Every finding on record at Mercy Health Services-Iowa Corp

The recertification survey, conducted 11/8/21 through 11/16/21, found the agency operating out of compliance with the Condition of Participation 42 CFR 484.102 Emergency Preparedness with the following standard level deficiency.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] 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:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan. The agency provided services to 48 patients at the time of the survey, including 47 patients who received services from the Dubuque parent office and 1 patient from the Galena, Illinois branch office. Findings include: The agency policy failed to identify a procedure for notification of appropriate agencies and officials of homebound patients in need of evacuation due to an emergency situation. During an interview on 11/16/21at 10:15 AM, Staff A, Administrator/Clinical Manager, reported the term homebound was not used in the emergency preparedness policy The agency provided no further information prior to the end of the survey.

The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 11/8/21 through 11/16/21. The recertification survey found the home health agency operating out of compliance with the following standard level home health regulations: The home health agency was found to be in substantial compliance in relation to CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

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, staff interview and agency policy review, the agency failed to ensure the completion of all pertinent components of the update to the comprehensive assessment 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 (Patient #9). The agency provided services to 48 patients at the time of the survey, including 47 patients who received services from the Dubuque parent office and 1 patient from the Galena, Illinois branch office. The survey identified the deficient practice occurred at the Dubuque parent office. Failure to complete an update to the comprehensive assessment at the time of resumption of care in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: Review of the undated agency policy, titled Provision of Care, Assessment/Reassessment of Clients, clinicians must complete the update to the comprehensive assessment at resumption of care within 48 hours of the patient's return home or of the organization's knowledge of the patient's return from a 24-hour hospital admission for other than diagnostic testing. Patient #9, a pediatric patient, had a start of care date of 2/2/2020 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The Plan of Care, dated 3/28/2021 to 5/28/2021, included a physician order for skilled nursing services. b. A skilled nursing visit note, dated 4/6/21, included documentation the patient had a spinal surgery scheduled for 4/22/21 and would be in the hospital for 4 to 5 days. c. A skilled nursing visit note, dated 4/29/21, identified the hospital admitted the patient on 4/22 and discharged the patient on 4/26/21. d. The clinical record lacked documentation of an update to the comprehensive assessment completed at the time of resumption of care after an inpatient hospital stay. On 11/8/21 at 3:55 PM, the Administrator/Clinical Manager reported the agency did have a pediatric comprehensive assessment. On 11/9/21 at 3:50 PM, during an interview, the Administrator/Clinical Manager reported the nurse missed doing the update to the comprehensive assessment at the time of resumption of care due to agency nursing staff not being used to having to do a resumption of care for a pediatric patients. The Administrator/Clinical Manager received the above findings and agency staff provided no further 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 clinical record review, agency policy review and home visit observation, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 6 of 17 sampled patients (Patients #1, #2, #3, #6, #7 and #17). The agency provided services to 48 patients at the time of the survey, including 47 patients who received services from the Dubuque parent office and 1 patient from the Galena, Illinois branch office. 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. 4. Patient #1 had a start of care date of 10/31/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: The POC, dated 10/31/21 to 12/29/21, identified the patient had physician orders that included Docusate (stool softener) 100 mg 2 times a day. On 11/8/21 at 3:10 PM, during a home visit observation with Staff H, Occupational Therapist, (OT), the surveyor observed the patient had the medication Docusate 50 mg with Senna 8.6 mg 2 times a day. During an interview during the same home visit, the patient reported he/she had that medication since he/she came home form the hospital and at start of services. The POC failed to identify the patient's current medication. 5. Patient #7 had a start of care date of 7/25/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: The POCs, dated 7/25/21 to 9/22/21 and 9/21/21 to 11/21/21, identified the patient used the following medical equipment and supplies: wound supplies, reachar, toilet seat riser, tub bench, chair lift, glucometer with supplies, orthotics, boot, walker, wheelchair and negative pressure wound supplies. On 11/10/21 at 9:00 AM, during a home visit observation with Staff G, RN, the surveyor observed the patient had a black cushion in the recliner. In an interview, during the same home visit observation, the patient reported he/she had the cushion since the start of home care services. The POC failed to identify the patient's cushion. 6. Patient #17 had a start of care date of 2/16/19 and received agency services from the Dubuque parent office and discharged on 2/28/19. The POC, dated 2/16/19 to 4/16/19, identified the patient used the following medical equipment and supplies: oxygen supplies, rails/grab bars, respiratory supplies, shower/tub equipment, walker and gloves and tape supplies. The home health aide care plan dated 2/16/19 included RN instructions for the home health aide to provide perineal care and change incontinent briefs. The POC failed to identify the patient required incontinent briefs. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. 3. Patient #2 had a start of care date of 10/29/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: The Plan of Care (POC), dated 10/29/21 to 12/27/21, identified the patient used the following medical equipment and supplies: Ted compression hose, walker, reacher, grab bars, shower chair, cane, long-handled shoe horn, scales and Ace wrap. On 11/9/21 at 9:57 AM, during a home visit observation with Staff D, Physical Therapist (PT), the surveyor observed the patient had a medication planner filled with medications. In an interview, during the same home visit observation, the patient reported a family member of the patient bought the medication planner the day the patient discharged from the hospital. The patient reported using the medication planner since the day the family member bought it for the patient. Staff D, PT, reported agency staff admitted the patient the day after the patient discharged from the hospital. The POC failed to identify the patient used a medication planner. 1. Patient #6 had a start of care date of 11/2/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 11/2/21 to 12/31/21, identified the patient used the following medical equipment and supplies: Ted compression hose, wheeled walker, toilet seat riser, grab bars, cane, crutches, ice machine, continuous positive airway pressure (Cpap) machine, incentive spirometer, sharps container, infusion supplies, tape and gloves. On 11/10/21 at 8:30 AM, during a home visit observation with Staff E, Registered nurse (RN), the surveyor observed the patient had a hand held shower. During an interview during the same home visit observation the patient identified using the hand held shower since the start of home care services. The POC failed to identify the patient used a hand held shower. b. The Plan of Care, dated 11/2/21 to 12/31/21, included orders for the following medications: Acetaminophen 500 mg (milligram) tablet 2 tablets every 6 hours PRN (as needed), Celecoxib 200 mg capsule 1 capsule AM (morning) and PM evening, enoxaparin 40 mg subcutaneous (under the skin) injection every AM, escitalopram 10 mg tablet every AM, gabapentin 300 mg capsule 2 times daily AM and bedtime, hydrocodone 5 mg 1 tablet every 4 hours PRN for moderate pain or 2 tablets every 4 hours for moderate to severe pain, Melatonin 10 mg capsule at bedtime PRN, Milk of Magnesia 400mg/5ml (milliliter) 10 ml daily PRN, Oyster shell calcium/vitamin D3 500 mg (1250mg)-200 unit tablet every AM, Phillips colon health 1.5 billion cell capsule every AM. During the same home visit, the surveyor reviewed and observed all medications from the patient’s medication supply. The surveyor identified a bottle of Celecoxib 200 mg 1 capsule daily, gabapentin 300 mg capsule 1 capsule at bedtime, melatonin 5 mg tablet 1 tablet at bedtime PRN, Vitafusion gummies calcium and D3 500mg/25mcg (microgram), Phillips colon health 1.75 billon capsule. The patient reported having the celecoxib filled prior to admission by a different physician and the Vitafusion calcium and D3 was purchased over the counter at Sam’s club. The plan of care failed to correctly identify all medications used by the patient. 2. Patient #3 had a start of care date of 10/15/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: The Plan of Care (POC), dated 10/15/21 to 12/13/21, identified the patient used the following medical equipment and supplies: Wheeled walker, walker platform, grab bars, cane, continuous glucometer, cpap, oxygen, O2 tanks, oxygen supplies, hand held shower, incentive spirometer, trach supplies, Orthotic support (thoracic, lumbar, sacral), hand splint, Incentive spirometer, trach supplies, wound care supplies, nebulizer and gloves/tape. On 11/921 at 10:07 AM, during a home visit observation with Staff E, Registered nurse (RN), the surveyor observed the patient had a shower bench, suction machine and wedge pillow. The POC failed to identify the patient used a shower bench, suction machine and wedge pillow.

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, agency policy review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 4 sampled patients receiving home health aide services (Patient #5, #7, #10 and #12). The agency provided services to 48 patients at the time of the survey, including 47 patients who received services form the Dubuque parent office and 1 patient from the Galena, Illinois branch office. The survey identified the deficient practice occurred at the Dubuque parent office. 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 patient's personal care needs were not adequately met 2. Patient #5 had a start of care date of 10/23/17 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/2/21 to 11/30/21, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 10/2/21, included registered nurse (RN) instructions to complete the following tasks: assist to the bedside commode, empty commode if needed per patient request, provide medication reminders, shower, pivot to shower using the grab bar, shampoo, hair care, perineal care to include may assist with application of barrier cream Phytoplex and Nystatin to areas of irritation or skin folds, dress with assist, other described as wash right stump with soap and water and dry, apply non-medicated lotion (may apply Eucerin cream to dry skin areas per patient request, other described as using a slide board to assist as needed or pivot transfer, patient uses wheelchair and has not been wearing prosthetic, other described as patient/caregiver screen for Covid 19 prior to visit per Centers for Disease Control and Prevention (CDC) and special instructions to remind patient to wear Lifeline (emergency response system). c. The home health aide visit notes, dated 10/4, 10/6, 10/8, 10/11, 10/13, 10/15, 10/18, 10/20, 10/22, 10/25, 10/27, 10/29, 11/1, 11/5 and 11/8/21, included documentation Staff C, Home Health Aide, completed the unspecified tasks and special instructions with no definition on what the home health aide did to complete the unspecified tasks and special instructions. d. The home health aide visit note, dated 10/6/21, included documentation the home health aide reported the task of shampooing was "not required this visit" with no further explanation of why this task would not be required. On 11/10/21 at 10:07 AM, during a interview, Staff C, Home Health Aide, reported she reminded the patient to wear the Lifeline every visit, washed the patient's right stump, (after an amputation, the bit that is left beyond a healthy joint) sometimes she pivot transfers the patient and sometimes she uses the slide board. She does not contact the patient prior to the visit to screen for Covid 19, but rather relies on the patient to call her if she has any symptoms. On 11/15/21 at 2:35 PM, during an interview, the Administrator/Clinical Manager reported training agency staff to call the patient prior to the home care visit and ask if the patient or any person in the home has any signs or symptoms of Covid 19. The home health aide failed to follow the home health aide care plan. 3. Patient #10 had a start of care date of 11/1/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The POC, dated 11/1/21 to 12/30/21, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 11/2/21, included RN instructions to the home health aide to complete the task of shampooing the patient's hair every visit. c. The home health aide visit notes, dated 11/2 and 11/4/21, included documentation the patient refused for the home health aide to complete the task of shampooing. The home health aide visit note, dated 11/9/21, included documentation the home health aide reported the task of shampooing was "not required this visit" with no further explanation of why this task would not be required. 4. Patient #12 had a start of care date of 7/1/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The POC, dated 8/30/21 to 10/28/21 and 10/29/21 to 12/27/21, included physician orders for home health aide services. The POCs included an order for Desitin 40 percent topical paste 4 times daily as needed to buttocks. b. The home health aide care plan, dated 8/30 and 10/26/21, to apply non-medicated lotion and specified the home health aide apply skin protectant cream to the perineal area and Eucerin cream to areas of dryness. c. The updated to the comprehensive assessment completed at the time of recertification, dated 8/25/21, included documentation which identified the patient's caregiver reported the patient had a yeast infection and had been, but was no longer using a cream to treat it. d. The home health aide visit notes, dated 8/30, 9/2, 9/7, 9/9, 9/13, 9/16, 9/20, 9/23, 9/27, 9/30, 10/4, 10/7, 10/11, 10/14, 10/18, 10/21, 10/25, 10/28, 11/2, 11/4 and 11/9/21, all included documentation Staff C, Home Health Aide, applied non-medicated lotion without any further specification of what the home health aide applied to the patient. On 11/10/21 at 10:18 AM, during an interview, Staff C, Home Health Aide, reported she had been applying Desitin paste every visit along with the topical Eucerin cream. She also reported applying a light layer of a topical antifungal cream above the tail bone area for the last couple months since the patient had a yeast infection in the recent past. The POC and Home Health Aide Care Plan lacked any orders or instructions for the home health aide to apply a medicated antifungal cream to the patient. Findings include: According to the undated agency policy titled Provision of Care, Planning for Care Treatment and Services, Physician Orders, written client care instructions for the home health side is prepared by the registered nurse or other appropriate professional who is responsible for the supervision of the home health aide and specifies specific duties the the home health aide to provide. The home health aide provides services that are ordered by the physician in the plan of care and that the aide is permitted to perform under State law. The duties of a home health aide include the provision of hands-on personal care,d performanced of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in reminding client regarding medications that are ordinarily self-administered. Any home health aide services offered by an HHA must be provided by a qualified home health aide. 1. Patient #7 had a start of care date of 7/25/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The POCs (Plan of Care), dated 7/25/21 to 9/22/21 and 9/23/21 to 11/21/21, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 9/21/21, included RN instructions to the home health aide to complete the task of apply heel protectors every visit. c. The home health aide visit note, dated 9/30/21 and 11/3/21, included documentation the home health aide reported the task of applying heel protectors was "not required this visit" with no further explanation of why this task would not be required.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 8 of 17 sampled patients (Patients #3, #5, #7, #10, #11, #12, #15 and #17). The agency provided services to 48 patients at the time of the survey, including 47 patients who received services from the Dubuque parent office and 1 patient from the Galena, Illinois branch office. The survey identified the deficient practice occurred at the Dubuque parent office. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patient's at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: 6. Patient #7 had a start of care date of 7/25/21, received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The POCs, dated 7/25/21 to 9/22/21 and 9/23/21 to 11/21/21, identified the patient had a non-pressure chronic ulcer to the left foot and included orders for skilled nursing services. The POC included orders to complete wound care to the left posterior, achilles tendon are and left foot metatarsal area and left lateral aspect of the foot 3 times a week. b. The week of 9/19/21 included documentation of 3 skilled nursing visits. The documentation lacked measurements of the patients wounds. The agency staff failed to complete weekly wound measurements. 7. Patient #11 had a start of care date of 10/21/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The POC, dated 10/21/21 to 12/19/21, included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. The home health aide care plan, dated 10/25/21, included RN instructions to complete the following tasks: assist client with weight, stand-by assistance with ambulation, shower, shampoo, hair care, assist with partial dressing, apply non medicated lotion,perform non-skilled wound care of phytoplex cream to bilateral buttock shearing until healed, other described as special instructions contact case manager for any falls, changes in condition, bleeding, medication concerns and safety, ambulate with a walker and patient/caregiver screen for Covid 19 prior to visit per Centers for Disease Control and Prevention (CDC). c. The home health aide visit notes, dated 10/27, 10/29, 11/1, 11/3, 11/5 and 11/8/21, included documentation Staff C, Home Health Aide, completed the task of non-medicated lotion and non skilled wound care without specifying what she specifically did to complete the task, completed 1 other task unspecified tasks and special instructions with no definition on what the home health aide did to complete the unspecified tasks and special instructions. 8. Patient #17 had a start of care date of 2/16/19 and received agency services from the Dubuque parent office and discharged on 2/28/19. Review of the clinical record revealed the following: a. The POC, dated 2/16/19 to 4/16/19, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 2/16/19, included RN instructions to complete the following tasks: transfer client from bed/chair, transfer client from chair/bed, assist to bedside commode, sponge bath, perineal care, file/clean nails, assist with complete dressing and apply non medicated lotion, change incontinence briefs, offer fluids, empty trash, wash linens, make bed and other contact case manager if no bowel movement in 3 days, contact case manager for any skin changes, increased pain, difficulty breathing, described as patient/caregiver screen for Covid 19 prior to visit per Centers for Disease Control and Prevention (CDC) and special instructions to ambulate with walker. c. The home health aide visit notes, dated 2/19, 2/21 and 2/27/19, included documentation Staff C, Home Health Aide, completed the task of non medicated lotion without specifying what she specifically did to complete the task. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. 5. Patient #3 had a start of care date of 10/15/21. Clinical record review revealed: a. The Plan of Care (POC), dated 10/15/21 to 12/13/21, included orders for skilled nursing to assess/evaluate conditions including multiple abrasions and contusions and wound treatment of abrasions to the right forehead/scalp, right elbow, left knee, left ankle and left hand. b. The skilled nursing visit note, dated 10/15/21 included documentation of measurement of wounds to the right forehead/scalp and right elbow but failed to include measurements for the left knee, left ankle and left hand. c. The skilled nursing visit notes, dated 10/16, 10/18, 10/20, 10/25, 10/28 and 11/1/21, failed to include wound measurements to the right forehead/scalp, right elbow, left knee, left ankle and left hand. During a home visit observation on 11/9/21 at 10:07 AM with Staff F, RN (registered nurse) the surveyor observed a scab on the patients left knee and a partially scabbed area on the patients left ankle/foot area. During an interview on 11/9/21 at 10:30 AM during the same home visit observation Staff F, RN reported that the wounds were not being measured each week because they were scattered over a large area and currently not measuring scabs on left knee and ankle. During an interview on 11/15/21 at 11:47 AM the Administrator/Clinical Manager reported scabbed wounds are not measured. The agency staff failed to complete weekly wound measurements. Review of the undated agency policy, titled Provision of Care, Planning of Care, Treatment and Services, Physician Orders, identified if a patient is not receiving skilled nursing services along with home health aide services, the nurse must supervise the home health aide no less frequently than every 62 days and while the home health aide is providing care. The RN prepares written instructions for the home health aide and specifies specific duties for the home health aide to provide. The home health aide provides services ordered by a physician in the plan of care. 1. Patient #5 had a start of care date of 10/23/17 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/2/21 to 11/30/21, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 10/2/21, included registered nurse (RN) instructions to complete the following tasks: assist to the bedside commode, empty commode if needed per patient request, provide medication reminders, shower, pivot to shower using the grab bar, shampoo, hair care, perineal care to include may assist with application of barrier cream Phytoplex and Nystatin to areas of irritation or skin folds, dress with assist, other described as wash right stump with soap and water and dry, apply non-medicated lotion (may apply Eucerin cream to dry skin areas per patient request, other described as using a slide board to assist as needed or pivot transfer, patient uses wheelchair and has not been wearing prosthetic, other described as patient/caregiver screen for Covid 19 prior to visit per Centers for Disease Control and Prevention (CDC) and special instructions to remind patient to wear Lifeline (emergency response system). c. The home health aide visit notes, dated 10/4, 10/6, 10/8, 10/11, 10/13, 10/15, 10/18, 10/20, 10/22, 10/25, 10/27, 10/29, 11/1, 11/5 and 11/8/21, included documentation Staff C, Home Health Aide, completed the task of perineal care without specifying what she specifically did to complete the task (such as apply Nystatin or Phytoplex), completed 3 other task unspecified tasks and special instructions with no definition on what the home health aide did to complete the unspecified tasks and special instructions. On 11/10/21 at 10:07 AM, during a interview, Staff C, Home Health Aide, reported she applies Nystatin every visit, but Phytoplex only some of the time if the patient is red or irritated in the perineal area. She reported she can see all of the instructions from the RN. She reminded the patient to wear the Lifeline every visit, washed the patient's right stump, sometimes she pivot transfers the patient and sometimes she uses the slide board. She does not use the slide board every visit. She does not contact the patient prior to the visit to screen for Covid 19, but rather relies on the patient to call her if she has any symptoms. The clinical record is unclear as to what interventions the home health aide completed at each of the visits. 2. Patient #10 had a start of care date of 11/1/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The POC, dated 11/1/21 to 12/30/21, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 11/2/21, included the following RN instructions to the home health aide: stand-by assist with ambulation, sponge bath, shampoo, hair care, perineal care, foot care, set-up assistance with oral care, assist with dressing, call case manager if no bowel movement (BM) in 3 days and other services to include screen for Covid 19 symptoms per CDC guidelines prior to the visit. c. The home health aide visits, dated 11/2, 11/4 and 11/9/21, included documentation by Staff C, Home Health Aide, it was "not required this visit" to contact the nurse if the patient had not had a BM in blank number of days. The home health aide documentation did not specify a number of days of when to contact the RN if no BM. The documentation also included the following: other services (please describe), and lacked any further description of what the home health aide needed to do to complete the task. Staff C, Home Health Aide documented a "Y" to indicate she completed this undescribed intervention. On 11/10/21 at 10:14 AM, during an interview, Staff C, Home Health Aide, reported she could see the instructions on her end when she documented in the computer for when to contact the RN if the patient had not had a BM. She reported the other services she documented yes to completing were in regards to screening the patient for Covid 19 symptoms prior to the visit. She reported she calls the patient prior to going to the visit. The clinical record lacked documentation of specific interventions completed by the home health aide. On 11/15/21 at 2:35 PM, during an interview, the Administrator/Clinical Manager reported an inability of her computer technology staff to find a way to integrate the specific assigned tasks by the RN to the home health aide into the home health aide's documentation of completed interventions. 3. Patient #12 had a start of care date of 7/1/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: The POC, dated 8/30/21 to 10/28/21 and 10/29/21 to 12/27/21, included physician orders for home health aide services and skilled nursing services one time every 60 days. a. The home health aide care plan, dated 8/30 and 10/26/21, included RN instructions to the home health aide to complete the following tasks: take temperature, stand-by assist with ambulation, transfer from bed/chair, use gait belt during transfers, use gait belt during ambulation, assist to toilet, shower, shampoo, oral care, assist with dressing, shave with electric razor, apply non-medicated lotion, change incontinent briefs, call case manager if no BM in 48 hours, other services described as screening patient/family for Covid 19 symptoms per CDC guidelines prior to visits and ambulate with walker. The home health aide visit notes, dated 8/30, 9/2, 9/7, 9/9, 9/13, 9/16, 9/20, 9/23, 9/27, 9/30, 10/4, 10/7, 10/11, 10/14, 10/18, 10/21, 10/25, 10/28, 11/2, 11/4 and 11/9/21, included documentation by Staff C, Home Health Aide, it was "not required this visit" to contact the nurse if the patient had not had a BM in blank number of days. The home health aide documentation did not specify a number of days of when to contact the RN if no BM. The documentation also included the following: other services (please describe), and lacked any further description of what the home health aide needed to do to complete the task. Staff C, Home Health Aide documented a "Y" to indicate she completed this undescribed intervention. b. The update to the comprehensive assessment completed at the time of recertification, dated 8/25/21, included documentation the nurse did not provide 60 day supervision of the home health aide. The home health aide visit note, dated 8/25/21, indicated the home health aide was present the same time as the nurse. On 11/8/21 at 3:55 PM, during an interview, the Administrator/Clinical Manager reported the expectation of the documentation be completed by staff the day of the visit. On 11/15/21 at 11:15 AM, during an interview, the Administrator/Clinical Manager reported the RN who completed the update to the comprehensive assessment was present and did supervise the home health aide on 8/25/21, but did not document this. On 11/15/21 at approximately 2:00 PM, the Administrator/Clinical Manager provided a copy of a late entry coordination note completed by a RN which identified she provided onsite supervision of the home health aide on 8/25/21. On 11/15/21 at 2:15 PM, during an interview, the Administrator/Clinical Manager, reported the agency did not have a policy for completion of visit notes. The RN completed the documentation of supervision late. 4. Patient #15 had a start of care date of 8/24/21, received agency services from the Dubuque parent office and discharged from agency services on 9/6/21. Review of the clinical record revealed the following: a. The POC, dated 8/24/21 to 10/22/21, identified the patient had left knee replacement surgery on 8/23/21 and included orders for skilled nursing services. The POC included orders to leave the occlusive dressing on the left knee wound intact until the patient saw the physician, unless the wound dressing became saturated. If saturated, the nurse may remove the wound dressing and apply Mepore or Mepilex (type of occlusive dressing). b. The week of 8/22/21 included documentation of 3 skilled nursing visits, the initial comprehensive assessment, dated 8/24/21, and routine skilled nursing visits, dated 8/25 and 8/27/21. The nurse documented at each of these visits the patient had a non-removable dressing covering a left knee wound. c. The week of 8/29/21 included documentation of 3 skilled nursing visits, 2 routine skilled nursing visits, dated 8/30 and 8/31/21, and one update to the comprehensive assessment completed at the time of resumption of care following an inpatient hospital admission, dated 9/3/21. The skilled nursing visits, dated 8/31 and 9/3/21, identified the patient had a non-removable dressing covering the left knee wound. The skilled nursing visit, dated 8/30/21, included documentation the wound dressing on the left knee wound had drainage on it. The nurse documented she completed a dressing change to the left knee wound. She assessed the wound was linear and closed with staples, but failed to document a length and width of the wound. On 11/8/21 at 3:35 PM, during an interview, the Administrator/Clinical Manager reported the expectation agency nursing staff measure wounds weekly. On 11/15/21 at 1:54 PM, during an interview, the Administrator/Clinical Manager reported the agency did not have a specific policy regarding wound assessment and measurement, but they did provide nursing staff with education and competency testing in regards to wound assessment and measuring. On 11/15/21 at 2:01 PM, the Administrator/Clinical Manager provided a copy of the education/competency for nursing staff in regards to wound assessment. The education/competency procedure, titled Integumentary/Wound Care, dated 12/1/2020, identified nurses need to measure wounds weekly if the patient's physician orders wound cares.

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 policy review and staff interview, the agency failed to ensure agency staff completed and sent a transfer summary to the health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of the planned transfer for 1 of 4 sampled patients requiring transmission of a transfer summary (Patient #9). The agency provided services to 48 patients at the time of the survey, including 47 patients who received services from the Dubuque parent office and 1 patient from the Galena, Illinois branch office. The survey identified the deficient practice occurred at the Dubuque parent office. 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 and care. Findings include: Review of the undated agency policy, titled Provision of Care, Planning for Care Treatment and Services, Physician Orders, identified planning care is individualized to meet the patient's unique needs. The modification of the Plan of Care, treatment or services may result in planning the patient's transfer to another setting. Review of the undated agency policy, titled Provision of Care, Assessment/Reassessment of Clients, identified the registered nurse (RN) is responsible for the coordination of care, treatment and services. The RN is responsible to notify the physician of the patient's transfer to another facility. Patient #9, a pediatric patient, had a start of care date of 2/2/2020 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The Plan of Care, dated 3/28/2021 to 5/28/2021, included a physician order for skilled nursing services. b. A skilled nursing visit note, dated 4/6/21, included documentation the patient had a spinal surgery scheduled for 4/22/21 and would be in the hospital for 4 to 5 days. c. A coordination note, dated 4/20/21, included documentation the patient's parent did not want a skilled nursing visit this week due to the patient's scheduled surgery this week. d. A skilled nursing visit note, dated 4/29/21, identified the hospital admitted the patient on 4/22 and discharged the patient on 4/26/21. e. The clinical record lacked documentation agency staff sent a transfer summary to the hospital within 2 business of the planned transfer. On 11/9/21 at 3:50 PM, during an interview, the Administrator/Clinical Manager reported the nurse missed sending the transfer summary to the hospital. She explained agency staff were not used to doing this for pediatric patients. On 11/15/21 at 2:15 PM, during an interview, the Administrator/Clinical Manager explained the policy for Provision of Care addressed the need to complete/send a transfer summary. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.