Every finding on record at Lutheran Home for the Aged

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 1/5/26 through 1/7/26 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 1/5/26 through 1/7/26 and the home health agency was found to be operating out of compliance with the following standard level regulatory requirements. The agency reported a census of 22 patients at the time 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 clinical record review, policy review and agency staff interview, the agency failed to follow physician orders for 1 of 7 sampled patients (Patient #2). Failure to ensure staff follow physician orders placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care, dated 7/11/25, the plan of care will be established and authorized in writing by the physician based on an evaluation of the patient’s immediate and long-term needs. The plan of care developed covering types of services and equipment required, frequency of visits, activities provided, medications and treatments, and any other appropriate items. Patient #2 had a start of care date of 11/17/25. Clinical record review revealed the following: a. Plan of Care, dated 11/17/25 to 1/15/26, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nurse to contact physician when weight gain of greater than 3 pounds in 24 hours or greater than 5 pounds in a week. b. Undated aide care plan, identified the task to assist patient with weighing on home scale, with a start date of 12/18/25. c. Aide visit note, dated 12/22/25, completed by Staff D, Home Health Aide (HHA), identified the task to assist patient with weighing on home scale was marked with a weight of 147.4 pounds. d. Aide visit note, dated 12/26/25, completed by Staff D, HHA, identified the task to assist patient with weighing on home scale was marked with a weight of 153 pounds, an increase of 5.6 pounds. e. Skilled nurse visit note, dated 12/29/25, completed by Staff B, Clinical Manager, failed to include documentation the physician was notified of the weight gain or a reason why the physician was not notified. During an interview on 1/7/26 at 3:34 PM, Staff B, Clinical Manager, reported the weight on 12/22/25 was inaccurate when looking at the weight flowsheet but she failed to include this information in the documentation on 12/29/25. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.

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 interview and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 5 sampled patients receiving home health aide services (Patient #6). The agency reported 13 patients received care provided by a home health aide. 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 patients would receive inappropriate or inconsistent home health aide services. Findings include: According to the policy, titled Home Health Aide/Homemaker Visit Note, dated 7/11/25, the aide must follow the care plan exactly. Each task/activity on the care plan must be charted, either completed or refused, with every visit. Patient #6 had a start of care date of 3/28/25 and a discharge date of 4/25/25. Clinical record review revealed: a. Plan of Care, dated 3/28/25 to 5/26/25, included primary diagnosis of acute cystitis without hematuria and physician orders for skilled nursing and home health aide services. b. Aide care plan, dated 3/31/25, included tasks bath: bed per patient request and bath: shower bench. c. Aide visit notes, dated 4/4, 4/11, 4/18, 4/22 and 4/25/25, included documentation the task bath: bed per patient request was not applicable and the task bath: shower bench was done. d. Aide visit notes, dated 4/1, 4/8 and 4/15/25, included documentation the task bath: bed per patient request patient refused and the task bath: shower bench was done. During an interview on 1/7/25 at 2:11 PM, Staff B, Clinical Manager, reported the aide task bath: shower bench should be entered on the care plan with the task bath: shower. Staff B indicated the task bath: shower bench would indicate the patient used a shower bench when bathing from the aide but the task bath: shower was not an option for the aide to document. The aide care plan failed to include all necessary specific tasks for the aide to complete. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical 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 5 sampled patients receiving home health aide services (Patient #2). The agency reported 13 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 Home Health Aide/Homemaker Visit Note, dated 7/11/25, the aide must follow the care plan exactly. Each task/activity on the care plan must be charted, either completed or refused, with every visit. Patient #2 had a start of care date of 11/17/25. Clinical record review revealed the following: a. Plan of Care, dated 11/17/25 to 1/15/26, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nurse and home health aide services. b. Undated aide care plan, identified the tasks bath: bed and bath: shower for the aide to complete. c. Aide visit note, dated 1/2/26, completed by Staff D, Home Health Aide, included documentation the tasks bath: bed and bath: shower were done. During an interview on 1/7/26 at 3:00 PM, Staff B, Clinical Manager reported she had reviewed the aide note and will contact the aide to annotate the correct bath type completed. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.

The Department of Inspections and Appeals conducted a recertification survey, dated 12/8/22 to 12/14/22, and found the following standard level deficient practices under the Emergency Preparedness Condition of Participation.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and policies, clinical record review, home visit observation and agency staff interview, the agency failed to ensure the clinical record included the development/review of patient's individualized emergency plan as part of the comprehensive assessment for 4 of 7 sampled patients (Patients #2, #3, #4 and #7) and the agency had a written policy and procedure that addressed the need to include the completion or review of an individualized emergency preparedness plan as part of the comprehensive assessment/update to the comprehensive assessment for each patient. Failure to ensure the agency developed policies and procedures to address the completion of individualized emergency preparedness plan as part of the comprehensive and update to the comprehensive assessment for each agency patient, placed patients at risk for staff and patients being unaware and unprepared to respond in a timely and effective manner to potential natural or man-made disasters the patient may encounter. Findings include: Review of the agency policy, titled Emergency and Disaster Preparedness for Patients, dated 5/11/22, identified each patient would have a written emergency and disaster plan upon admission, and the staff would update the plan as needed. The policy failed to identify agency staff needed to review and/or update the patient's individualized emergency preparedness plan with each update to the comprehensive assessment. 1. Patient #2 had a start of care date of 3/17/22. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 9/13/22 to 11/11/22 and 11/12/22 to 1/10/23, included an order for skilled nursing services. b. The update to the comprehensive assessment completed at the time of recertification, dated 11/7/22, and the update to the comprehensive assessment completed at the time of resumption of care, dated 12/8/22, lacked documentation the nurse reviewed the patient's emergency preparedness plan. On 12/12/22 at 2:00 PM, during a home visit observation, Staff E, Certified Occupational Therapy Assistant (COTA), provided occupational therapy services. The surveyor observed the patient’s emergency preparedness plan, dated 9/8/22 was located on the patient’s refrigerator. 2. Patient #3 had a start of care date of 10/30/17. Review of the clinical record revealed the following: a. The POCs, dated 8/15/22 to 10/13/22 and 10/14/22 to 12/12/22, included an order for skilled nursing services. b. The updates to the comprehensive assessment completed at the time of recertification, dated 10/10 and 12/8/22, lacked documentation the nurse reviewed the patient's emergency preparedness plan. 3. Patient #4 had a start of care date of 10/6/22. Review of the clinical record revealed the following: a. The POCs, dated 10/6/22 to 12/4/22 and 12/5/22 to 2/2/23, included an order for skilled nursing services. b. The update to the comprehensive assessment completed at the time of recertification, dated 112/1/22, lacked documentation the nurse reviewed the patient's emergency preparedness plan. 4. Patient #7 had a start of care date of 10/6/22 and discharged from services on 11/4/22. Review of the clinical record revealed the following: a. The POC, dated 10/6/22 to 12/4/22, included an order for skilled nursing services. b. The comprehensive assessment completed at the start of care, dated 10/6/22, and the update to the comprehensive assessment completed at the time of discharge, dated 11/4/22, lacked documentation the nurse developed/reviewed the patient's emergency preparedness plan. 12/14/22 at 12:10 PM, during an interview, the Clinical Manager reported an inability to find documentation of emergency preparedness review for all patients identified. She explained agency staff were reviewing the plans with the patients, but not documenting this. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of agency policy, training documentation and staff interview, the agency failed to ensure 1 of 2 sampled contract therapists (Staff H, Physical Therapist) received training in the agency's emergency preparedness policies and procedures. Failure to ensure the agency provided training in emergency preparedness policies and procedures to all contracted staff placed the agency at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: Review of the agency policy, titled Emergency Plan and Preparedness, dated 10/26/22, identified the agency will maintain an emergency preparedness training program for all existing and new staff including contract staff. On 12/12/22 at 8:04 AM, the Administrator sent an email with a list of contracted therapy staff. The list included a total of 23 contracted physical, occupational and speech therapists and assistants. On 12/14/22 at 9:17 AM, the surveyor selected Staff E, Certified Occupational Therapy Assistant, and Staff H, Physical Therapist (PT), for review. Staff H, PT had a start date of 8/22/22. On 12/14/22 at 1:15 PM, review of an email sent by the Administrator identified Staff H, PT, had not received training in emergency preparedness from the home health agency. On 12/14/22 at 1:27 PM, during an interview, the Administrator reported another contracted therapy staff, Staff E, Certified Occupational Therapy Assistant, had training on the agency's emergency preparedness plan and policies, but Staff H, did not. She was unsure which of the therapists had the training. She reported sometimes new therapists started, and she would be unaware of it. She explained Staff H, PT, was a traveling therapist contracted through a different company and had not had their EP training. 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 12/8/22 to 12/14/22. The survey identified the following standard level deficient practices. The agency reported a census of 20 patients at the time 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, patient and agency staff interview, the agency failed to ensure agency staff accurately completed all of the components comprising the Plan of Care for 3 of 3 sampled patients (Patients #1, #2 and #3) with a home visit observation. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not have equipment, medications and/or treatments according to the assessed needs of the patient and physician orders. Findings include Review of the agency policy, titled Plan of Care (POC), dated 5/11/22, identified the patient's POC includes medications and treatments and medical supplies and equipment required by the patient. A physician establishes and authorizes the POC and the agency staff review and update the POC with physician authorization at least once every 60 days. 1. Patient #1 had a start of care date of 4/4/19. Review of the clinical record revealed the following: The POCs, dated 7/17/22 to 9/14/22, 9/15/22 to 11/13/22 and 11/14/22 to 1/12/23, included an order for the skilled nurse to set up the patient's medications. The POCs included an order for Atorvastatin 40 milligrams (mg) tablets, take one-half tablet (20 mg) every day by mouth. The POC, dated 7/17/22 to 9/14/22, identified the order for the Atorvastatin start on 9/14/17 and identified the patient used a pill-cutter. The POCs, dated 9/15/22 to 11/13/22 and 11/14/22 to 1/12/23, did not identify the patient used a pill cutter for medical equipment/supplies. On 12/12/22 at 10:00 AM, during a home visit observation, Staff C, Registered Nurse (RN), set up the patient’s medications per the POC. The surveyor observed during the course of medication set up, Staff C, RN, used the patient’s own pill cutter to cut Atorvastatin tablets in half. On 12/14/22 at 8:16 AM, during an interview, Staff C, RN, confirmed she had noticed the POCs in the new electronic medical record (EMR) which started in August 2022 were missing some of the previously identified medical equipment and supplies. 2. Patient #2 had a start of care date of 3/17/22. On 12/12/22 at 2:00 PM, during a home visit observation, Staff E, Certified Occupational Therapy Assistant (COTA), provided occupational therapy services. During the visit, the surveyor observed diabetic test strips for a glucometer, a sock sleeve and a partially used tube of Aspercreme maximum strength topical pain reliever. In an interview, during the same home visit observation, the patient and Staff E, COTA, both reported the patient’s use of a sock sleeve for the last 4 to 6 months to aide in the application of the patient’s compression socks. The patient reported using a glucometer to check blood sugar levels for years. The patient reported using a reacher to aide in dressing for at least a year. The patient reported using Aspercreme for years for right shoulder pain. Review of the clinical record revealed the following: a. The POC, dated 7/15/22 to 9/12/22, identified the patient used diabetic testing supplies and glucometer. The POC did not identify the the patient's use of Aspercreme. b. The POCs, dated 9/13/22 to 11/11/22 and 11/12/22 to 1/10/23, failed to identify the patient's use of a sock sleeve, reacher, diabetic testing supplies and glucometer. The POCs failed to identify the patient used Aspercreme. 3. Patient #3 had a start of care date of 10/30/17. On 12/12/22 at 3:30 PM, during a home visit observation, Staff D, RN, assessed the patient and set up the patient’s medications. The surveyor observed patient ambulate without an assistive device. The surveyor observed an automated blood pressure machine and cuff sitting on the patient’s kitchen table. In an interview, during the same home visit observation, Staff D, RN, and the patient both reported the patient had not required the use of a cane or walker for a long time; more than a year. Staff D, RN, explained she identified on the comprehensive assessment update the walker and cane were in the home, but not in use. She thought if the equipment was in the home, it needed to be identified. The patient reported walking 2 miles a day up and down hills. They both reported the patient had the automated blood pressure machine for more than a year. Review of the clinical record revealed the following: The POCs, dated 8/15/22 to 10/13/22, 10/14/22 to 12/12/22 and 12/13/22 to 2/10/23, inaccurately identified the patient used a walker and cane for medical equipment/supplies. The POCs failed to identify the patient used an automatic blood pressure machine. On 12/14/22 at 8:16 AM, during an interview, the Clinical Manager explained she was identifying any medical equipment or supply in the home in the comprehensive assessments, but clarifying the assessments if the patient was using the medical equipment/supply or not. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, patient and 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 in writing by the skilled professional assigning the home health aide to the patient for 2 of 2 sampled patients receiving home health aide services (Patients #3 and #7). 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: On 12/8/22 at 10:45 AM, during an interview, the Clinical Manager reported if a home health aide is unable to complete an assigned task, the home health aide is to document the reason why. If the patient requests the patient to do an unassigned task, the home health aide must obtain prior approval from the registered nurse (RN). The RN will update the home health aide assignment upon approval of the task. 1. Patient #3 had a start of care date of 10/30/17. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 8/15/22 to 10/13/22, 10/14/22 to 12/12/22 and 12/13/22 to 2/10/23, included orders for home health aide services 1 to 3 times per week and weekly skilled nursing services. The POCs included instructions for the home health aides to shave the patient with an electric razor every visit. The POCs included instructions for the home health aide to assist the patient with showering, dressing, shampooing and assisting with transfers. The POCs lacked instructions for any type of skin care. b. The home health aide visit notes, dated 10/11, 10/12, 10/14, 10/18, 10/19, 10/21, 10/25, 10/26, 10/28, 11/1, 11/2, 11/4, 11/8, 11/9, 11/10, 11/15, 11/18, 11/22, 11/23, 11/29, 12/1, 12/2, 12/6, 12/8 and 12/9/22, lacked documentation regarding the assigned task of shaving the patient. The visit notes did not include any documentation of the home health aide providing skin care. On 12/12/22 at 3:30 PM, during a home visit observation, Staff D, RN, assessed the patient and set up the patient’s medications. In an interview, during the same home visit observation, Staff D, RN, reported the home health aides provide care 1 to 3 times per week, but typically on Tuesdays, Thursdays and Fridays. The patient reported the home health aides help with washing the patient’s back and legs. Staff D, RN, reported the home health aides assisted with shampooing the patient's hair, dressing and getting in and out of the shower. The patient denied the home health aides ever helped the patient with shaving. Staff D, RN, reported the home health aides apply lotion for skin care. On 12/13/22 at 3:10 PM, during an interview, Staff F, Home Care Aide (HCA), reported she applies lotion to the patient after showers. On 12/12/22 at 3:30 PM, during an interview, Staff G, HCA, reported she puts lotion on the patient every time. The home health aides failed to document whether or not the patient refused assistance with shaving, provided skin care with the application of lotion without direction and failed to document they provided skin care. 2. Patient #7 had a start of care date of 10/6/22 and discharged from agency services on 11/4/22. Review of the clinical record revealed the following: a. The POC, dated 10/6/22 to 12/4/22, included orders for home health aide services 1 to 2 times per week starting the week of 10/9/22. The POC included instructions for the home health aides to complete the following tasks per patient request: shave, apply medicated Diclofenac 1% cream, pericare, oral care and shampoo. The POC included instructions for the home health aide to assist the patient with ambulation, transfers, dressing, skin care, showers and use a shower chair. b. The home health aide visit notes, dated 10/13 and 10/18/22, lacked documentation whether or not the patient requested or the home health aide offered to complete the tasks of shaving, applying medicated cream, providing pericare and oral care. c. The home health aide visit note, dated 10/20/22, lacked documentation whether or not the patient requested or the home health aide offered to complete the tasks of shaving, applying medicated cream, providing pericare, shampooing and oral care. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.