of admission, dated 11/11/2020, documented the agency received the physician referral on 10/26/2020. c. The clinical record lacked documentation of any follow up with the referring physician to report the inability to reach the patient to set up the initial visit. The clinical record lacked documentation of any physician's order to delay the home health initiation of services. The clinical record lacked documentation of any communication with the patient requiring delay in admission. The patient was not admitted to service until 8 days after receiving the referral information. 5. Patient #9 had a start of care date of 12/14/2020. Clinical record review revealed the following: a. The physician's initial referral order, dated 12/2/2020 and sent to the agency by facsimile on 12/4/2020, ordered home health services for nursing care, home health aide for personal care assistance, and evaluation of physical therapy and occupational therapy therapy services. The referral did not specify an ordered start of care date. b. The clinical record lacked documentation of any follow up with the referring physician to report the inability to reach the patient to set up the initial visit. The clinical record lacked documentation of any physician's order to delay the home health initiation of services. The clinical record lacked documentation of any communication with the patient requiring delay in admission. The patient was not admitted to service until 10 days after receiving the referral information. The above stated findings for Patients #1, #2, #5, #6 and #9 were reviewed with the Administrator, Staff C, Boone Branch Manager, and Staff D, Chief of Organizational Performance. The agency provided no additional 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 clinical record review and agency policy review, the agency failed to ensure completion of the update to the comprehensive assessment with accompanying drug regimen review 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 (Patients #4). The agency provided services to 61 patients at the time of the survey and performed 12 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 Initial and Comprehensive Assessments and dated as revised 5/2018, an update to the comprehensive assessment for resumption of care following a hospital inpatient admission will be completed within 48 hours of the patient's return home from the facility, within 48 hours of the agency's knowledge of the patient's return home from an inpatient admission or on the physician ordered resumption of care date. Patient #4 had a start of care date of 3/8/2021. Clinical record review revealed the following: a. The patient was hospitalized on 6/4/2021 and returned home on 6/5/2021. b. The communication note, dated 6/5/2021, documented the patient contacted the agency to report he/she was leaving the hospital. c. The nurse initiated the update to the assessment on 6/7/2021 but did not complete the assessment until 6/8/2021, 3 days after the agency received knowledge the patient had returned home from the inpatient stay. The assessment was completed 1 day late as required by regulation and the agency's own policy. The above stated findings for Patient #4 were reviewed with the Administrator, Staff C, Boone Branch Manager, and Staff D, Chief of Organizational Performance. The agency provided no additional information prior to the end of the survey.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient/caregiver interview and agency staff interview, the agency: 1) failed to ensure each patient received services as ordered (G572); 2) failed to ensure all supplies/equipment/medications/treatments required by the patient to meet his/her needs were included and accurate on each patient's Plan of Care (G574); 3) failed to provide medications, treatments and services only as ordered by a physician (G580); 4) failed to promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or the plan of care should be altered (G590); and 6) failed to assure communication/coordination of all staff involved in the patient's care (G606). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 61 patients.

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, agency policy 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 4 of 7 sampled patients (Patients #3, #4, #5 and #7). The agency reported a census of 61 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 6/15/2021 at 2:50 PM, the Clinical Manager reported clinicians document communication with the physician in communication notes or by physician order. The Clinical Manager 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. According to the agency policy, titled Care Planning Process and dated April 2019, clinicians will inform the patient's physician of any changes suggesting a need to alter the Plan of Care. Changes will be in writing, dated and signed by the person making the change. In the event visits are provided less than ordered, the agency will consider the reason for the missed visit and the potential/actual impact on the patient. The physician will be updated timely by the clinician if there is an actual/potential significant impact to the patient's health or medical treatment. The agency may wait until the end of the 60 day period to notify the physician if no significant impact was identified. 1. Patient #3 had a start of care date of 10/12/2020. Clinical record review revealed the following: a. The Plan of Care, dated 4/10/2021 to 6/8/2021, included physician orders for home health aide visits twice weekly. The clinical record included documentation of only one home health aide visit during the weeks of 4/25/2021-5/1/2021; 5/9/2021-5/15/2021; and 5/30/2021-6/5/2021. The clinical record lacked documentation of any home health aide visits during the weeks of 4/11/2021-4/17/2021; 4/18/2021-4/24/2021; and 5/16/2021-5/22/2021. b. The clinical record lacked documentation of the reason for the missed visits. The clinical record lacked documentation of any contact with the patient's physician to report the missed visits either verbally or by written notification. The clinical record lacked documentation of any physician orders changing the frequency of planned home health aide visits. 2. Patient #4 had a start of care date of 3/8/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/8/2021 to 5/6/2021, included physician orders for home health aide visits twice daily for 60 days. The clinical record lacked documentation of any home health aide visits on 3/13, 3/14, 3/20, 3/21 3/27, 3/28, 4/3, 4/4, 4/10, 4/11, 4/17, 4/18, 4/22, 4/25, 5/1 and 5/2/2021. The clinical record included documentation of only one home health aide visit on the days of 3/23/2021; 4/1/2021; 4/21/2021; 5/5/2021 and 5/6/2021. The clinical record lacked documentation of the reason for the missed visits. The clinical record lacked documentation of any contact with the patient's physician to report the missed visits either verbally or by written notification. The clinical record lacked documentation of any physician orders changing the frequency of planned home health aide visits. b. The Plan of Care, dated 5/7/2021 to 7/5/2021, included physician orders for home health aide visits twice daily 5 days per week for 60 days. The clinical record included documentation of only one home health aide visit on the days of 5/27/2021; 6/2/2021; and 6/10/2021. The clinical record lacked documentation of the reason for the missed visits. The clinical record lacked documentation of any contact with the patient's physician to report the missed visits either verbally or by written notification. The clinical record lacked documentation of any physician orders changing the frequency of planned home health aide visits. c. The Plan of Care, dated 3/8/2021 to 5/6/2021, directed an evaluation for medical social work services. The interim physician order, dated 3/21/2021, ordered medical social work visits once weekly for 60 days. The clinical record lacked documentation of any social work visits during the weeks of 4/4-10/2021 and 4/18-24/2021. The clinical record lacked documentation of the reason for the missed visits. The clinical record lacked documentation of any contact with the patient's physician to report the missed visits either verbally or by written notification. The clinical record lacked documentation of any physician orders changing the frequency of planned medical social work visits. d. The Plan of Care, dated 3/8/2021 to 5/6/2021, directed skilled nursing visits 3 times weekly for wound care. The clinical record included documentation of only two skilled nursing visits during the week of 5/2-8/2021. The clinical record lacked documentation of the reason for the missed visit. The clinical record lacked documentation of any contact with the patient's physician to report the missed visits either verbally or by written notification. The clinical record lacked documentation of any physician orders changing the frequency of planned skilled nursing visits. e. The Plan of Care, dated 3/8/2021 to 5/6/2021, ordered a physical therapy evaluation. The patient's clinical record lacked documentation of any physical therapy evaluation. The clinical record lacked documentation of the reason for the omission of the physical therapy evaluation as ordered in the Plan of Care. The clinical record lacked documentation of any communication with the physician to report the failure of the agency to initiate the physical therapy evaluation as ordered by the physician. 3. Patient #5 had a start of care date of 11/11/2020. Clinical record review revealed the following: a. The Plan of Care, dated 11/11/2020 to 1/9/2021, directed a medical social worker evaluation. The interim physician order, dated 12/21/2021, decreased the medical social worker frequency of visits to once every other week. b. The Plan of Care, dated 1/10/2021 to 3/10/2021, ordered medical social worker visits increased to once weekly for 60 days. The clinical record lacked documentation of any social work visits during the weeks of 1/17-23/2021; 1/31-2/6/2021; 2/14-20/2021; and 2/28-3/6/2021. The clinical record lacked documentation of the reason for the missed visit. The clinical record lacked documentation of any contact with the patient's physician to report the missed visits either verbally or by written notification. The clinical record lacked documentation of any physician orders changing the frequency of planned medical social work visits. 4. Patient #7 had a start of care date of 3/26/2021 and was discharged from agency services on 4/21/2021. Clinical record review and associated interviews revealed the following: a. The Plan of Care, dated 3/26/2021 to 5/24/2021, ordered a medical social work evaluation once during the first week of service. The clinical record lacked any medical social work evaluation during the first week of services. The clinical record lacked documentation of the reason for omission of the evaluation. The clinical record lacked documentation of any contact with the patient's physician to report the missed visit either verbally or by written notification. b. Agency staff interview on 6/16/2021 at 8:00 AM revealed Staff C, Boone Branch Manager, reported she contacted the nurse and social worker the night before. Both agreed the social worker evaluation was ordered but the patient refused the services. She concurred no documentation of the reason for omission or contact with the physician was documented. The above stated findings for Patients #3, #4, #5 and #7 were reviewed with the Administrator, Staff C, Boone Branch Manager, and Staff D, Chief of Organizational Performance. During agency staff interview on 6/16/2021 at 4:15 PM, Staff C, Boone Branch Manager, reported the scheduler had been checking the wrong box in the agency's electronic medical record system therefore a missed visit notification was not generated for the above stated visits. The agency provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation, agency staff interview and patient interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all medications, treatments, and supplies/equipment used by the patient and physician approved staff interventions for 3 of 7 sampled patients with clinical record review (Patients #1, #3 and #6). The agency reported a current census of 61 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 Care Planning Process, dated 4/2019, the individualized plan of care includes the following: all pertinent diagnoses, the patient's mental, psychosocial and cognitive status, medications including dose, frequency, and route, the types of services, supplies and equipment required, the frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, 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 6/1/2020. Clinical record review, home visit observation and accompanying interviews revealed the following the Plan of Care, dated 5/27/21 to 7/25/21, included orders for Tresiba Flex Touch 200 units per milliliter (ml) with a dose taken by the patient 35 units per ml. During a home visit observation with Staff F, Licensed Practical Nurse (LPN), the surveyor reviewed medication the patient was taking. The patient reported use of 35 units from the 200 units per ml insulin pen. The Plan of Care, dated 5/27/21 to 7/25/21, lacked inclusion of the correct dosage of Tresiba used by the patient. 2. Patient #6 had a start of care date of 11/5/2020 and was discharged from the agency on 5/21/21. Clinical record review revealed the following: a. The Plan of Care, dated 11/5/2020 to 1/3/21, 1/4/21 to 3/4/21, 3/5/21 to 5/3/21 and 5/4/21 to 7/2/21, included physician orders for oxygen 2 1/2 liters per minute by nasal cannula. b. The initial comprehensive assessment completed at start of care, dated 11/5/2020, documented the patient's current use of oxygen at 2 Liters per minute by nasal cannula. c. The updates to the comprehensive assessment for recertification, dated 12/30/2020, 3/2/21, documented the patient's current use of oxygen at 2 Liters per minute by nasal cannula. d. The update to the comprehensive assessment for recertification, dated 5/21/21 , documented the patient's current use of oxygen at 3 Liters per minute by nasal cannula. The Plans of Care, dated 11/5/2020 to 1/3/21, 1/4/21 to 3/4/21, 3/5/21 to 5/3/21 and 5/4/21 to 7/2/21, lacked inclusion of the correct dosage of oxygen used by the patient. 3. Patient #3 had a start of care date of 10/12/2020. Clinical record review, patient interview and associated agency staff interview revealed the following: a. On 6/16/2021 at 9:30 AM, the surveyor accompanied Staff E, Licensed Practical Nurse (LPN) to Patient #3's home. During the home visit, the surveyor observed the patient had an emergency response system in the home. The patient wore the emergency response pendant around his/her neck. During patient interview while in the patient's home, Patient #3 reported he/she had been using the emergency response system for approximately 2 years. The patient reported also having an internal pacemaker/defibrillator placed in 2005. The patient reported routinely monitoring the pacemaker/defibrillator using a portable monitor since insertion. b. The Plans of Care, dated 12/11/2020 to 2/8/2021, 2/9/2021 to 4/9/2021, 4/10/2021 to 6/8/2021 and 6/9/2021 to 8/7/2021, did not include the emergency response system or the internal pacemaker/defibrillator monitoring device as equipment used by the patient to meet his/her needs. During the same home visit described above, the surveyor observed Staff E, LPN, set up the patient's medications into a weekly medication planner. The surveyor observed the following medication discrepancies: c. The Plans of Care, dated 4/10/2021 to 6/8/2021 and 6/9/2021 to 8/7/2021, documented the patient took Folic Acid 1 milligram every morning. The patient did not have any Folic Acid in the home. The patient had a 3/4 empty bottle of Prenatal Vitamins with Folic Acid (originally holding 50 caplets) in the home. Each caplet contained 800 micrograms of Folic Acid. During patient interview, Patient #3 reported taking one caplet each morning. d. The patient had a 7/8 empty bottle of Vitamin D3 50 micrograms per caplet (originally holding 600 caplets). During patient interview, Patient #3 reported taking one caplet every day "for a long time. The doctor put me on it." The Plans of Care, dated 4/10/2021 to 6/8/2021 and 6/9/2021 to 8/7/2021, lacked documentation indicating the patient took Vitamin D3. e. The patient had a 3/4 empty bottle of B Complex Vitamins (originally holding 60 caplets). During patient interview, Patient #3 reported taking one caplet every day "for a long time. The doctor put me on it." The Plans of Care, dated 4/10/2021 to 6/8/2021 and 6/9/2021 to 8/7/2021, lacked documentation indicating the patient took B Complex Vitamins. f. The patient had a 3/4 empty bottle of Iron tablets 65 milligrams per tablet (originally holding 100 tablets). During patient interview, Patient #3 reported taking one tablet twice daily "for a long time. The doctor put me on it due to low hemoglobin." The Plans of Care, dated 4/10/2021 to 6/8/2021 and 6/9/2021 to 8/7/2021, lacked documentation indicating the patient took Iron. During agency staff interview, Staff E, LPN, reported this was the first time she had provided care to Patient #3 and referred the correction of the discrepancies to the patient's primary registered nurse by telephone call. The registered nurse concurred with the patient that he/she had been taking the medications and the registered nurse immediately added the medications to the patient's Plan of Care so the LPN could set up the 4 medications correctly in the patient's medication planner. The Plans of Care did not include accurate equipment and medication orders for Patient #3. The above stated findings for Patients #1, #3 and #6 were reviewed with the Administrator, Staff C, Boone Branch Manager, and Staff D, Chief of Organizational Performance. The agency provided no additional information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 3 sampled patients with orders for wound care (Patient #6). The agency reported a current patient census of 61 patients. The agency reported providing care to 9 patients with wounds at the time of the survey. 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 the agency policy, titled Care Planning Process, dated 4/2019, the individualized Plan of Care must include orders for patient specific home health service needs identified in the comprehensive assessment and the responsible discipline(s), treatments and procedures, including amount/frequency/duration. Patient #6 had a start of care date of 11/5/2020 and discharged from agency services on 5/21/21. Clinical record review revealed: The Plan of Care, dated 5/4/21 to 7/2/21, included orders for skilled nursing and home care aide services and included orders for application of compression socks for 30 minutes daily and then wraps afterwards and for staff to monitor lower extremities for red or open areas and report areas to the physician. The home health aide visit, dated 5/18/21, completed by the licensed practical nurse (LPN), documented the patient had a skin tear to the left shin measuring 2.5 centimeters longs with skin still attached. The LPN applied an unidentified ointment after the shower and covered the area with gauze. The Plan of Care lacked orders for the application of gauze and ointment to the skin tear. The above findings were reviewed with the agency Administrator. Agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review, review of agency therapy contracts and agency staff interview, the agency failed to notify the physician of changes in patient condition or needs that suggest an alteration to the Plan of Care for 4 of 7 sampled patients (Patients #2, #4, #5 and #6). The agency reported a current census of 61 patients. Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: During agency staff interview on 6/15/2021 at 2:50 PM, the Clinical Manager reported clinicians document communication with the physician in communication notes or by physician order. The Clinical Manager 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. According to the agency policy, titled Care Planning Process and dated April 2019, clinicians will inform the patient's physician of any changes suggesting a need to alter the Plan of Care. Changes will be in writing, dated and signed by the person making the change. In the event visits are provided less than ordered, the agency will consider the reason for the missed visit and the potential/actual impact on the patient. The physician will be updated timely by the clinician if there is an actual/potential significant impact to the patient's health or medical treatment. The agency may wait until the end of the 60 day period to notify the physician if no significant impact was identified. According to the same agency policy, a plan of care will be developed from information obtained during initial and comprehensive assessments. The patient's physician will be consulted for approval of additions or modifications to the Plan of Care after each assessment is completed. According to the agency policy, titled Reassessment/Recertification and dated February 2014, the Plan of Care must be reviewed by the physician at least every 60 days or more often when warranted by the condition of the patient. Any assessment findings that suggest a need to alter the Plan of Care must be reported to the patient's physician. The clinician will notify the physician if there is a significant change in the patient's condition or care environment. During agency staff entrance interview on 6/14/2021 at 9:55 AM, the Administrator reported the agency had struggles staffing therapy services in all areas of the agency's geographic service area. She reported the agency had active contracts for therapy services from one company that would service the city of Fort Dodge only and one company who would service the city of Humbolt only. On 6/15/2021 at 1:55 PM, Staff D, Chief of Organizational Performance, reported the agency had experienced difficulty getting contracted therapy services for the past 3-4 years. She reported looking to see if there were any other active contracts for therapy services besides the two already mentioned by the Administrator and was unable to locate any. 1. Patient #4 had a start of care date of 3/8/2021. Clinical record review and associated interviews revealed the following: a. The Plan of Care, dated 3/8/2021 to 5/6/2021, documented the diagnoses of extensive burns over 60-69% of the body, traumatic amputation of the right forearm and the left hand. The Plan of Care ordered skilled nursing services 3 times weekly, home health aide services twice daily, medical social work services once weekly beginning on 3/14/2021, a physical therapy evaluation and an occupational therapy evaluation. b. The patient's clinical record lacked documentation of any occupational therapy evaluation until 5/14/2021, over 2 months from when the physician ordered the evaluation. The clinical record documented early on in the patient's care, one of the fingers on the patient's hand prosthesis broke and needed repair; thereby delaying occupational therapy services. The clinical record lacked documentation of any communication with the physician to report the failure of the agency to initiate the occupational therapy evaluation timely or any attempt to seek direction from the physician on how to proceed. Agency staff interview on 6/16/2021 at 8:00 AM revealed the Administrator concurred the reason for delay of the occupational evaluation visit was due to the broken finger on the prosthesis requiring repair. 2. Patient #5 had a start of care date of 11/11/2020. Clinical record review revealed the following: a. The Plan of Care, dated 11/11/2020 to 1/9/2021, ordered physical therapy evaluation visit once during the first week of services. The clinical record lacked any physical therapy evaluation during the first week of services. The clinical record included documentation of a physical therapy evaluation, dated 12/7/2020, 26 days after admission. The clinical record lacked documentation of communication with the physician to obtain orders for the delayed physical therapy evaluation. The patient's clinical record included physician orders, dated 5/21/2021, (6 months after completing the visit) delaying the evaluation date to 12/7/2021. The physical therapy evaluation, dated 12/7/2020, documented a plan to see the patient twice weekly for 30 days. The clinical record included physical therapy visits as planned on 12/11, 12/16, 12/18, 12/21, 12/28/2020 and 1/4/2021. The patient's clinical record included physician orders, dated 5/20/2021, (6 months after completing the evaluation and the therapist began making the planned visits) ordering physical therapy visits twice weekly from 12/7/2020 through 1/5/2021. The physical therapy reevaluation on 1/4/2021, documented a plan to continue to see the patient twice weekly for an additional 30 days. The clinical record included physical therapy visits as planned on 1/8, 1/15 and 1/18/2021, then discharged the patient from therapy services. The clinical record lacked documentation of communication with the physician at the time of the reevaluation or at the time of early discharge. The clinical record included a physician's interim order, dated 5/21/2021 (6 months after completing the reevaluation visit and the therapist began making the visits) ordering physical therapy visits twice weekly for another 30 days. b. The Plan of Care, dated 11/11/2020 to 1/9/2021, ordered occupational therapy evaluation visit once during the first week of services. The clinical record lacked any occupational therapy evaluation during the first week of services. The clinical record lacked documentation of the reason for omission of the evaluation. The clinical record lacked documentation of any contact with the patient's physician to report the missed visit either verbally or by written notification. The clinical record included documentation of an occupational therapy evaluation, dated 12/7/2020, 26 days after admission. The clinical record lacked documentation of communication with the physician to obtain orders for the delayed physical therapy evaluation. The patient's clinical record included physician orders, dated 5/21/2021, (6 months after completing the visit) delaying the evaluation date to 12/7/2021. The occupational therapy evaluation, dated 12/7/2020, documented a plan to see the patient twice weekly for 30 days. The clinical record included occupational therapy visits as planned on 12/11, 12/16, 12/18, 12/21, 12/28/2020 and 1/4/2021. The patient's clinical record included physician orders, dated 5/20/2021, (6 months after completing the evaluation and the therapist began making the planned visits) ordering occupational therapy visits twice weekly from 12/7/2020 through 1/5/2021. The occupational therapy reevaluation on 1/4/2021, documented a plan to continue to see the patient twice weekly for an additional 30 days. The clinical record included occupational therapy visits as planned on 1/8,15/2021, then discharged the patient from therapy services. The clinical record lacked documentation of communication with the physician at the time of the reevaluation or at the time of early discharge. The clinical record included a physician's interim order, dated 5/21/2021 (6 months after completing the reevaluation visit and the therapist began making the visits) ordering occupational therapy visits for two additional visits (1/8 and 1/15). c. The Plan of Care, dated 11/11/2020 to 1/9/2021, ordered speech therapy evaluation visit once during the first week of services. The clinical record lacked any speech therapy evaluation during the first week of services. The clinical record lacked documentation of the reason for omission of the evaluation. The clinical record lacked documentation of any contact with the patient's physician to report the missed visit either verbally or by written notification. The clinical record included documentation of a speech therapy evaluation, dated 12/11/2020, 30 days after admission. The clinical record lacked documentation of communication with the physician to obtain orders for the delayed speech therapy evaluation. The patient's clinical record included physician orders, dated 5/21/2021, (6 months after completing the visit) delaying the evaluation date to 12/11/2021. 3. Patient #2 had a start of care date of 10/20/2020. Clinical record review revealed the following: a. The Plan of Care, dated 10/20/2020 to 12/18/2020, included the diagnosis of hypertensive heart and chronic kidney disease with heart failure and identified the need for skilled nursing visits 1 time per week, home care aide visits two times per week, and physical therapy to evaluate and treat the patient. b. The initial comprehensive assessment at start of care, dated 10/2020, documented therapy need was not applicable since no case mix group was defined by assignment and included the ordered evaluation for physical therapy. c. The clinical record lacked documentation the physical therapy evaluation was completed. d. Interview on 6/16/21 at 2:50 PM, with agency Administrator revealed the patient did not receive physical therapy as the patient lived in an area that the agency did not have a physical therapist available to provide services. The clinical record lacked documentation of communication with the physician regarding the agency's inability to provide physical therapy services in the patient's geographic location. 4. Patient #6 had a start of care date of 11/5/2020 and discharged from agency services on 5/21/21. Clinical record review revealed: The Plan of Care, dated 5/4/21 to 7/2/21, included orders for skilled nursing and home care aide services and included orders for application of compression socks for 30 minutes daily and then wraps afterwards and for staff to monitor lower extremities for red or open areas and report areas to the physician. The home health aide visit, dated 5/18/21, completed by the licensed practical nurse (LPN), documented the patient had a new skin tear to the left shin measuring 2.5 centimeters longs with skin still attached. The clinical record lacked documentation of communication with the physician to report the new skin tear and to obtain direction for treatment of the new wound. The above findings for Patients #2, #4, #5 and #6 were reviewed with agency Administrator, Staff C, Registered Nurse/Boone Branch Manager, and Staff D, Chief of Organizational Performance. Agency staff provided no further information prior to the end of the survey.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to coordinate services provided by all disciplines in a manner to effectively meet the identified needs of the patient for 5 of 9 sampled patients (Patients #4, #5, #6, #8 and #9). The agency reported a current census of 61 patients. Failure to coordinate services provided by all disciplines placed agency patients at risk for inadequate or ineffective care. Findings include: According to the agency policy, titled Home Health Assignment Record and dated February 2015, patient case managers develop the home health aide assignment record in an individualized patient specific manner. 1. Patient #4 had a start of care date of 3/8/2021. Clinical record review revealed the following: The Plan of Care, dated 3/8/2021 to 5/6/2021, included physician orders for physical therapy evaluation during the first week of services. The patient's clinical record lacked documentation of any evaluation being completed. The clinical record lacked documentation of any communication between the physical therapist and the registered nurse to coordinate the evaluation. During agency staff interview on 6/16/2021 at 8:00 AM, the Administrator reported she was unaware the physical therapy evaluation was never completed. 2. Patient #5 had a start of care date of 11/11/2020. Clinical record review revealed the following: a. The Plan of Care, dated 11/11/2020 to 1/9/2021, ordered speech therapy evaluation visit once during the first week of services. The clinical record lacked any speech therapy evaluation during the first week of services. The clinical record included documentation of a speech therapy evaluation, dated 12/11/2020. The evaluation documented no further plan of speech therapy visits The 3/3/2021 Plan of Care Addendum, dated 1/10/2021 to 3/10/2021, included an addition of physician orders for speech therapy visits once weekly beginning on 1/10/2021 despite the speech therapy evaluation indicating no further services were planned. The clinical record lacked any further speech therapy visits after the evaluation. b. The clinical record included a physician interim order, dated 12/28/2020 and written by the social worker, ordering social work visits every 14 days. The Plan of Care, dated 1/10/2020 to 3/10/2021 and completed by the nurse, ordered medical social work visits weekly for 60 days, which contradicted the order written by the social worker. The clinical record included medical social work visits was planned by the social worker every two weeks on 1/14, 1/28, 2/11, 2/25, 3/11 and 3/25/2021. The coordination between the nurse and social worker failed. c. The Plans of Care, dated 11/112020 to 1/9/2021, 1/10/2021 to 3/10/2021, 3/11/2021 to 5/9/2021 and 5/10/2021 to 7/8/2021, included physician orders for home health aide visits twice weekly. The home health aide assignments between 1/11/2021 and 6/16/2021, directed the home health aide to assist the patient with toileting and oral hygiene every home visit. The home care aide visit notes, dated 1/11, 1/13, 1/27, 2/1, 2/3, 2/5, 2/10, 2/12, 2/15, 2/19, 2/22, 2/24, 3/1, 3/3, 3/5, 3/8, 3/10, 3/12, 3/15, 3/17, 3/19, 3/22, 3/24, 3/26, 3/29, 3/31, 4/5, 4/7, 4/9, 4/12, 4/14, 4/16, 4/20, 4/23, 4/26, 4/28, 5/3, 5/5, 5/7. 5/10, 5/12, 5/17, 5/19, 5/21, 5/24, 5/26, 5/28, 6/3, 6/4, 6/7, 6/9 and 6/11/2021, documented omission of the task of oral hygiene, documenting the reason for omission was the patient could perform oral hygiene independently. The registered nurse did not remove the task from the aide assignment despite the aide's repeated documentation indicating the assignment was not individualized or specific to the patient's needs. The home care aide visit notes, dated 1/11, 1/13, 1/15, 1/29, 2/1, 2/3, 2/5, 2/12, 2/15, 2/17, 2/19, 2/24, 3/1, 3/3, 3/5,3/8, 3/10, 3/12, 3/15, 3/17, 3/19, 3/22, 3/24, 3/26, 3/29, 3/31, 4/5, 4/7, 4/9, 4/12, 4/14, 4/16 4,20, 4/21, 4/23, 4/26, 4/28, 4/30, 5/3, 5/5, 5/7. 5/10, 5/12, 5/17, 5/19, 5/21, 5/24, 5/26, 5/28, 6/3, 6/4, 6/7, 6/9 and 6/11/2021, documented omission of the task of toileting assistance, documenting the reason for omission was the patient could perform toileting independently. The registered nurse did not remove the task from the aide assignment despite the aide's repeated documentation indicating the assignment was not individualized or specific to the patient's needs. d. The patient's clinical record included the following physician interim orders taken from the physician by a licensed practical nurse (LPN): 2/10/2021- Added new medication Fentanyl patch 3/3/2021- Change dosage Fentanyl- Requested additional skilled nursing visit to change patch to higher dose 5/10/2021- Methadone dosage change. 5/24/2021- Methadone dosage change and Remeron dosage change None of the above stated physician orders were documented as reviewed/noted or cosigned by the patient's primary registered nurse, indicating the registered nurse was aware of the changes. 3. Patient #8 had a start of care date of 1/13/2021. Clinical record review and associated agency staff interviews revealed the following: a. The Plan of Care, dated 1/13/2021 to 3/13/2021, included orders for a physical therapy evaluation during the first week of service with continued therapy only services. The physical therapist evaluation, dated 1/18/2021, documented a plan to visit the patient twice weekly for 4 weeks. b. The physical therapy reevaluation, dated 2/15/2021, documented the patient was responding appropriately to therapy services. The therapist documented a recommendation the patient continue to receive physical therapy services twice weekly for an additional 4 weeks of service. c. The clinical record lacked any documentation of communication with the physician or registered nurse to discuss the continued needs. c. The clinical record lacked any documentation of further physical therapy visits. The clinical record lacked any documentation explaining why no visits were made. d. The physical therapy discharge summary, dated 3/9/2021, discharged the patient back dating to 2/19/2021 for the discharge date without explaining why. 4. Patient #9 had a start of care date of 12/14/2020. Clinical record review revealed the following: a. The referral order, dated 12/2/2020, for evaluation for therapy services was sent to the agency by facsimile from the nursing home advance nurse practitioner (ARNP) on 12/4/2020. b. A second referral was made by the Veteran's Administration (VA) on 12/9/2020 requesting skilled nursing and home health aide services. c. The agency admitted the patient on 12/14/2020. The Plan of Care, dated 12/14/2020 to 2/11/2021, included physician orders for skilled nursing every other week, home health aide services twice weekly and evaluations for physical therapy, occupational therapy and medical social work. d. The referral form, dated 12/14/2020, made the referral for physical and occupational therapy evaluations and the form was placed into the patient's hard chart. A sticky note was attached stating "awaiting MSW (medical social worker) and therapy referrals from VA". e. The patient's clinical record lacked any documentation indicating physical therapy, occupational therapy or medical social work evaluations were ever completed. f. During agency staff interview on 6/16/2021 at 8:00 AM, the Administrator reported she was unsure why the three evaluations were never complete. The Administrator reported she was unaware of the oversight. 5. Patient #6 had a start of care date of 11/5/2020 and discharged from the agency on 5/21/21. Clinical record review revealed: a. The Plans of Care, dated 3/5/21 to 5/3/21 and 5/4/21 to 7/2/21, included orders for the home health aide to assist with personal cares, provide foot care, shave patient, assist with mobility, check patient's skin, apply compression stockings to lower extremity, provide medication reminders, perform weights. b. The home care aide visit notes, dated 3/24, 3/25, 3/29, 4/1, 4/3, 4/5, 4/6, 4/8, 4/13, 4/17, 5/5, 5/17, and 5/18/21, documented declined weight due to the patient not having a scale. c. The home care aide visit notes, dated 4/21, 4/23, 4/27, 4/28, 4/29, 5/3, 5/4, and 5/6/21 documented the patient declined a weight check as the scale was broken. The clinical record failed to include documentation of the agency communicating the inability to obtain a weight with the nurse and the Plan of Care physician. The above findings for Patients #4, #5, #6, #8 and #9 were reviewed with agency Administrator, Staff C, Registered Nurse/Boone Branch Manager, and Staff D, Chief of Organizational Performance. Agency staff provided no further information prior to the end of the survey.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, home visit observation and agency policy review, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 1 of 3 sampled patients (Patients #1) with home visit observations. The agency reported a current census of 61 patients. The agency reported 9 patients had wounds at the time of the survey. Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: According to the undated agency policy, titled Skin and Wound Care -Photo Documentation, the nurse is to position the patient, wash hands, put on clean gloves, prepare a clean field for the cell phone, remove the dressing from the skin and discard the dressing, wash hands, put on clean gloves, cleanse skin condition and surrounding areas as ordered by the physician, and observe the skin's appearance, discard gloves, wash hands, take photo, and perform dressing change. Patient #1 had a start of care date of 6/1/2020. Review of the clinical record revealed the following: The Plan of Care (POC), dated 5/27/21 to 7/25/21, included physician orders for skilled nursing and home care aide services. During a home visit observation with Staff F, Licensed Practical Nurse (LPN), met with the patient in the patient's home. The nurse placed a barrier on the floor and placed the nursing bag on the barrier. The nurse placed an additional barrier on the table and placed vital signs equipment and laptop computer on it. The nurse performed hand hygiene and completed the patient's assessment, properly placing equipment on dirty barrier after use and on clean barrier afterwards to dry. The nurse then removed gloves, performed hand hygiene and documented findings in the computer. Staff F, LPN, gathered wound care supplies and placed a clean barrier next to patient and placed supplies on the barrier. An underpad was also placed under the patient's left lower leg. The nurse performed hand hygiene and applied gloves. No dressings were present on skin. The nurse cleansed three open areas to the left lower leg using a syringe with saline starting with the mid shin open wound and blotting dry with a gauze pad, proceeding to another open area located above the mid shin open wound closer to the knee and dried this area with the same gauze pad. The nurse then obtained a different gauze pad and cleansed a lower inner dark area with the saline and blotted dry with the new gauze pad. Standard infection control practices were not followed. Using the same gauze pad to dry the two wounds may potentially contaminate wounds by transferring bacteria from one wound to another. The nurse then labeled all wounds and took photos per protocol. Hands were sanitized and Aquacel was applied to the wounds and wrapped with gauze and tubagrips were applied as ordered by the physician. Hand hygiene was again performed. Failure to follow standard wound precautions placed the patient at risk for infection. The above findings were reviewed with agency Administrator, Staff C, Registered Nurse/Boone Branch Manager, and Staff D, Chief of Organizational Performance. Agency staff provided no additional information prior to the end of the survey.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, agency staff interview, the agency clinicians failed to including measurements of wounds, including length, width and depth, weekly as required for 1 of 3 sampled patients with wounds (Patient #1). The agency reported a current census of 61 patients at the time of the survey, including 3 currently receiving wound care by the agency. Failure to assess wounds, including measurement, may result in unidentified worsening of the wounds. Findings include: According to undated agency policy, titled Skin and Wound Care-Assessment: Wounds need to be reassessed regularly and treated according to the needs of the patient and wound. In home care, a professional reassessment of most wounds is usually indicated at least once a week. The policy further states basic wound assessment for all wounds includes length, width, and depth. During agency staff interview on 6/15/2021 at 2:50 PM, the Clinical Manager reported wounds are documented on a wound flow sheet, which is part of the comprehensive assessment and the routine skilled nurse visit notes. The clinician should measure length, width and depth of the wound every visit and take photos of the wounds every visit. Patient #1 had a start of care date of 6/1/2020. The Plan of Care, dated 5/27/21 to 7/25/21, included diagnoses of type 2 diabetes mellitus with diabetic neuropathy and physician orders for skilled nursing services, atherosclerosis of native arteries of left leg with ulceration of calf, and nonpressure chronic ulcer of left lower leg with fat layer exposed. The Plan of Care also included orders the skilled nurse or caregiver to change the dressing to the right lower leg three times per week as follows: clean with soapy warm water or saline and pat dry. Apply calcium alginate with silver to the wounds and cover with 4x4's and rolled gauze. Patient to wear own senna socks or ready wraps. Clinical record review revealed: a. The skilled nursing visit note, dated 5/3/21, completed by the licensed practical nurse, documented the wounds on the patient's left leg are healing and wounds cleansed and dressings applied, but lacked documentation of wound measurements (length, width, and depth). b. The skilled nursing visit note, dated 5/12/21, completed by the licensed practical nurse, documented the wounds on the patient's left leg are healing and patient would not let nurse apply dressing to left leg and patient has a mild compression sock on the left legs and allowed ready wrap to be applied. The note lacked documentation of wound measurements (length, width, and depth). c. The skilled nursing visit note, dated 6/8/21, completed by the licensed practical nurse, documented the wound bed on 2nd left toe was debrided and cleansed and area is pink not bloody anymore. Left leg was cleansed and covered with dressing. The note lacked documentation of wound measurements (length, width, and depth). Interview on 6/16/21 at 9:08 AM, with Staff C, Boone Branch Manager, revealed inability to locate wound measurements for the above dates. The above findings were reviewed with agency Administrator, Staff C, Registered Nurse/Boone Branch Manager, and Staff D, Chief of Organizational Performance. Agency staff provided no additional information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, clinical record review and agency staff interview, the agency failed to ensure 3 of 6 sampled home health aides (Staff H, I and J), demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently for 1 patient (Patient #6). The agency reported a current census of 61, including 42 patients who received home health aide services at the time of the survey. The agency employed 9 home health aides at the time of the survey. Failure to ensure that home health aides demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently, increased the potential risk of harm to the patient. Findings include: Patient #6 had a start of care date of 11/5/2020. Clinical record review revealed the following: a. The Plans of Care, dated 1/4/21 to 3/4/21, 3/5/21 to 5/3/21, 5/4/21 to 7/2/21, included physician orders for skilled nursing and home health aide services. b. The home health aide assignment directed the aide to shave the patient, weigh the patient, apply compression stockings and apply a compression pump to the patient's lower extremities. c. Shaving, weighing a patient and the application of compression stockings and compression pumps require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff H, I and J, Home Health Aides, provided care to Patient #6. Personnel file review revealed the following: d. Staff H, had a hire date of 12/14/2020 and had never been competency tested to perform application of a compression pump. e. Staff I, had a hire date of 7/13/2020 and had never been competency tested to perform application of compression stockings, application of a compression pump, weighing a patient or shaving a patient. f. Staff J had a hire date of 3/22/2021 and had never been competency tested to perform application of a compression pump. The above stated findings for Patients #6 were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on clinical record review, the agency failed to ensure a registered nurse completed home health aide supervision at least every 60 days while observing the home health aide present and providing direct patient care for 1 of 1 sampled patients who received hands on personal care services with no skilled service provision. (Patient #10). The agency reported a current census of 61 patients, including 1 patient who received personal care assistance by a home health aide without any skilled service provision. Failure to supervise home health aide services, at least every 60 days while the aides provided direct patient care, increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: Patient #10 had a start of care date of 9/26/2014. Clinical record review revealed the following: The Plans of Care, dated 10/24/2020 to 12/22/2020; 12/23/2020 to 2/20/2021; 2/21/2021 to 4/21/2021; and 4/22/2021 to 6/20/2021, included physician orders for home health aide services without the provision of skilled services. Patient #10's clinical record included a supervisory note, dated 2/17/2021, documenting direct supervision of the home health aide. The next supervisory visit occurred on 4/21/2022; however, the home health aide was not present during the supervisory visit. The clinical record lacked any other documentation of home health aide supervision when the aide was present and performing direct patient care from 2/17/2021 through 6/16/2021. The above stated findings for Patient #10 were reviewed with the Administrator, Staff C, Boone Branch Manager, and Staff D, Chief of Organizational Performance. The agency provided no additional 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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 3 of 4 sampled patients with transfers/ discharges (Patients #1, #6, and #7). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy, titled Discharge and/or Transfer Criteria and Process, dated 4/2018, agency staff will complete a discharge summary for the physician and a copy will be sent to the physician within 5 business days of the discharge. According to the agency policy, titled Transfer/Referral Criteria and Process, dated 11/2018, within 48 hours of the transfer, the clinician will complete a transfer summary. A copy of the transfer summary will be also be sent to the physician. According to the agency policy, titled Discharge Summary, dated 5/2018, the discharge summary will be completed and submitted within 72 hours of discharge from service. A copy of the discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient within 5 business days of the patient's discharge. 1. Patient #1 had a start of care date of 6/1/2020. Clinical record review revealed the following: a. The Plan of Care, dated 1/27/21 to 3/27/21, documented the patient's diagnoses as stage 3 chronic kidney disease and type 2 diabetes mellitus. b. The transfer assessment, dated 3/9/21, documented the patient was admitted to the hospital on 3/9/2021 for sepsis. c. The clinical record lacked documentation of completion of a transfer summary for the transfer. d. An update to the comprehensive assessment for resumption of care, dated 3/15/21, documented a hospital discharge date of 3/14/21. During findings on 6/16/2021 at 2:50 PM, the surveyor requested documentation of a transfer summary and evidence of summary sent to the hospital. The agency did not provide any such document prior to the end of the survey. 2. Patient #6 had a start of care date of 11/5/2020 and was discharged from the agency on 5/21/21. Clinical record review revealed the discharge assessment, dated 5/21/21, documented the patient was discharged from the agency due to patient's request and included a discharge summary documented the summary was sent to patient/patient representative/facility and the physician was notified of the discharge before the discharge date per agency policy and timeline. During agency staff interview on 6/16/21 at 2:50 PM, Staff C, Boone Branch Manager revealed the discharge summary was completed and was working with software vendor for faxing to provide proof of the summary being sent to the physician caring for the patient at the time of the discharge. The agency did not provide any such document prior to the end of the survey. 3. Patient #7 had a start of care date of 3/26/2021 and was discharged on 4/21/2021. Clinical record review revealed the following: The discharge summary documented a completion date of 4/21/2021. The discharge summary lacked documentation indicating the summary had ever been sent to the patient's physician. The clinical record lacked any documentation indicating the discharge summary was sent to the patient's physician. The above stated findings for Patients #1, #6 and #7 were reviewed with the Administrator, Staff C, Boone Branch Manager, and Staff D, Chief of Organization Performance. The agency provided no additional 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 clinical record review and agency staff interview, the agency failed to ensure completion of documentation for routine visit notes were completed within the agency's administrative expectations for 7 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #8). The agency reported a current census of 61 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: During agency staff entrance interviews on 6/14/2021 at 9:55 AM, the Administrator reported her expectation that all nursing and social work documentation for routine visit notes be completed by midnight of the same day of each visit; home health aide documentation must be completed immediately following the completion of each visit while still at the patient's residence; and all therapy documentation should be completed by midnight the same day of each service with electronic submission on Mondays for the entire previous weeks documentation. During agency staff interview on 6/15/2021 at 8:25 AM, Staff C, Boone Branch Manager, reported the agency expectation required all nursing and social work documentation for routine visit notes be completed by midnight of the same day of each visit; home health aide documentation must be completed immediately following the completion of each visit while still at the patient's residence; and all therapy documentation should be completed by midnight the same day of each service with electronic submission on Mondays for the entire previous weeks documentation. 1. Patient #3 had a start of care date of 10/12/2020. Clinical record review revealed the following: a. The electronic routine skilled nurse visit note, dated 4/21/2021, was not electronically created or signed as complete until 4/25/2021, making the completion of the document 4 days late according to the administration's expectation. b. The electronic routine skilled nurse visit note, dated 4/26/2021, was not electronically created or signed as complete until 5/2/2021, making the completion of the document 6 days late according to the administration's expectation. c. The electronic routine skilled nurse visit note, dated 5/3/2021, was not electronically created or signed as complete until 5/9/2021, making the completion of the document 6 days late according to the administration's expectation. d. The electronic routine skilled nurse visit note, dated 5/12/2021, was not electronically created or signed as complete until 5/16/2021, making the completion of the document 4 days late according to the administration's expectation. 2. Patient #4 had a start of care date of 3/8/2020. Clinical record review revealed the following: a. The electronic routine skilled nurse visit note, dated 4/2/2021, was not electronically created or signed as complete until 4/5/2021, making the completion of the document 3 days late according to the administration's expectation. b. The electronic routine skilled nurse visit note, dated 4/9/2021, was not electronically created or signed as complete until 4/11/2021, making the completion of the document 2 days late according to the administration's expectation. c. The electronic routine skilled nurse visit note, dated 4/12/2021, was not electronically created or signed as complete until 4/15/2021, making the completion of the document 3 days late according to the administration's expectation. d. The electronic routine skilled nurse visit note, dated 4/16/2021, was not electronically created or signed as complete until 4/18/2021, making the completion of the document 2 days late according to the administration's expectation. e. The electronic routine skilled nurse visit note, dated 4/28/2021, was not electronically created or signed as complete until 5/2/2021, making the completion of the document 4 days late according to the administration's expectation. f. The electronic routine skilled nurse visit note, dated 4/30/2021, was not electronically created or signed as complete until 5/3/2021, making the completion of the document 3 days late according to the administration's expectation. g. The electronic routine skilled nurse visit note, dated 5/10/2021, was not electronically created or signed as complete until 5/16/2021, making the completion of the document 6 days late according to the administration's expectation. h. The electronic occupational therapy evaluation, dated 5/14/2021, was not electronically created or signed as complete until 5/20/2021, making the completion of the document 6 days late according to the administration's expectation. i. The electronic routine skilled nurse visit note, dated 5/28/2021, was not electronically created or signed as complete until 5/30/2021, making the completion of the document 2 days late according to the administration's expectation. j. The electronic routine skilled nurse visit note, dated 6/9/2021, was not electronically created or signed as complete until 6/11/2021, making the completion of the document 2 days late according to the administration's expectation. k. The electronic routine skilled nurse visit note, dated 6/11/2021, was not electronically created or signed as complete until 6/13/2021, making the completion of the document 2 days late according to the administration's expectation. 3. Patient #5 had a start of care date of 11/11/2020. Clinical record review revealed the following: a. The electronic routine occupational therapy visit note, dated 12/11/2020, was not electronically created or signed as complete until 12/14/2020, making the completion of the document 3 days late according to the administration's expectation. The electronic routine occupational therapy visit note, dated 12/16/2020, was not electronically created or signed as complete until 12/18/2020, making the completion of the document 2 days late according to the administration's expectation. The electronic routine occupational therapy visit note, dated 12/18/2020, was not electronically created or signed as complete until 12/21/2020, making the completion of the document 3 days late according to the administration's expectation. The electronic routine occupational therapy visit note, dated 12/28/2020, was not electronically created or signed as complete until 12/30/2020, making the completion of the document 2 days late according to the administration's expectation. The electronic routine occupational therapy visit note, dated 1/8/2021, was not electronically created or signed as complete until 1/10/2021, making the completion of the document 2 days late according to the administration's expectation. The electronic routine occupational therapy visit note, dated 1/15/2021, was not electronically created or signed as complete until 1/20/2021 making the completion of the document 5 days late according to the administration's expectation. b. The electronic routine physical therapy visit note, dated 12/16/2020, was not electronically created or signed as complete until 12/21/2020, making the completion of the document 5 days late according to the administration's expectation. The electronic routine physical therapy visit note, dated 12/18/2020, was not electronically created or signed as complete until 12/21/2020, making the completion of the document 3 days late according to the administration's expectation. The electronic routine physical therapy visit note, dated 12/28/2020, was not electronically created or signed as complete until 12/30/2020, making the completion of the document 2 days late according to the administration's expectation. The electronic routine physical therapy visit note, dated 1/8/2021, was not electronically created or signed as complete until 1/11/2021, making the completion of the document 3 days late according to the administration's expectation. The electronic routine physical therapy visit note, dated 1/15/2021, was not electronically created or signed as complete until 1/18/2021, making the completion of the document 3 days late according to the administration's expectation. c. The electronic routine skilled nurse visit note, dated 4/12/2021, was not electronically created or signed as complete until 4/15/2021, making the completion of the document 3 days late according to the administration's expectation. The electronic routine skilled nurse visit note, dated 4/16/2021, was not electronically created or signed as complete until 4/18/2021, making the completion of the document 2 days late according to the administration's expectation. The electronic routine skilled nurse visit note, dated 4/20/2021, was not electronically created or signed as complete until 4/25/2021, making the completion of the document 5 days late according to the administration's expectation. The electronic routine skilled nurse visit note, dated 4/26/2021, was not electronically created or signed as complete until 5/2/2021, making the completion of the document 6 days late according to the administration's expectation. The electronic routine skilled nurse visit note, dated 5/13/2021, was not electronically created or signed as complete until 5/16/2021, making the completion of the document 3 days late according to the administration's expectation. 4. Patient #8 had a start of care date of 1/13/2021. Clinical record review revealed the following: a. The electronic routine physical therapy visit note, dated 1/18/2021, was not electronically created or signed as complete until 1/20/2021, making the completion of the document 2 days late according to the administration's expectation. b. The electronic physical therapy visit note/summary, dated 2/19/2021, was not electronically created or signed as complete until 3/9/2021, making the completion of the document 18 days late according to the administration's expectation. 5. Patient #1 had a start of care date of 6/1/2020. The Plans of Care, dated 3/28/21 to 5/26/21 and 5/27/21 to 7/25/21, included orders for skilled nursing, home health aide, and medical social worker services. The patient's clinical record included the following: a. The skilled nursing visit note, dated 4/26/21, included an electronic signature with all required components, including a date of completion of 4/27/21, 1 day late according to agency expectation. b. The licensed practical nursing visit note, dated 5/3/21, included an electronic signature with all required components, including a date of completion of 5/9/21, 6 days late according to agency expectation. c. The licensed practical nursing visit note, dated 5/12/21, included an electronic signature with all required components, including a date of completion of 5/16/21, 4 days late according to agency expectation. d. The licensed practical nursing visit note, dated 6/2/21, included an electronic signature with all required components, including a date of completion of 6/4/21, 2 days late according to agency expectation. e. The licensed practical nursing visit note, dated 6/8/21, included an electronic signature with all required components, including a date of completion of 6/11/21, 3 days late according to agency expectation. 6. Patient #2 had a start of care date of 10/20/2020. The Plan of Care, dated 4/18/21 to 6/16/21, included orders for skilled nursing and home health aide services. The patient's clinical record included the following: a. The licensed practical nursing visit note, dated 4/22/21, included an electronic signature with all required components, including a date of completion of 4/26/21, 4 days late according to agency expectation. b. The licensed practical nursing visit note, dated 5/18/21, included an electronic signature with all required components, including a date of completion of 5/19/21, 1 day late according to agency expectation. c. The licensed practical nursing visit note, dated 6/3/21, included an electronic signature with all required components, including a date of completion of 6/6/21, 3 days late according to agency expectation. 7. Patient #6 had a start of care date of 11/5/2020 and discharged from the agency on 5/21/21. The Plan of Care, dated 3/5/21 to 5/3/21, included orders for skilled nursing and home health aide services. The patient's clinical record included the following: a. The licensed practical nursing visit note, dated 3/26/21, included an electronic signature with all required components, including a date of completion of 3/28/21, 2 days late according to agency expectation. b. The licensed practical nursing visit note, dated 4/2/21, included an electronic signature with all required components, including a date of completion of 4/5/21, 3 days late according to agency expectation. c. The licensed practical nursing visit note, dated 4/16/21, included an electronic signature with all required components, including a date of completion of 4/18/21, 2 days late according to agency expectation. d. The home health aide visit note, dated 5/3/21, included an electronic signature with all required components, including a date of completion of 5/13/21, 3 days late according to agency expectation. The above findings for Patients #1, #2, #3, #4, #5, #6, and #8 were reviewed with agency Administrator, Staff C, Registered Nurse/Boone Branch Manager, and Staff D, Chief of Organizational Performance. Agency staff provided no additional information prior to the end of the survey.