Every finding on record at Pella Regional Health Center

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 1/26/26 through 1/28/26 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 1/26/26 through 1/28/26. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a current census of 144 patients.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to report changes in patient needs to the physician for 1 of 1 sampled patients with home visit medication set up (Patient #3). Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Assessment Policy, last revised 9/2021, the skilled nurse determines reassessment need: depending on plan of treatment. Frequency of visits is determined by Registered Nurse after initial visit is made and in cooperation under direction of certifying provider. Reassessments may be triggered by such things as : condition, progress towards goals, significant changes in condition, diagnosis changes, care, environment or support system change. Patient #3 had a start of care date of 12/9/25. Clinical record review revealed the following: a. The Plan of Care, dated 12/9/25 to 2/6/26, included the diagnosis of Bipolar disorder. The POC included physician orders for skilled nurse visits 1 time a week for medication set up and medication orders. The POC included the patient goal the patient will demonstrate effective medication management by taking medications as set up in weekly pill planner 90% of the time. b. The skilled nurse visit note, dated 1/6/26, Staff B, Registered Nurse (RN), documented the patient missed the PM doses 2 times. The clinical record lacked physician notification of missed medications. c. The skilled nurse visit note, dated 1/13/26, Staff B, RN, documented the patient missed multiple doses the past week. The clinical record lacked physician notification of missed medications. d. The skilled nurse visit note, dated 1/20/26, Staff B, RN, documented the patient missed 1 PM dose. The clinical record lacked physician notification of missed medications. e. During an observation home visit on 1/27/26 at 2:45 PM with Staff B, RN, the surveyor observed the mediset missed 3 evening doses that included 5 pills and one morning dose that included 5 pills. The agency failed to provide timely notification to the physician of missed prescribed doses of medications. The above findings reviewed with the Administrator/Clinical Manager.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to provide medication set up as ordered by a physician for 1 of 1 sampled patients with home visits for medication set up (Patient #3). Failure to ensure staff obtain physician orders for administration of services provided by agency staff, including medication set up, placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled as a clients condition and needs change, warranting a change in services, frequency of visits, treatments, etc,, the plan of care will be adjusted accourdingly under the direction of the ordering provider and the home health plan of care will be revised within the electronic medical record. Any deviation from the ordered plan of care requires a verbal or phone order to change the treatment. Patient #3 had a start of care date of 12/9/25. Clinical record review revealed: a. The Plan of Care (POC), dated 12/9/25 to 2/6/26, included a primary diagnosis of Bipolar disorder and orders for skilled nursing services and orders for medication set up and multiple medication orders.. b. An observational skilled nurse visit on 1/28/26 at 2:45 PM with Staff B, Registered Nurse (RN), the surveyor observed Staff B set up the following medications in the mediset: 1) Quetiapine 25 milligrams (mg), 1/2 tablet every moning, (the POC included 2 times a day as needed). 2) Prazosin 2 mg, 1 capsule every evening (the POC ordered administration at bedtime). 3: Atorvastatin 40 mg 1 tablet every evening (the POC ordered administration at bedtime). 4. Eszopicline 3 mg 1 tablet every evening (the POC ordered administration at bedtime). c. During an interview on 1/27/26 during the same home visit, the patient stated he/she had taken all the medications in the morning and evening at 5:00 PM for the past 6 months. The agency skilled nurse failed to set up the patient's medications per the physicians order on the POC. The findings were reviewed with the Administrator/Clinical Manager.

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 observations, agency staff interviews, record review and policy review, the agency failed to send a transfer summary 2 business days of becoming aware of transfer and discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 2 sampled patients transferred to another facility and 1 of 1 patients discharged from the agency and transferred to another facility. ( Patient #4, and #6) 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 during inpatient care or after discharge. Findings include: According to the undated policy, titled Home Health Discharge/Transfer Criteria, last revised 9/2021, completion of a summary report for all transfers/discharges: Discharge sumary to be set within 5 business days (of the patient's discharge) to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge from the agency. Transfer summary to be sent within 2 business days (for a planned transfer), if the patient's care will be immediately continued in a health care facility; or Transfer suummary to be sent within 2 business days of becoming aware of an unplanned transfer, if the patinet is still receiving care in a health facility when the agency becomes aware of the transfer. During an interview on 1/28/26 at 9:10 AM the Administrator/Clinical Manager stated the nurse did not send a copy of the discharge summary to the receiving facility for Patient #4. 1.Patient #4 had a start of care date of 11/3/25. Clinical record review revealed the following: a. The Plans of Care (POC), dated 11/3/25 to 1/1/26 and 1/2/26 to 3/2/26, included orders for skilled nursing services and Physical Therapy services. b. The physical therapy note, dated 12/4/25 and signed by Staff E, Physical therapy assistant (PTA) on 12/8/25, documented staff E arrived at the patient's home for acheduled appountment with no one at home. The agency scheduler reached out to the patient's family and they reported the patient is going in for surgery in 30 minutes and they forgot to let the agency know. c. The comprehensive assessment at resumption of care, dated 12/10/25, documented the patient inpatient hospital with a discharge date of 12/9/25. d. The clinical record lacked documentation of a completed transfer summary. The agency failed to completed the transfer summary and send to the receiving facility within 2 business days of knowledge of the transfer to the hospital. 2. Patient #7 had a start of care date of 8/14/24 and discharge date of 12/24/24. Clinical record review revealed the following: a. The POC, dated 12/13/24 to 2/9/25, identified the patient had a diagnosis of cancer of the brain and included orders for skilled nursing services. b. The comprehensive assessment at discharge, dated 12/24/24, identified the patient requested services from a specific hospice. The nurse verified with the specific hospice via telephone call, the patient contact for services the same day. The physican contacted the home health agency and reported the specific hospice contacted him for services. c. The discharge summary, dated 12/31/25, included the patient discharged from the agency due to admission to hospice. The discharge summary sent to the physician. The documentation failed to include a copy of the discharge summary sent to the receiving hospice facility. The agency failed to send a copy of the discharge summary to the receiving hospice facility. The agency failed to completed the transfer summary and send to the receiving facility within 2 business days of knowledge of the transfer or 5 business days following discharge. The above findings reviewed with the Administrator/Clinical Manager.

The Department of Inspections and Appeals conducted a recertification survey, dated 1/30/23 to 2/1/23, and found the following standard level deficient practice under the Emergency Preparedness Condition of Participation.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of emergency preparedness documentation and staff interview, the agency failed to document participation in an actual disaster event, any community based, tabletop, inter-facility based, regionally based or facility designed full scale disaster exercise in 2021 and 2022. Failure for the agency to conduct/participate and review disaster exercises of any type as part of the emergency preparedness plan, could lead to missed opportunities for improvements to the plan that can be implemented for the safety of patients when emergencies and/or disasters occur potentially placing the patients and community at risk of lost services. Findings include: On 2/1/23 at 10;40 AM, during an interview with Administrator, the Administrator provided evidence of an actual event related to the Covid 19 pandemic for 2020. The Administrator reported they did not have any exercises done for emergency preparedness for 2021 and 2022 due to dealing with the Covid 19 pandemic. They reported they were supposed to do a full scale with the hospital last year, but the hospital canceled it. The Administrator reported they were in the process of preparing a Table Top exercise for this year. The Administrator received the above findings and 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 1/30/23 to 2/1/23. The survey identified the following standard level deficient practices. The agency reported a census of 38 patients at the time of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; 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 comprehensive assessments included wound measurements and provided an accurate reflection of the patient’s status for 1 of 2 sampled patients with wounds (Patient #2). Failure to ensure agency staff completed accurate comprehensive assessments for all patients that included the patient’s current health, psychosocial, functional, and cognitive status put the patients at risk of not receiving adequate care and potentially not have their needs met. Findings include: On 1/30/23 at 2:00 PM, during an interview, the Administrator reported the requirement for nursing staff to assess wounds each time they perform wound care and to measure wounds weekly, typically the first visit of the week. The surveyor reviewed the above stated findings with the Administrator and the agency provided no additional information prior to the end of the survey. The agency policy, titled Assessment Policy, dated 4/2022, included the initial and ongoing assessments will include collections of data, identifying problems, needs, and strengths of patients and caregivers. Patient #2 had a start of care date of 7/7/22. Clinical record review revealed: 1. Plans of Care, dated 7/7/22 to 9/4/22, 9/5/22 to 11/3/22, 11/4/22 to 1/2/23, and 1/3/23 to 3/3/23, included orders for skilled nursing services to provide wound care. 2. Start of Care Comprehensive Assessment, dated 7/7/22, included documentation wound care was provided to areas on the left back leg with large amount of drainage, left front leg with small amount of drainage, right back leg with moderate amount of drainage, and right front leg with small amount of drainage, but failed to include wound measurements for the four area. 3. Recertification Comprehensive Assessment, dated 9/2/22, included documentation wound care was provided to area on the left back leg with a small amount of drainage, but failed to include wound measurements. 4. Recertification Comprehensive Assessment, dated 10/30/22, included documentation wound care was provided to area on left lower leg and patient has a non-removable theraskin dressing (dressing used to assist in healing chronic wounds) in place, wound care was provided to right and left leg, but failed to identify area on right leg and wound measurements for all areas. During an interview on 1/31/23 at 9:30 AM, Administrator reported they had reviewed the documentation and confirmed wound measurements were not documented. Comprehensive Assessments failed to include wound measurements for all open areas identified. The surveyor reviewed the above stated findings with the Administrator and the agency provided no additional information prior to the end of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to complete a drug regimen review with the discharge comprehensive assessment for 1 of 2 sampled patients with discharge (Patient #7). Failure to ensure a drug regimen review is completed with each comprehensive assessment increased the potential for unidentified medication interactions and side effect risks to the patient at the time of discharge comprehensive assessment. Findings include: According to the agency policy, titled Drug Regime Review, dated 4/2022, the drug regime review is an integral aspect of the home health comprehensive assessment. The registered nurse or therapist is required to complete a drug regimen review at the time of each comprehensive assessment for every agency patient. During an interview on 1/30/23 at 2:00 PM, Administrator reported the registered nurse completes all drug regimen reviews for all comprehensive assessments including discharge. Patient #7 had a start of care date of 5/31/22 and had a discharge date of 7/8/22. Clinical record review revealed Discharge Comprehensive Assessment, dated 7/8/22, but failed to include a drug regimen review corresponding with the discharge comprehensive assessment. The above stated findings were reviewed with the Administrator and the agency provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to update the Plan of Care with healthcare practitioner orders obtained during a 60 day certification period (interim orders) for 4 of 5 sampled patients (Patients #2, #3, #5 and #7) with interim healthcare practitioner orders. Failure to update the Plan of Care with interim healthcare practitioner orders increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 3. Patient #2 had a start of care date of 7/7/22. Clinical record review revealed: a. Plans of Care, dated 11/4/22 to 1/2/23 and 1/3/23 to 3/3/23, included orders for skilled nursing and occupational therapy services. b. Interim physician orders, dated 12/7/22 and 12/14/22, included documentation to provide daily dressing changes. c. Interim physician order, dated 1/12/23, included documentation to provide daily wound care. d. Interim physician order, dated 1/19/23, included documentation to provide wound care 3 times a week. The agency failed to completed updated plan of cares to include interim physician orders. 4. Patient #7 had a start of care date of 5/31/22 and a discharge date of 7/8/22. Clinical record review revealed: a. Plan of Care, dated 5/31/22 to 7/29/22, included orders for skilled nursing, physical and occupational therapy services. b. Interim physician order, dated 6/13/22, included documentation to increase skilled nursing services to 2 times a week for 4 weeks. The agency failed to complete an updated plan of care to include the interim physician order. The surveyor reviewed the above stated findings with the Administrator and the agency provided no additional information prior to the end of the survey. Review of the agency policy, titled Home Health Care Planning Process, dated 4/2022, identified agency staff will keep the Plan of Care (POC) updated with all changes including frequency, equipment, medications, treatments, goals and discharge plans. Staff will add new orders to the POC, generate a revised POC and place the POC in the patient's medical record. On 1/30/23 at 2:00 PM, during an interview, the Administrator reported when agency staff receive an interim order, they add this to the electronic medical record (EMR) and generate a revised POC. They explained the EMR did not automatically add interim orders to the POC and staff have to add the order to the EMR and initiate the generation of a revised POC in order to create a POC that includes all current orders. 1. Patient #3 had a start of care date of 9/21/22. Review of the clinical record revealed the following: a. The POC, dated 11/20/22 to 1/18/23, included orders for skilled nursing services 1 time per week for 9 weeks, occupational therapy services 1 time per week for 9 weeks, physical therapy 1 to 2 times per week for 8 weeks and then 1 time for one week and home health aide services 2 times per week for 8 weeks. b. Interim orders, dated 12/1/22, including the following orders: Bumetanide 2 milligrams (mg) 2 tablets for a total of 4 mg for 2 days, and then Bumetanide 2mg 1 tablet every day; hold Lantus Insulin indefinitely due to low blood sugar. c. A skilled nurse phone call documentation note, dated 12/16/22, identified the nurse received a one time healthcare practitioner order for Bumex 4 mg. d. An interim order, dated 12/28/22, included an order for the discontinuation of physical therapy due to the patient meeting most of the therapy goals. e. Interim orders, dated 1/10/23, included the following orders: taper Cymbalta 60 mg 1 tablet daily for one week, then 30 mg daily for one week and then discontinue; start Fluoxetine 20 mg 1 tablet daily after discontinuing the Cymbalta; and, increase Robaxin 500 mg to 4 times per day as needed for leg pain f. An interim order, dated 1/12/23, included an order to discontinue occupational therapy services due to the patient meeting the goals "mostly". g. Interim orders, dated 1/13/23, included the following orders: Bumetanide 2 mg 1 tablet 3 times per week on Mondays, Wednesdays and Fridays; and, increase Levothyroxine 300 micrograms (mcg) to Levothyroxine 325 mcg (a 300 mcg tablet and 25 mcg tablet) take every morning on an empty stomach. h. A skilled nurse phone call documentation note, dated 1/13/23, identified the nurse received healthcare practitioner orders for the patient to start a 1200 milliliter (ml) fluid restriction, start Calcium 600 mg twice per day; obtain a blood draw for thyroid stimulating hormone in 6 weeks and complete a blood draw on 1/16 or 1/17/23 for a basic metabolic panel. i. The clinical record lacked documentation of a revised POC that included interim orders received from 12/1/22 through 1/13/23. 2. Patient #5 had a start of care date of 8/23/22. Review of the clinical record revealed the following: a. The POC, dated 8/23/22 to 10/21/22, included orders for skilled nursing services 1 time per week for 3 weeks and then 1 time every other week for 6 weeks and home health aide services 2 times per week for 9 weeks. 1) An interim order, dated 9/19/22, include an order to increase home health aide services to 3 times per week for 5 weeks. 2) Interim orders, dated 9/20/22, included an order for an as needed skilled nursing visit for a leaking catheter and a separate order for the nurse to irrigate the urinary catheter with Normal Saline or Sterile Water 30 to 60 cubic centimeters (cc) as needed. 3) An interim order, dated 9/22/22, included an order with an effective date of 9/20/22, for the skilled nurse to change the patient's urinary catheter. 4) An interim order, dated 9/29/22, for an as needed skilled nursing visit (no reason provided). 5) The clinical record lacked documentation of a revised POC that included interim physician orders obtained on 9/19, 9/20, 9/22 and 9/29/22. b. The POC, dated 10/22/22 to 12/20/22, included orders for skilled nursing services one time per week. 1) An interim order, dated 12/14/22, included an order for an as needed skilled nursing visit for a resumption of care. 2) The clinical record lacked documentation of a revised POC that included the interim order obtained on 12/14/22. c. The POC, dated 12/21/22 to 2/18/23, included an order for skilled nursing services one time per week for 8 weeks. 1) An interim order, dated 1/12/23, included an order for one as needed skilled nursing visit for medication set up. 2) Interim orders, dated 1/17/23, included an order to increase skilled nursing services to 2 times per week for 5 weeks and to complete a blood draw for Potassium 1 time per week for 5 weeks. 3) The clinical record lacked documentation of revised POCs that included the interim physician orders obtained on 1/12 and 1/17/23. On 1/31/23 at 2:45 PM, during an interview, the Administrator confirmed an inability to find revised POCs with the interim orders for Patient #5.

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 patients clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 1 of 2 sampled patients with wounds (Patient #2). 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: During an interview on 1/30/23 at 2:00 PM, Administrator reported wound measurements are typically completed weekly on the first visit of the week. Patient #2 had a start of care date of 7/7/22. Clinical record review revealed: 1. The Plan of Care, dated 11/4/22 to 1/2/23, included orders for skilled nursing to perform wound care 6 times per week to left leg. 2. Skilled nursing visit notes, dated 12/12/22, 12/15/22, 12/16/22, and 12/17/22, included documentation wound care provided to left lower leg, but failed to include wound measurements. c. Skilled nursing visit note, dated 12/19/22, included documentation of left lower leg wound with a length of 0.10 cm (centimeter) and width of 0.8 cm, but failed to include a depth measurement. The agency failed to document weekly wound measurements. The above stated findings were reviewed with the Administrator and the agency provided no additional 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 policy review and agency staff interview, the agency failed to complete and send a discharge summary to the physician or other health care professionals responsible for providing care to the patient after discharge within 5 business days of the patient's discharge for 1 of 2 sampled patients requiring discharge (Patient #6). 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 discharge or transfer. Findings include: According to agency policy titled, Home Health Discharge/Transfer Criteria, dated 4/2022, agency staff on last visit will complete discharge summary of service and send to physician within five days of discharge. Patient #6 had a start of care date of 7/19/22 and was discharged from agency services on 8/8/22. Clinical record review revealed Discharge Comprehensive Assessment, dated 8/8/22, but failed to include a discharge summary. During an interview on 1/31/23 at 3:15 PM, Administrator reviewed the clinical record and confirmed no discharge summary had been completed. The agency failed to complete a discharge summary and send to the physician or other health care professionals responsible for providing care to the patient after discharge within 5 business days of the patient's discharge. The above stated findings were reviewed with the Administrator and the agency provided no additional information prior to the end of the survey.