Every finding on record at Kossuth Regional Health Center

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 2/23/26 through 2/25/26 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 2/23/26 through 2/25/26. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 68 patients at the time of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to provide a complete comprehensive assessment for patients with wounds during start of care for 1 of 3 sampled patients with wounds (Patient #7). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency policy titled Wound Care Assessment and Documentation, dated 6/2025, the Registered Nurse (RN) is responsible for completing a thorough head-to-toe assessment on admission; including completing the wound assessment documentation in the patient's electronic medical record. A complete wound assessment, including measurement of the wound is to be completed at a minimum of weekly. During an interview on 2/24/26 at 10:23 AM, Staff B, Clinical Manager, stated wound care assessments, measurements and documentation are completed within the RN's visit note. Staff B, Clinical Manager also stated wounds are to be measured on the first visit of each week. Patient #7 had a start of care date of 6/10/25 and a discharge date of 7/14/25. Clinical record review revealed: a. The Plan of Care (POC), dated 6/10/25 to 8/8/25, identified the patient had diagnoses of traumatic subarachnoid hemorrhage and pressure ulcer, stage 2 to the sacral region. The POC included physician orders for skilled nursing services to assess skin integrity and overall condition of the skin and to provide wound care. b. The comprehensive assessment at start of care, dated 6/10/25, completed by Staff F, RN, identified the patient had a small laceration to right forehead with glue intact and the patient had three pressure ulcers to the coccyx. The clinical record lacked wound assessments/measurements for the identified wounds. The RN failed to complete a wound assessment/measurements for all identified wounds on admission. The findings were reviewed with the Administrator and Clinical Manager.

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 staff interview, clinical record reviews and agency policy review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of patient's return home from an inpatient facility for 1 of 2 sampled patients requiring a resumption of care assessment (Patient #6). Failure to complete a 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's policy titled Initial and Comprehensive Update to the Comprehensive Assessment, dated 6/2025, the comprehensive assessment must be updated and revised within 48 hours of the patient's return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests or physician ordered resumption date. During an interview on 2/24/26 at 10:23 AM, Staff B, Clinical Manager, stated resumptions of care are to be completed within 48 hours of patient's return home. Patient #6 had a start of care date of 10/17/24 and a discharge date of 4/2/25. Clinical record review revealed: a. The patient's electronic medical record identified the patient was discharged from the hospital on 11/1/24 and the agency received an order for resumption of care on the same date. b. The resumption of care comprehensive assessment, dated 11/4/24, completed by Staff H, Registered Nurse, 1 day late per regulation. The agency failed to complete the resumption of care comprehensive assessment within 48 hours of the patient's return home from an inpatient stay. The findings were reviewed with the Administrator and Clinical Manager.

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 staff interview and clinical record reviews, 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 of Care for 3 of 5 sampled patients with missed visits (Patients #1, #3 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: 3. Patient #1 had a start of care date of 1/17/26. Clinical record review revealed: a. The POC, dated 1/17/26 to 3/7/26, identified the patient had a primary diagnosis of acute encephalopathy and included physician orders for physical therapy services 2 times a week for 8 weeks. b. The electronic medical record identified physical therapy missed visits on 2/16/26. The clinical record lacked documentation of physician notification of the missed physical therapy visit on 2/16/26. The agency failed to notify the physician of the missed physical therapy visit. The above findings reviewed with the Administrator and Clinical Manager. During an interview on 2/24/26 at 10:23 AM, Staff B, Clinical Manager identified the agency does not have a policy on missed visits; however, agency staff are expected to identify the missed visit and notify the physician if visit frequency is not met. 1.Patient #3 had a start of care date of 9/22/25. Clinical record review revealed: a. The Plan of Care (POC), dated 1/20/26 to 3/20/26, identified the patient had a primary diagnosis of multiple sclerosis and included physician orders for physical therapy services 2 times a week for 8 weeks. b. The electronic medical record identified physical therapy missed visits on 2/6/26 and 2/16/26. The clinical record lacked documentation of physician notification of the two missed physical therapy visits. The agency failed to notify the physician of the missed physical therapy visits. 2. Patient #7 had a start of care date of 6/10/25 and a discharge date of 7/17/25. Clinical record review revealed: a. The POC, dated 6/10/25 to 8/8/25, identified the patient had a primary diagnosis of traumatic subarachnoid hemorrhage and included physician orders for physical therapy services 2 times a week for 8 weeks. b. The electronic medical record identified physical therapy missed visits on 6/13/25 and 7/4/25. The clinical record lacked documentation of physician notification of the two missed physical therapy visits. The agency failed to notify the physician of the missed physical therapy visits.

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 reviews 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, all medications, and treatments used by the patient for 2 of 3 sampled patients with home visits (Patients #2 and #3). Failure to maintain complete and accurate POCs with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #3 had a start of care date of 9/22/25. Clinical record review revealed: a. The POCs, dated 11/21/25 to 1/19/26 and 1/20/26 to 3/20/26, identified the patient had a primary diagnosis of multiple sclerosis and included physician orders for medical supplies and equipment used by the patient. The POC included the following medical supplies and equipment used by the patient: incontinent supplies, reacher, shower chair, grab bars/safety rails, lift chair, heating pad, medication planner, pill cutter and four wheeled walker. b. The skilled nurse visit note, dated 12/18/25, completed by Staff F, RN, identified the patient uses a cane. c. During a home observation visit on 2/24/26 at 2:30 PM with Staff G, RN, the surveyor identified a cane in the patient's living room. The patient identified he/she utilizes the cane and it is not new. The agency failed to include all medical equipment/supplies on the patient's POC, including cane. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency plicy titled Care Planning & Coordination, dated 5/2025, the individualized plan of care must include the types of services, supplies, and equipment required. 1.Patient #2 had a start of care date of 2/11/26. Clinical record review revealed: a. The plan of care (POC), dated 2/11/26 to 4/11/26, identified the patient had a primary diagnosis of after care following joint replacement surgery and included physician orders for medical supplies and equipment used by the patient. The POC included the following medical supplies and equipment used by the patient: adult diapers, walker, shower bench, rolling walker, gait/transfer belt, reacher, hand held shower, grab bars/safety rails, shower mat, glasses, CPAP (continuous positive pressure), incontinence products, lift chair, medication planner, bike, bistro, ice machine, zero degree knee pillow, scale, electric bed, wound vac, heating pad, incentive spirometer and 4 wheeled walker. b. During a home observation visit on 2/24/26 at 2:15 PM with Staff C, Registered Nurse (RN), the patient stated he/she utilized Ted hose (anti-thrombosis stockings) and had them since the start of home health services following surgery. The agency failed to include all medical equipment/supplies on the patient's POC, including Ted hose.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure nurses taking verbal orders from a physician documented the orders in the clinical record (signed, dated and timed) sending the orders to the physician for authentication, including signature and date of signature for 1 of 1 sampled patients with a catheter (Patient #4). Failure to document physician orders taken into patient clinical records placed the patient at risk for inappropriate, inadequate care resulting in potential injury or harm. Findings include: According to the agency policy, titled Care Planning & Coordination, dated 5/2025, all drugs, services, and treatments in the plan of care are administered only as ordered by a physician. Patient #4 had a start of care date of 12/11/25. Clinical record review revealed: a. The plans of care, dated 12/10/25 to 2/7/26 and 2/8/26 to 4/8/26, identified the patient had diagnoses of pressure ulcer of the sacral region, quadriplegia and neurogenic bladder. The POC included orders for skilled nursing services and suprapubic catheter change every month and as needed with size16 French catheter. b. The skilled nurse visit note, dated 1/14/26, Staff F, Registered Nurse, identified the suprapubic catheter changed with a size 18 French catheter. c. Review of the clinical record lacked documentation of a verbal order for the change in catheter size to 18 French catheter. During an interview on 2/24/26 at 4:10 PM the Administrator verified unable to locate an order for the suprapubic catheter size change to 18 French. The agency failed to include verbal orders for all supplies and treatments required by the patient including catheter size. The findings reviewed with the Administrator and Clinical Manager.

The Department of Inspections and Appeals conducted a recertification survey, dated 2/20/23 to 2/22/23, and found the agency to be operating in substantial compliance under the Emergency Preparedness Condition of Participation.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 2/20/23 to 2/22/23. The survey identified the following standard level deficient practices. The agency reported a census of 78 patients at the time of the survey.

HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review, personnel file review and agency staff interview, the agency failed to ensure 1 of 2 sampled home health aides (Staff E), performing tasks requiring extra skills exceeding the level of basic home health aide skills for 2 of 3 sampled patients (Patients #2 and #6), had documented evidence of a successful return competency demonstration signed off by a registered nurse prior to documenting the independent performance of the extra skill task with a patient. Failure to ensure home health aides were competent in any assigned skill which exceeded the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: 1. Patient #2 had a start of care date of 2/8/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/8/23 to 4/8/23, included physician orders for skilled nursing services one time per week and home health aide services 2 times per week. The POC included the following home health aide interventions: "assist with ambulation, transfers and exercise program." To assist a patient with an exercise program would require the home health aide to successfully return demonstrate the ability to competently assist the patient with their home exercise program prior to performing this task. b. The home health aide visit notes, dated 2/9, 2/14 and 2/17/23, included documentation of the 3 assigned tasks of assisting with ambulation, transfers and exercise program on the same line with a one-word response of "done" by Staff E, Home Health Aide. Review of personal information provided by agency staff revealed the following: Staff E, Home Health Aide, had a hire date of 10/4/04. The personal file for Staff E, Home Health Aide, lacked documentation of any type of competency training in a personal exercise program for Patient #2. 2. Patient #6 had a start of care date of 9/17/21, and transferred from agency services on 4/7/22 to a skilled nursing facility. Review of the clinical record revealed the following: a. The POC, dated 3/21/22 to 5/19/22, included physician orders for skilled nursing services one time per week and home health aide services 2 times per week. The POC included the following home health aide interventions: "assist with ambulation, transfers and exercise program." To assist a patient with an exercise program would require the home health aide to successfully return demonstrate the ability to competently assist the patient with their home exercise program prior to performing this task. b. The home health aide visit notes, dated 3/21, 3/25, 3/28, 3/30 and 4/4/22, included documentation of the 3 assigned tasks of assisting with ambulation, transfers and exercise program on the same line with a one-word response of "done" by Staff E, Home Health Aide. Review of personal information provided by agency staff revealed the following: The personal file for Staff E, Home Health Aide, lacked documentation of any type of competency training in a personal exercise program for Patient #6. 2/21/23 at 4:14 PM, during an interview, the Clinical Manager reported Staff E, Home Health Aide, did not have competency skills training in an exercise program specific to Patients #2 and #6. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, patient, caregiver/family and agency staff interview, the agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 2 of 6 sampled patients receiving home health aide services (Patients #1 and #2). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: Review of the agency policy, titled Home Health Aide Services, dated 2/2023, identified the supervising registered nurse (RN) was responsible for ensuring the home health aide followed the patient's Plan of Care (POC). The home health aide will provide services only as listed on the assignment. Review of the agency policy, titled Care Planning and Coordination, dated 2/2023, identified agency staff will provide services based on each patient's individualized POC. The RN is responsible for coordinating the delivery of care to meet the needs of the patient. On 2/21/23 at 2:10 PM, during an interview, the Clinical Manager reported the admitting registered nurse (RN) or the Clinical Manager was responsible for creating and updating the home health aide care plan. The home health aide and RN meet monthly to review the care plan. The home health aide is responsible for notifying the RN if something is incorrect on the care plan. 1. Patient #1 had a start of care date of 10/31/22. Review of the clinical record revealed the following: The Plans of Care (POCs), dated 10/31/22 to 12/29/22 and 12/30/22 to 2/27/23, included orders for skilled nursing services one time per week and home health aide services 3 times per week. The POCs included instructions to the home health aide to complete the task of skin care (inform skilled nurse if rash to right side of torso/groin does not get better or worsens; spouse applying medicated ointment). On 2/20/23 at 2:55 PM, during a home visit observation, Staff F, Physical Therapist, instructed the patient on physical therapy exercises. In an interview, during the same home visit observation, the caregiver/spouse for the patient reported the home health aide applied lotion on the patient for skin care. The home health aide instructions on the POC failed to specify for the patient to apply lotion. On 2/21/23 at 2:40 PM, during an interview, the Clinical Manager reported the POC instructions for the home health aides needed to include more than just the instructions of "skin care" and should specify the application of lotion. 2. Patient #2 had a start of care date of 2/8/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/8/23 to 4/8/23, identified a diagnosis of left femur fracture and included physician orders for skilled nursing services one time per week and home health aide services 2 times per week. The POC included an order for the patient to be none weight bearing on the left leg. The POC included the following home health aide interventions: "skin care" and to "assist with transfers, ambulation and exercise program". b. The home health aide visit notes, dated 2/9, 2/14 and 2/17/23, included documentation the home health aide completed the tasks of skin care, ambulation, transfer and exercise program assistance. On 2/21/23 at 9:15 AM, during a home visit observation, Staff C, RN, completed an assessment on the patient. In an interview, during the same home visit observation, the patient reported the home health aide did not assist with ambulation, as the patient was non-weight bearing and used a wheelchair. The patient reported the home health did not assist with an exercise program and the patient denied needing assistance with this. The patient reported the home health aide not apply lotion or perform any skin care that the patient was aware of. The patient reported not needing assistance with skin care. The POC failed to specify home health aide interventions specific to the patient's needs. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review, agency written expectations and agency staff interview, the agency failed to 1) ensure agency staff completed and sent a transfer summary to the receiving facility within 2 business days of the patient's transfer for 1 of 1 sampled patients (Patient #6) with a transfer; and, 2) ensure agency staff completed a discharge summary and sent that summary to the healthcare practitioner assuming care of the patient within 5 business days of the patient's discharge for 1 of 1 sampled patients with a discharge from the agency (Patient #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 after the patient transfers or discharges. Findings include: Review of the agency's undated, written expectations, titled Charting Expectations, revealed agency staff must complete and send a transfer summary within 2 business days of awareness of the transfer and complete and send a discharge summary to the healthcare practitioner assuming care of the patient within 5 business of discharge. 1. Patient #6 had a start of care date of 9/17/21, and transferred from agency services on 4/7/22 to a skilled nursing facility. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/21/22 to 5/19/22, included orders for skilled nursing, physical therapy and home health aide services. b. A transfer Outcome Assessment and Information Set (OASIS), dated 4/7/22, identified the patient completed a planned transfer to a skilled nursing facility. c. A transfer summary, dated 4/7/22, included documentation of a signature of completion, dated 4/13/22 (2 days late). On 2/21/23 at 12:00 PM, during an interview, the Clinical Manager confirmed agency staff completed the transfer summary and sent it to the patient's physician late. 2. Patient #7 had a start of care date of 2/3/22 and discharged from agency services on 3/31/22. Review of the clinical record revealed the following: a. The POC, dated 2/3/22 to 4/3/22, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. A update to the comprehensive assessment completed at the time of discharge, dated 3/31/22, included documentation the patient discharged from agency services due to just cause on 3/31/22. c. The clinical record lacked documentation agency staff completed a discharge summary and sent this to the patient's primary healthcare practitioner. On 2/21/23 at 12:00 PM, during an interview, the Clinical Manager confirmed the patient's clinical record lacked documentation of a discharge summary. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.