Every finding on record at Keokuk County Public Health Nursing Service

The Department of Inspections and Appeals conducted a recertification survey, dated 11/21/22 to 11/30/22, and found the following standard level deficient practice under the Emergency Preparedness Condition of Participation.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness policies and agency staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients and staff at risk for not receiving needed assistance during or due to an emergency situation. Findings include: On 11/29/22 at 4:10 PM, during an interview, the Administrator confirmed an inability to find language in the agency emergency preparedness plan which addressed a procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. She reported she would continue to try to look through policies for the missing information. The agency staff provided no further information prior to the end of the survey.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 11/21/22 to 11/30/22. The survey identified the following standard level deficient practices. The agency reported a census of 14 patients at the time of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient interview and staff interview, the agency failed to ensure agency staff accurately completed a drug regimen which included a review of all medications used by the patient for 1 of 3 sampled patients (Patient #2) with a home visit observation. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate increased the potential for unidentified medication interactions and side effect risks to the patient. Findings include: Review of the agency policy, titled Drug Regimen Review (DRR), dated 1/20/22, identified the registered nurse is responsible for completing the DRR as part of the comprehensive assessment and update to the comprehensive assessment. The DRR will include a review of all medications, including over the counter medications, for potential adverse effects, significant drug interactions, duplicate drug therapy, ineffective drug therapy and non-compliance. On 11/22/22 at 11:10 AM, during an interview, the Clinical Manager reported she was the primary nurse for all patients. She explained she was responsible for completing the DRRs for each patient with each comprehensive assessment and updates the comprehensive assessment. Patient #2 had a start of care date of 2/19/2020. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 8/7/22 to 10/5/22 and 10/6/22 to 12/4/2022, included orders for medications and skilled nursing services weekly. b. The clinical record included documentation of DRRs, dated 8/2/22 and 10/4/22, included documentation the nurse had completed a DRR based on the patient's current medications. On 11/22/22 at 8:10 AM, during a home visit observation, the Clinical Manager set up the patient's medications for a week. The surveyor observed a bottle of Tums, Calcium Carbonate 750 milligram tablets on the patient’s counter. The bottle originally had 96 tabs, but less than 10 remained in the bottle. In an interview, during the same home visit observation, the patient reported taking Tums 1 a day as needed for years. The patient typically only takes the Tums once a week for stomach upset. c. The POCs and clinical record lacked an order for the Tums and lacked a DRR that included the Tums medication. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on 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 doctor of medicine, osteopathy or podiatry or notify the physician of the need to vary from the physician ordered Plan for Care for 2 of 7 sampled patients (Patients #1 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 Plan of Care (POC), dated 1/12/22, revealed agency staff provide services under a plan of care established by a physician. Agency staff implement the POC and provide services and treatments as ordered. Agency staff promptly notify the physician to any changes that suggest a need to alter the POC. On 11/29/22 at 9:58 AM, during an interview, the Clinical Manager reported physical therapy staff were responsible for notifying the physician of missed physical therapy visits and sending documentation of physician notification to the home health agency. 1. Patient #1 had a start of care date of 6/8/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/6/22 to 12/4/22, included a physician order for physical therapy to evaluate and treat the patient. b. An initial physical therapy evaluation, dated 10/6/22, included orders for physical therapy services 2 times per week for 6 weeks. c. The week of 10/9/22 included documentation of one physical therapy visit, dated 10/12/22. The clinical record lacked any further documentation to explain why physical therapy failed to provide a second visit the week of 10/9/22 per physician orders and lacked documentation of physician notification of the missed therapy visit. 2. Patient #7 had a start of care date of 8/2/22 and discharged from agency services on 9/12/22. Review of the clinical record revealed the following: a. The POC, dated 8/2/22 to 9/30/22, included physician orders for skilled nursing services 1 to 2 times per week for 60 days for medication management. The POC included an order for the skilled nurse to set up the patient's medications. b. A skilled nursing visit note, dated 8/5/22 (a Friday), included documentation the nurse set up the patient's medications for 1 week. c. The week of 8/7/22 included documentation of 1 skilled nursing visit, dated 8/9/22 (a Tuesday). The visit note included documentation of an assessment of the patient and the patient's medication compliance. The visit note lacked documentation the nurse set up the patient's medications. The clinical record lacked documentation of a plan to visit the patient later the week of 8/7/22 to set up the patient's medications and lacked any documentation to explain why the nurse failed to complete a second visit that week to set up the patient's medications. d. A skilled nursing communication note, dated 8/15/22, included documentation the patient called the agency on 8/15/22 to report the patient tested positive for Covid 19 today with active symptoms that started on Friday, 8/12/22. The nurse documented the cancellation of homemaker services for the day and the review of quarantine procedures with the patient. The communication note lacked any information about skilled nursing services or whether or not the patient needed assistance with setting up the patient's medications. e. The week of 8/14/22 included documentation of 1 skilled nursing visit, dated 8/19/22 (a Friday). The visit note included documentation the nurse set up the patient's medications for one week. Agency nursing staff failed to ensure the patient had medications set up between 8/12 and 8/18/22. 11/29/22 at 3:40 PM, during an interview, the Administrator reported the nurse had not set up the medications the week of 8/7/22, due to the patient having Covid. According to the Administrator, the patient reported the patient could manage setting up the patient’s own medications that week. She confirmed agency staff had not notified the physician that the nurse did not set up the patient's medications for a week. The Administrator and Clinical Manager received the above findings. On 11/29/22 at 4:10 PM, during an interview, the Administrator reported an inability to find any further information.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #6). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive medications according to assessed needs and physician orders. Findings include: Review of the agency policy, titled Plan of Care (POC), dated 1/12/22, revealed agency staff provide services under a plan of care established by a physician. The registered nurse develops the POC based on the assessed needs of the patient. Agency staff review and update the POC at least once every 60 days. Review of the agency policy, titled Drug Regimen Review (DRR), dated 1/20/22, identified the registered nurse is responsible for completing the DRR as part of the comprehensive assessment and update to the comprehensive assessment. The DRR will include a review of all medications, including over the counter medications. 1. Patient #1 had a start of care date of 6/8/22. a. On 11/21/22 at 1:25 PM, during a home visit observation with Staff D, Physical Therapy Assistant (PTA), the surveyor observed the patient use the functions of an electric lift chair to assist the patient with standing and sitting during the therapy session. The surveyor also observed a wheelchair in the home. In an interview, during the same home visit observation, the patient and patient's spouse reported while the patient's wheelchair in the home was new, the patient had a previous wheelchair. The patient and patient's spouse reported the patient had been using a wheelchair when out at appointments since the patient's stroke last December (2021). The patient and spouse verified the use of the lift chair since the patient's stroke. Review of the clinical record revealed the following: The POCs, dated 6/8/22 to 8/6/22, 8/7/22 to 10/5/22, 10/6/22 to 12/4/22, included orders for skilled nursing and physical therapy services and identified the medical equipment and supplies used by the patient. The POCs failed to identify the patient used a wheelchair and electric lift chair. On 11/29/22 at 3:15 PM, during an interview, the Administrator and Clinical Manager explained the patient’s wheelchair was new wheelchair because the other wheelchair had been broken. b. The POCs, dated 6/8/22 to 8/6/22, 8/7/22 to 10/5/22, 10/6/22 to 12/4/22, included an order for Polyethylene Glycol 3350 (Miralax) oral powder mix in 8 ounces of water and take by mouth daily. The POCs lacked a dosage amount for the medication. On 11/21/22 at 1:25 PM, in an interview, during a home visit observation with Staff D, PTA, the patient and patient's spouse reported the patient used one capful, 17 grams, of Miralax per day. The POCS failed to include all medical equipment and supplies used by the patient and failed to include a complete medication order for the Miralax. 2. Patient #2 had a start of care date of 2/19/2020. Review of the clinical record revealed the following: The POCs, dated 8/7/22 to 10/5/22 and 10/6/22 to 12/4/2022, included orders for skilled nursing services and an order for Nystatin powder and Mupirocin ointment twice per day. The order lacked a dosage amount or location of application of the topical medications. The POCs included an order for Nicotine Transdermal 21 milligram (mg) patch, apply 1 patch daily for 2 weeks and then step down to 14 mg patch for 2 weeks. The POCs identified the patient started the 21 mg patches on 8/5/2020. The POCs failed to maintain a current order for the Nicotine patches. On 11/22/22 at 8:10 AM, in an interview, during a home visit observation with the Clinical Manager, the patient denied using Nicotine patches and reported not using them since getting out of the hospital. The Clinical Manager reported the patient had been using the patches when the patient got out of the hospital in mid October about 6 weeks ago. The patient denied using Nystatin powder with Mupirocin ointment topically for several months. 3. Patient #3 had a start of care date of 6/10/2020. Review of the clinical record revealed the following: The POCs, dated 9/28/22 to 11/26/22 and 11/27/22 to 1/25/23, included orders for skilled nursing services. The POCs included the exact same orders for Nicotine Transdermal System, Step 2 14 mg patch daily, change daily for 5 weeks and then Step 3, 7 mg patch for 2 weeks. The POCs included an order for Spiriva Respimate Inhaler 2 puffs daily, but lacked a dosage for the medication. The POCs included an order for Acetaminophen 325 mg 2 tabs every 6 hours as needed for pain. On 11/22/22 at 9:20 AM, during a home visit observation, the Clinical Manager informed the patient she would be performing a comprehensive assessment visit due to the patient's need for recertification of home health services. The nurse set up the patient's medications for 2 weeks and completed an assessment of the patient. The surveyor observed the patient had a box of Nicotine patches and a bottle of Acetaminophen 500 mg tablets on the kitchen table. The Clinical Manager did not ask the patient about either of these medications. In an interview, during the same home visit observation, the patient reported taking Acetaminophen 500 mg 2 tablets every day since the patient had stomach surgery last month on 10/18/22. The patient reported he/she had not been using the Nicotine patches for at least a month or longer. The patient reported a plan to start using them again, and had a box of 21 mg patches. 11/29/22 at 3:10 PM, during an interview, the Clinical Manager reported she was unaware the Spiriva inhaler had a specific dosage amount until she looked it up in the drug book. The nurse failed to update medication information on the current POC. 4. Patient #4 had a start of care date of 9/19/22. Review of the clinical record revealed the following: The POCs, dated 9/19/22 to 11/17/22 and 11/18/22 to 11/16/23, included an order for skilled nursing services. The POCs included an order for Ketoconazole cream 2 percent apply topically every day. The POCs failed to specify the location of application for the topical medication. 5. Patient #6, a pediatric patient, had a start of care date of 10/3/22 and discharged from agency services on 10/24/22. Review of the clinical record revealed the following: a. The POC, dated 10/3/22 to 12/1/22, included an order for skilled nursing services and an order for Miconazole 2 percent powder apply topically to affected areas twice per day. The POCs failed to specify a location for the application of the topical medication. b. A skilled nursing visit note, dated 10/12/22, identified the patient's parent applied Miconazole to the patient's neck folds. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to ensure agency staff updated the Plan of Care with all new physician orders for 1 of 1 sampled patients (Patient #1) with interim orders for physical therapy services. The agency reported one patient received physical therapy services at the time of the survey. Failure to update the Plan of Care increased the potential for an inaccurate provision of care. Findings include: On 11/21/22 at 12:15 PM, during an interview, the Clinical Manager verified she added all physician interim orders into an updated Plan of Care (POC). When asked about therapy orders, she reported physical therapy maintained their orders separately from the POC and she did not add those orders to an updated POC. Patient #1 had a start of care date of 6/8/22. On 11/21/22 at 1:25 PM, during a home visit observation, the surveyor observed Staff D, Physical Therapy Assistant, provide physical therapy services to the patient. On 11/29/22, review of the clinical record revealed the following: a. The POC, dated 10/6/22 to 12/4/22, included a physician order for physical therapy to evaluate and treat the patient. b. An initial physical therapy evaluation, dated 10/6/22, included an order for physical therapy services 2 times per week for 6 weeks and identified patient specific therapy-related interventions and goals. c. The clinical record lacked documentation of a physical therapy visit note after 11/8/22. d. The POC update for the certification period, dated 10/6/22 to 12/4/22, lacked any orders for physical therapy, beyond the initial order for evaluation and treatment, dated 10/6/22. The POC update lacked any goals or interventions related to physical therapy services. On 11/29/22 at 9:58 AM, during an interview with the Clinical Manager, the surveyor requested physical therapy visit notes and orders since 11/8/22. On 11/29/22 at 11:05 AM, during an interview, the Clinical Manager provided a copy of the patient’s physical therapy visit notes since 11/8/22. The visit notes included a physical therapy discharge summary visit, dated 11/11/22, and an initial evaluation for physical therapy services, dated 11/15/22. The initial evaluation for physical therapy services, dated 11/15/22, included physician orders for therapy interventions, goals and services 2 times per week for 8 weeks. Agency staff failed to maintain an updated POC which included all interim orders within a certification period. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and staff interview, the agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 1 of 3 sampled patients with a home visit observation (Patient #1). Failure to follow agency expectations and accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: Review of the agency policy, titled Bag Technique, dated 12/2019, identified staff should perform hand hygiene prior to entering the staff's bag in order to prevent contamination of the bag and contamination between patients. Staff should clean reusable patient equipment wearing gloves and with a germicidal product prior to returning the equipment to the bag. Patient #1 had a start of care date of 6/8/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/6/22 to 12/4/22, included a physician order for physical therapy to evaluate and treat the patient. b. An initial physical therapy evaluation, dated 10/6/22, included orders for physical therapy services 2 times per week for 6 weeks. c. A subsequent physical therapy evaluation, dated 11/15/22, included orders for physical therapy services 2 times per week for 8 weeks. On 11/21/22 at 1:25 PM, during a home visit observation with Staff D, Physical Therapy Assistant (PTA), sanitized her hands with an alcohol-based hand sanitizer prior to entering the patient’s home. Staff D, PTA, opened the patient's door and set her bag on a chair. Staff D, PTA, removed a blood pressure cuff and stethoscope from an outside zipped pocket in her bag without applying sanitizer to her hands again. The blood pressure cuff was in a separate smaller bag. Staff D, PTA, placed the cuff on the patient’s bare left upper arm and placed the bell of the stethoscope on the patient’s bare inner elbow. She measured the patient’s blood pressure, touching the patient’s arm in the process. Staff D, PTA, returned the used blood pressure cuff to the smaller bag and stethoscope to the same zipped outer pocket of her bag without sanitizing her hands or the used equipment. In an interview, during the same home visit observation, Staff D, PTA, reported she cleans the equipment back at the office and then puts the equipment back in her bag. On 11/22/22 at 11:10 AM, during an interview, the Clinical Manager confirmed the agency required physical therapy staff to follow the agency's bag technique policy. She verified physical therapy staff needed to sanitize their hands prior to getting into the bag and clean used equipment prior to returning the equipment to the bag. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.