Every finding on record at Recover Health of Iowa, Inc.

As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City location, the Department of Inspections, Appeals & Licensing conducted a complaint survey for complaint #111354-C from 12/30/24 to 12/31/24. The complaint survey identified the following: 1.Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care was investigated and no condition level deficiency and 2 standard level deficiencies were identified. (G572, G574) and 2.Condition of Participation 42 CFR 484.80 Home Health Aide Services, was investigated and no condition level deficiency and 3 standard level deficiencies were identified. (G798, G800, G818) The agency reported a census of 97 patients at the time of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency staff interview, clinical record reviews and agency policy review, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan of Care for 4 of 5 sampled patients with missed visits (Patients #1, #2, #3 and #4). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 3. Patient #1 had a start of care date of 11/16/16. Clinical record review revealed the following: a. The POC, dated 10/4/24 to 12/3/24 and 12/4/24 to 2/1/25, included physician orders for home health aide services 14 times a week for eight weeks. The POC identified the patient had a diagnosis of quadriplegia. b. The electronic medical record identified home health aide missed visits on 11/21/24, 11/26/24, 12/5/24 and 12/11/24 The clinical record lacked documentation of physician notification of the 4 missed home health aide visits. The agency failed to notify the physician of missed visits. 4. Patient #3 had a start of care date of 11/13/24. Clinical record review revealed the following: a. The POC, dated 11/13/24 to 1/11/25, included physician orders for home health aide services one time a week for eight weeks. The POC identified the patient had a diagnosis of a fractured left femur. b. The electronic medical record identified home health aide missed visits on 11/28/24. The clinical record lacked documentation of physician notification of the 1 missed home health aide visit. The agency failed to notify the physician of the missed visit. The above findings reviewed with the Administrator and Clinical Manager. According to the agency policy titled Missed Visits, dated 9/28/23, frequency of services are ordered by a physician and a missed visit affects the plan of care, which may need to be updated or changed. The physician must be notified when scheduled services, visits or shifts are not provided for any reason and documentation of the notification must be in the patient's record to reflect the alteration of the plan of care. During an interview on 12/30/24 at 2:45 PM, Staff A, Administrator, reported if missed visits are processed in the office, they don't generate a workflow; therefore, missed visit notes were not being faxed to the physician. 1.Patient #2 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/4/24 to 1/2/25, included physician orders for home health aide services three times a week for eight weeks. The POC identified the patient had a diagnosis of hemiplegia following cerebral infarction affecting right dominant side. b. The electronic medical record identified home health aide missed visits on 11/22/24, 11/29/24, 12/2/24, 12/4/24, 12/6/24, 12/20/24 and 12/25/24. The clinical record lacked documentation of physician notification of the 7 missed home health aide visits. 2.Patient #4 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The POC, dated 11/4/24 to 1/2/25, included physician orders for home health aide services five times a week for eight weeks. The POC identified the patient had a diagnosis of autistic disorder. b. The electronic medical record identified home health aide missed visits on 11/21/24, 11/22/24,, 11/28/24, 11/29/24, 12/2/24, 12/3/24,12/4/24, 12/5/24, 12/6/24, 12/20/24 and 12/25/24. The clinical record lacked documentation of physician notification of the 11 missed home health aide visits.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home visit observation, patient interview, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 4 of 5 sampled patients (Patients #1, #2, #3 and #4). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies and/or treatments according to assessed needs and physician orders. Findings include: 3. Patient #1 had a start of care date of 11/16/16. The clinical record revealed the following. a. The POCs, dated 10//24 to 12/3/24 and 12/4/24 to 2/1/25, identified the patient had a diagnosis of quadriplegia. The POC included the following DME: bed rails, elevated toilet seat, grab bars, hospital bed, mechanical lift, tub/shower bench, vital signs equipment, wheelchair and gloves. b. During an observation home visit with Staff D, RN and Staff E, HCA the surveyor identified the following DME utilized by the patient: urinal, wheelchair cushion, reacher and lifeline. The patient stated during the same home visit that he/she had the DME prior to the home health agency start of care. The agency failed to include all DME utilized by the patient on the POC. 4. Patient #3 had a start of care date of 11/13/24. Clinical record review revealed the following. a. The POC, dated 11/13/24 to 1/11/25, identified the patient had a diagnosis of a left femur fracture. The POC included the following DME: elevated toilet seat, transport wheelchair, grab bars, hospital bed, vital sign equipment, walker, exercise equipment, gloves, incontinence, nursing supplies, skin care supplies, therapy supplies, urology supplies and wound care supplies. b. The aide care plan, dated 11/17/24, identified the patient required the use of a gait belt for transfers. The agency failed to include a gait belt required be the patient for transfers. The above findings reviewed with the Administrator and Clinical Manager. According to the agency policy titled Physician Orders, dated 12/7/23, a complete, individualized Plan of Care (POC) will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The POC must be reviewed and revised as frequently as the patient's condition or needs require, but no less frequently than every 60 days. The POC must include, but is not limited to the following: a description of any treatments, procedures and services to be performed, frequency and duration of services, medications and treatments, equipment and related supplies, and any medical, physical, psychosocial or environmental precautions that affect implementation of care. 1.Patient #2 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The POC, dated 11/4/25 to 1/2/25, identified the patient had a diagnosis of hemiplegia following cerebral infarction affecting right dominant side. The POC included the following durable medical equipment (DME) used by the patient: cane, grab bars, vital sign equipment, gloves and nursing supplies. b. The Recertification Visit note, dated 10/31/24, completed by Staff G, Registered Nurse (RN), identified the patient utilizes incontinence supplies. The POC failed to identify all DME/supplies the patient required for use. 2.Patient #4 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The POC, dated 11/4/25 to 1/2/25, identified the patient had a diagnosis of Autistic Disorder. The POC included the following DME used by the patient: grab bars, tub/shower bench, vital sign equipment, gloves and nursing supplies. b. The Recertification Visit note, dated 10/30/24, completed by Staff D, RN, identified the patient utilizes an elevated toilet seat. The POC failed to identify all DME/supplies the patient required for use.

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 reviews and agency policy review, the agency failed to provide individualized and specific written patient care instructions from a registered nurse to agency home health aides for 3 of 4 sampled patients receiving home health services (Patients #1, #2 and #4). 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: 3. Patient #1 had a start of care date of 11/16/16. Clinical record review revealed the following: a. The POC, dated 10/5/24 to 12/3/24 and 12/4/24 to 2/1/25, included orders for skilled nurse and home health aide services. The POC identified the patient had a diagnosis of quadriplegia. b. The aide care plan, dated 10/5/24 to 12/3/24 and 12/4/25 to 2/1/25, included instructions for the home health aide to complete the following tasks: transfer from chair/bed at bedtime . The aide care plan lacked direction on how the home health aide to transfer the patient. c. During an observation home visit with Staff Dm RN and Staff C, RN the surveyor observed Staff C transfer the patient from bed to the shower chair by physical lift with use of a gait belt. The nurse failed to individualize the tasks for the patient. The above findings shared with the Administrator and Clinical Manager. According to the agency policy titled Aide assignments and Duties, dated 5/23/23, an individualized care plan will be developed by the appropriate personnel to ensure care and services are specific to the patient's needs/problems. 1.Patient #2 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The Plans of Care (POC), dated 9/5/24 to 11/3/24 and 11/4/24 to 1/2/25, included orders for skilled nurse and home health aide services. The POC identified the patient had a diagnosis of hemiplegia following cerebral infarction affecting right dominant side. b. Aide care plans, dated 9/5/24 to 11/3/24 and 11/4/24 to 1/2/25, included instructions for the home health aide to complete the following tasks: cane, dressing and skin care. The nurse failed to individualize the tasks for the patient. 2.Patient #4 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The POC, dated 9/5/24 to 11/3/24 and 11/4/24 to 1/2/25, included orders for skilled nurse and home health aide services. The POC identified the patient had a diagnosis of Autistic Disorder. b. Aide care plans, dated 9/5/24 to 11/3/24 and 11/4/25 to 1/2/25, included instructions for the home health aide to complete the following task: hair care. The nurse failed to individualize the task for the patient.

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 and agency policy review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 4 sampled patients receiving home health aide services (Patients #1). Failure to ensure home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the plan of care increased the risk that patients' personal care needs were not adequately met. Findings include: According to the agency policy titled Aide assignments and Duties, dated 5/23/23, an individualized care plan will be developed by the appropriate personnel to ensure care and services are specific to the patient's needs/problems. Home Health Aides must document to the tasks assigned on the written aide care plan. Patient #1 had a start of care date of 11/16/16. The clinical record revealed the following. a. The plans of care (POC) dated, 10/1/24 to 12/3/24 and 12/4/24 to 2/1/25, included orders for skilled nursing and home health aide. The POC identified the patient to have a diagnosis of quadriplegia. b. The home health aide care plans, dated 1/17, 11/18, 11/19, 11/20, 11/22, 11/23, 11/24, 11/25, 11/17, 11/28, 11/29, //30, 12/1, 11/3, 11/4, 11/5, 10/1/24 to 12/3/24 and 12/4/24 to 2/1/25, included assigned tasks to provide oral care every visit, dressing every visit, transfer from bed chair at bedtime and position in bed at bedtime. c. The home health aide visit notes, dated 10/27, 10/28, 10/29, 10/30, 10/31/24, 11/3, 11/4, 11/5,, 11/6, 11/7, 11/8, 11/9, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/22, 11/23, 11/24, 11/25, 11/27, 11/28, 11/29, 11/30/24, 12/1, 12/3, 12/4, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13 and 12/14/24, failed to include documentation the aide provided oral care. d. During an interview on 12/31/24 at 9:00 AM, Staff E, HCA stated staff do not complete oral care for the patient at bedtime. The home health aide failed to follow the aide care plan as written. The above findings reviewed with the Administrator and Clinical Manager. According to the agency policy titled Aide assignments and Duties, dated 5/23/23, an individualized care plan will be developed by the appropriate personnel to ensure care and services are specific to the patient's needs/problems. Home Health Aides must document to the tasks assigned on the written aide care plan. Patient #1 had a start of care date of 11/16/16. The clinical record revealed the following. a. The plans of care (POC) dated, 10/1/24 to 12/3/24 and 12/4/24 to 2/1/25, included orders for skilled nursing and home health aide. The POC identified the patient to have a diagnosis of quadriplegia. b. The home health aide care plans, dated 1/17, 11/18, 11/19, 11/20, 11/22, 11/23, 11/24, 11/25, 11/17, 11/28, 11/29, //30, 12/1, 11/3, 11/4, 11/5, 10/1/24 to 12/3/24 and 12/4/24 to 2/1/25, included assigned tasks to provide oral care every visit, dressing every visit, transfer from bed chair at bedtime and position in bed at bedtime. c. The home health aide visit notes, dated 10/27, 10/28, 10/29, 10/30, 10/31/24, 11/3, 11/4, 11/5,, 11/6, 11/7, 11/8, 11/9, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/22, 11/23, 11/24, 11/25, 11/27, 11/28, 11/29, 11/30/24, 12/1, 12/3, 12/4, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13 and 12/14/24, failed to include documentation the aide provided oral care. d. During an interview on 12/31/24 at 9:00 AM, Staff E, HCA stated staff do not complete oral care for the patient at bedtime. The home health aide failed to follow the aide care plan as written.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record reviews and agency policy review, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in patient condition and honoring patient rights for 4 of 4 sampled patients receiving home health aide services (Patients #1, #2, #3, and #4). A total of 26 patients received home health aide services and the agency employed 5 home health aides at the time of the survey. Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting patients' personal care needs. Findings include: 3. Patient #1 had a start of care date of 11/16/16. Clinical record review revealed the following: a. The POC, dated 10/1/24 to 12/3/24 and12/4/24 to 2/5/24, included orders for skilled nursing and home health aide services. The POC identified the patient had a diagnosis of quadriplegia. b. Skilled nursing visit notes, dated 10/29/24, 11/12/24, 11/26/24 and 12/17/24, included documentation home health aide supervision was completed and the aide demonstrated competency with assigned tasks, complied with infection control and prevention policies and honored patient rights. The note lacked documentation of the elements: following the plan of care, maintaining open communication with patient/caregiver and reporting changes in patient condition. The agency failed to include all required tasks during home care aide supervision. 4. Patient #3 had a start of care date of 11/13/24. Clinical record review revealed the following: a. The POC, dated 11/13/24 to 1/11/24, included orders for skilled nursing and home health aide services. The POC identified the patient had a diagnosis of a fractured right femur. b. Skilled nursing visit notes, dated 11/19/24, 11/26/24 and 12/10/24, included documentation home health aide supervision was completed and the aide demonstrated competency with assigned tasks, complied with infection control and prevention policies and honored patient rights. The note lacked documentation of the elements: following the plan of care, maintaining open communication with patient/caregiver and reporting changes in patient condition. The agency failed to include all required tasks during home care aide supervision. The above findings shared with the Administrator and Clinical Manager. According to the agency's policy titled Employee Supervision, dated 9/6/23, home health aides will be supervised by a Registered Nurse (RN). Home health aide supervision must ensure aides furnish care in a safe and effective manner, including but not limited to, the following elements: Following the patient's plan of care, maintaining an open communication process with the patient, representative, caregivers and family, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in patient's condition and honoring patient rights. 1.Patient #2 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/5/24 to 11/3/24, included orders for skilled nursing and home health aide services. The POC identified the patient had a diagnosis of hemiplegia following cerebral infarction affecting right dominant side. b. Skilled nursing visit note, dated 10/31/24 included documentation home health aide supervision was completed and the aide demonstrated competency with assigned tasks, complied with infection control and prevention policies and honored patient rights. The note lacked documentation of the elements: following the plan of care, maintaining open communication with patient/caregiver and reporting changes in patient condition. 2.Patient #4 had a start of care date of 8/24/15. Clinical record review revealed the following: a. The POC, dated 9/5/24 to 11/3/24, included orders for skilled nursing and home health aide services. The POC identified the patient had a diagnosis of Autistic Disorder. b. Skilled nursing visit note, dated 10/30/24 included documentation home health aide supervision was completed and the aide demonstrated competency with assigned tasks, complied with infection control and prevention policies and honored patient rights. The note lacked documentation of the elements: following the plan of care, maintaining open communication with patient/caregiver and reporting changes in patient condition.

A complaint investigation, from 7/11/22 to 7/12/22, for complaint number 70808-C identified the following: The complaint related to 484.50 Patient Rights was unsubstantiated; The complaint related to 484.60 Care planning, Coordination, Quality of Care was substantiated; (See G574 and G580) The complaint related to 484.75 Skilled Professional Services was unsubstantiated; The complaint related to 484.105 Organization and Administration of Services was unsubstantiated; The survey investigation found the agency to have the following standard level deficiencies and be in substantial compliance with the above mentioned Conditions of Participation. The agency identified a census of 89 current patients. Collap

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 agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 2 of 5 sampled patients (Patients #1 and #5). 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. Findings include: Review of the agency's policy, titled Plan of Care (POC), dated 12/18/17, identified agency staff will develop an individualized POC for each patient to meet the patient's specific identified needs. The POC will include patient-specific interventions and treatments. 1. Patient #1 had a start of care date of 6/2/22. Review of the clinical record revealed the following: a. The POC, dated 6/2/22 to 7/31/22, included orders for oxygen 2 liters per minute continuous. The order on the POC lacked a route of use such as a mask or nasal cannula. b. The comprehensive assessment completed at the start of care, dated 6/2/22, and the skilled nursing visit, dated 6/6/22, both identified the patient used 6 liters of oxygen at night. c. The clinical record lacked documentation agency nursing staff notified the patient's physician of the patient's use of oxygen at 6 liters per minute at night. On 7/12/22 at 1:52 PM, during an interview, Staff D, Registered Nurse (RN), reported the patient used oxygen 2 liters per minute during the day and oxygen 6 liters per minute at night via nasal cannula since prior to starting agency services. On 7/12/22 at 2:12 PM, during an interview, the Clinical Services Manager confirmed the inability to find an order on the POC or in the clinical record for the patient's use of oxygen at 6 liters per minute at night. The POC failed to include a complete order for the rate and route of oxygen used by the patient. 2. Patient #5, a pediatric patient, had a start of care date of 5/24/21 and discharged from agency services on 4/27/22. Review of the clinical record revealed the following: a. The POC, dated 3/20/22 to 5/18/22, included physician orders for skilled nursing services 5 to 10 hours per day for 5 to 7 days per week. The POC included an order for the skilled nurse to apply a Spio Vest daily and remove at bath time or as needed if patient shows signs of discomfort or agitation, effective 1/17/22. b. The clinical record included documentation of 9 days of skilled nursing visits up 9 hours a day, dated 3/21, 3/24, 3/30, 3/31, 4/1, 4/4, 4/7, 4/8 and 4/13/22. The nurse providing care during this time frame, Staff E, RN, documented interventions performed during the shifts. The documentation failed to identify whether or not Staff E, RN, applied the Spio Vest per POC orders. On 7/12/22 at 2:02 PM, during an interview, Staff E, RN, explained the Spio Vest was a specialized vest to help the patient with sitting up and posture. Physical therapy determined the initial need for the vest. The patient became able to sit up on the patient's own. Physical therapy determined the patient no longer needed the vest and did not want the patient to wear it and be dependent on it. Staff E, RN, reported she had spoken with the previous supervisor for private duty nursing about the need to change the POC, and she had agreed to take care of this. Staff E, RN, reported the Spio Vest should not have been on the POC (dated 3/20/22 to 5/18/22) and identified the vest was not used on the patient during the last certification period. Agency staff failed to communicate with the physician about changes in the patient's care in order to ensure the POC contained accurate treatment orders. The Clinical Services Manager and Private Duty Nursing Supervisor received the above findings and agency staff provided no further information prior to the end 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 agency policy review, clinical record review and agency staff interview, the agency failed to provide treatments or services as ordered by the physician and per the Plan of Care for 2 of 5 sampled patients (Patients #4 and #5). Failure to ensure staff follow physician orders for administration of treatments and services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency's policy, titled Client's Plan of Care (POC), dated 12/18/17, revealed the patient's Plan of Care must include all medications and treatments. Drugs services and treatments are administered only as ordered by a physician. The agency must promptly alert the relevant physician to any changes in the patient's condition or needs that suggest that outcomes are not being met and/or that the plan of care should be altered. Review of the agency's policy, titled Physician Orders, dated 10/13/21, identified agency staff will provide care and services in accordance with physician orders. 1. Patient #4, a pediatric patient, had a start of care date of 6/24/22. Review of the clinical record revealed the following: The POC, dated 6/24/22 to 8/22/22, included physician orders for skilled nursing services 9 to 12 hours per day, 4 to 7 days per week. The POC included orders for the skilled nurse to assess the patient's neurological system every 2 hours and as needed and to include level of consciousness, activity level, seizure activity and pupillary response. The POC included orders for the skilled nurse to assess the patient's gastrointestinal system every 2 hours and as needed to prevent failure or compromise and include all 4 quadrants of bowel sounds, whether the abdomen is flat, round, firm, distended or non-distended and gastric tube site and tolerance of feedings. The POC included orders for the skilled nurse to assess the patient's respiratory system every 4 hours and as needed and to include lung sounds, respiratory effort, blood oxygen saturation and condition to prevent failure or compromise. The POC included orders for the skilled nurse to assess the patient's cardiovascular system including heart rhythm, pulse, pulse description, skin color and capillary refill to prevent failure or compromise. The POC included orders for the skilled nurse to assess the patient's pain by using a non-verbal scale every 4 hours and as needed. a. The skilled nursing visit note, dated 6/29/22, included documentation the nurse worked 12:00 PM to 5:45 PM. The nurse documented doing an initial assessment at 12:00 PM of the patient's gastrointestinal system and pain level. The visit note lacked documentation of any further pain or gastrointestinal system assessment for the remainder of the shift. b. The skilled nursing visit note, dated 7/1/22, included documentation the nurse worked 8:30 AM to 4:45 PM. The nurse documented she completed an assessment of the patient's gastrointestinal and neurological systems at 9:00 AM, and then did not complete the next assessment on the 2 systems until 12:00 PM (1 hour late). c. The skilled nursing visit notes, dated 7/2/22, included documentation a nurse worked 8:00 AM to 11:30 PM, and a second nurse worked 12:30 PM to 5:45 PM. The nurse who worked 8:00 AM to 11:30 AM, documented she completed an initial assessment of all body systems at 8:30 AM. The visit note lacked documentation the nurse assessed the patient's gastrointestinal and neurological systems every 2 hours and prior to leaving at 11:30 AM. The nurse who worked 12:30 PM to 5:45 PM, documented she did a full assessment of the patient's body systems at 12:30 PM. d. The skilled nursing visit note, dated 7/11/22, included documentation the nurse worked 6:30 AM to 5:30 PM. The nurse documented she completed an assessment on the patient's neurological, gastrointestinal, cardiac and respiratory systems and assessed the patient's pain at 7:00 AM. The nurse documented she completed the next neurological and gastrointestinal assessment at 10:00 AM ( 1 hour late). She documented she completed the next respiratory and cardiac system assessment at 12:00 PM ( 1 hour late). The visit note lacked documented the nurse assessed the patient's pain level for the remainder of the shift after the initial assessment at 7:00 AM. On 7/12/22 at 2:16 PM, during an interview, the Private Duty Nurse Supervisor thought there was a glitch in the computer system which caused documentation issues on 6/29/22. She reported the nurse should be documenting why if the nurse is unable to follow an order. 2. Patient #5, a pediatric patient, had a start of care date of 5/24/21 and discharged from agency services on 4/27/22. Review of the clinical record revealed the following: The POC, dated 3/20/22 to 5/18/22, included physician orders for skilled nursing services 5 to 10 hours per day for 5 to 7 days per week. a. The POC included an order for the skilled nurse to check the patient's blood sugar reading twice daily, once in the morning before the first feeding and one time in the mid/late afternoon before a feeding, and report to the findings to the parents. The POC included order for the skilled nurse to administer Pedialyte 60 milliliters via gastric tube if the blood sugar reading was less than 60 and report to parents. 1) The skilled nursing visits, dated 3/21, 3/31, 4/1 and 4/4/22, included documentation the nurse worked 7:00 AM to 4:00 PM and only obtained one blood sugar reading during the morning part of the shift. 2) The skilled nursing visit, dated 3/20/22, included documentation the nurse worked 7:00 AM to 3:00 PM and only obtained one blood sugar reading during the morning part of the shift. 3) The skilled nursing visit, dated 4/7/22, included documentation the nurse worked 12:00 PM to 5:00 PM and lacked documentation the nurse obtained a blood sugar reading. 4) The skilled nursing visit, dated 4/8/22, included documentation the nurse worked 12:30 PM to 5:00 PM and lacked documentation the nurse obtained a blood sugar reading. 5) The skilled nursing visit, dated 4/13/22, included documentation the nurse worked 7:00 AM to 4:05 PM and only obtained one blood sugar reading during the morning part of the shift. b. The POC included orders for the skilled nurse to check the patient's urine for keystones daily in the morning and report the results to the parents. 1) The skilled nursing visit, dated 4/4/22, included documentation the nurse worked 7:00 AM to 4:00 PM. The visit note included documentation which identified the patient either needed or had a keystone urine check done, but lacked documentation any results of a keystone check or parent notification of the results. 2) The skilled nursing visit, dated 4/7/22, included documentation the nurse worked 12:00 PM to 5:00 PM. The visit note included documentation which identified the patient either needed or had a keystone urine check done, but lacked documentation of results. The documentation was unclear if the nurse did a keystone urine check outside of the orders to complete the check in the morning. 3) The skilled nursing visit, dated 4/8/22, included documentation the nurse worked 12:30 PM to 5:00 PM. The visit note included documentation which identified the patient either needed or had a keystone urine check done, but lacked documentation of results. The documentation was unclear if the nurse did a keystone urine check outside of the orders to complete the check in the morning. On 7/12/22 at 2:02 PM, during an interview, Staff E, Registered Nurse (RN), explained the need to check the patient's blood sugar readings changed to one time per day when the patient went from feedings 4 times a day to 6 times per day. The patient needed blood sugar reading checks due to starting a ketogenic diet. She reported the patient's blood sugar readings became more stable once the patient switched to feedings 6 times per day. When the patient was getting feedings 4 times per day, the parents would have been doing the blood sugar check in the evening, but she was doing the blood sugar checks initially before the first feeding and in the afternoon. She further explained one of the patient's parents was a nurse and did not want blood sugar checks twice a day once the patient was stable. She reported doing a urine check for keystones daily. On 7/12/22 at 2:33 PM, during an interview, the Private Duty Nursing Supervisor, reviewed the clinical record and confirmed the inability to find documentation of a second blood sugar reading in the afternoons. She agreed the dates in question lacked results of the urine keystone check and was unable to determine if the nurse completed the urine keystone check. The Private Duty Nurse Supervisor received the above findings and agency staff provided no further information prior to the end of the survey.