Every finding on record at Mercy Health Services Iowa Corporation

As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City Location, the Department of Inspections, Appeals and Licensing conducted an unannounced complaint survey for complaint #107382-C from 6/26/24 to 7/3/24. The complaint survey identified the following: Condition of Participation 42 CFR 484.110 Clinical Records, was investigated and no condition level deficiencies were identified and one standard level deficiency was identified (G1012). The agency reported a census of 39 patients at the time of the survey.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; 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 patients clinical record included accurate documentation of assessments and maintained pertinent current information in the patient record for 2 of 7 sampled patients (Patients # 4 and #6). Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patients 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: Review of the agency's policy, titled Clinical Record: Creation, Documentation and Retention, dated 08/2022, identified visits are documented in the client home as completely as possible, on the day they occur. During an interview on 7/1/24 at 4:49 PM with Staff I, Previous Interim Administrator, reported agency had a documentation issue with Staff G, RN (registered nurse). The agency had identified Staff G, RN did not make skilled nursing visits that Staff G, RN said he/she did. Without having paperwork to reference, Staff I, Previous Interim Administrator, reported "unsure of the date but February sounded about right and thinks there may have been a couple patients involved". During an interview on 7/2/14 at 11:07 AM with Staff B, Clinical Leader, on 2/22/24, the agency office staff had received a call from family/caregiver for Patient #4, who was wondering when Staff G, RN, was coming to do Review of the the nurse visit. Staff G, RN schedule showed Staff G, RN, had already completed Patient #4 nurse visit on 2/21/24. An internal investigation was initiated and showed that Staff G, RN had documented visits on 2/21/24 for Patient #4 and Patient #6 that did not occur in the patient's homes. Staff G was placed on administrative leave and terminated the next day. 1. Patient# 4 had a start of care date of 2/7/24. Clinical record review revealed: a. Plan of Care, dated 2/7/24 to 4/6/24, included physician orders for skilled nursing services. b. Skilled nurse visit note, dated 2/21/24, included documentation Staff G, RN, had completed a nursing assessment. c. Skilled nursing visit note, dated 2/22/24, included documentation Staff E, RN, had completed a nursing assessment. Patient #4's caregiver had called into home care office and reported mepilex dressing had fallen off Patient #4's wound. A New skin tear to left upper arm elbow area was identified. Patient #4's caregiver reported skin tear occurred on 2/20/24. Staff E, RN called physician office and obtained orders for wound care to skin tear and scheduled clinic visit for patient to be seen by physician on 2/23/24. The clinical record lacked accurate documentation of skilled nursing visit on 2/21/24. 2. Patient # 6 had a start of care date of 2/10/24. Clinical record review revealed: a. Plan of Care, dated 2/10/24 to 4/9/24, included physician orders for skilled nursing services. b. Skilled nurse visit note, dated 2/21/24, included documentation Staff G, RN, had completed a nursing assessment. c. Paper documentation, dated 2/22/24, identified Staff B, Clinical Leader, and Staff I, Previous Interim Administrator, made a phone call to Patient #6 asking what time Staff G, RN, had made a visit on 2/21/24. Patient #6 reported a nursing visit was documented on the calendar for 2/21/24 but no nurse made a home visit on 2/21/24. The clinical record lacked accurate documentation of skilled nursing visit. The above information was reviewed with Staff B, Clinical Leader.