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

A complaint investigation, from 7/11/22 to 7/12/22, for complaint number 70812-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 G572 & 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 reported a current census of 166 patients, 140 home health patients and 26 private duty nursing patients.

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 policy review, clinical record review, patient caregiver interviews and agency staff interviews, 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 for Care for 2 of 3 sampled private duty nursing patients (Patients #1 and #2). 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: According to the agency policy, titled Care Plan and dated 5/23/22, the care plan is initiated within 5 days of admission to care and services or per applicable law and regulation. It is developed based on the initial assessment and will be updated on an ongoing basis. The care plan is evaluated and updated on an ongoing basis as patient condition, problems, and goals change. The care plan includes a statement of identified problems and needs, reasonable and measurable patient goals, and notation of specific services to be provided and actions to be taken to meet patient goals, including the type, frequency, and duration. According to the agency policy, titled Missed Services, patients/caregivers should be consulted in advance regarding scheduling of services so the patient receives the ordered services. Because the frequency of services are ordered by the physician, a missed service affects the plan of care, which may need to be updated or changed. When scheduled services, visits, or shifts are not provided for any reason, the appropriate notification should be completed and sent to the physician or other appropriate ordering provider/entity in a timely manner. A copy of the notification is placed in the patient's record to reflect the alteration of the plan of care. During agency staff interview on 7/11/22 at 12:06 PM, the Administrator for Private Duty Nursing reported the agency was dealing with the usual nursing shortages. The agency recruits nurses for the specific home that a nurse is needed for. If the nurse leaves, the recruiting process starts again. During agency staff interview on 7/11/22 at 12:20 PM, the Clinical Manager for Private Duty Nursing reported nursing staff should document communication with the physician in the communication notes in the electronic health record. 1. Patient #1 had a start of care date of 5/7/16. The patient received private duty nursing services and had a diagnosis of moderate hypoxic ischemic encephalopathy. During review of the agency's complaint log for private duty nursing on 7/11/22, a complaint was received on 5/7/22, related to staffing concerns and the lack of communication when a nurse is taking time off. The complaint was followed up on 5/18/22 and the resolution was the Administrator spoke with the patient's caregiver and explained the agency will do back end searches, sponsor ad, and the office will update the patient caregiver biweekly through emails. The caregiver was pleased with the plan. The resolution included an update stating as of 7/6/22, the patient had Monday through Friday covered in the home which was what the patient caregiver requested. Clinical record review and associated agency staff interviews revealed the following: a. The Plans of Care, dated 4/12/22 to 6/10/22 and 6/11/22 to 8/9/22, included physician orders for skilled nursing visits 12 hours per day for 3-5 days per week for complex skilled hourly registered nurse/licensed practical nurse services. b. Skilled nursing visit notes for the week of 5/8/22, included documentation of 3 skilled nursing visits, dated 5/10/22, 5/12/22, and 5/13/22. The notes identified the patient received only 10.45 hours of service on 5/10/22 and only 10.68 hours of service on 10/12/22. The patient lacked receiving the ordered number of hours and 2 days of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 6/8/22, documented for the week of 5/8/22 through 5/15/22 the patient caregiver was notified and the physician was notified on 6/8/22. The report noted the agency was recruiting as the former nurse on a medical leave of absence resigned and the total hours provided for the week was 33.25. c. Skilled nursing visit notes for the week of 5/15/22, included documentation of 1 skilled nursing visit, dated 5/17/22. The note identified the patient received only 10.52 hours of service. The patient lacked receiving the ordered number of hours and 2 days of skilled nursing services as ordered on the Plan of Care. d. Skilled nursing visit notes for the week of 5/22/22, included documentation of 2 skilled nursing visits, dated 5/24/22 and 5/26/22. The notes identified the patient received only 10.92 hours of service on 5/24/22 and only 10.4 hours of service on 5/26/22. The patient lacked receiving the ordered number of hours and 1 day of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 6/8/22, documented for the week of 5/22/22 through 5/28/22 the patient caregiver was notified and the physician was notified on 6/8/22. The report noted the agency was recruiting as the former nurse on a medical leave of absence resigned and a nurse was on vacation on 5/27/22. The total hours provided for the week was 21.25. e. Skilled nursing visit notes for the week of 5/29/22, included documentation of 2 skilled nursing visits, dated 5/31/22 and 6/3/22. The notes identified the patient received only 10.52 hours of service on 5/31/22 and 12 hours of service on 6/3/22. The patient lacked receiving the ordered number of hours and 1 day of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 6/8/22, documented for the week of 5/29/22 through 6/4/22 the patient caregiver was notified and the physician was notified on 6/8/22. The report noted the agency was recruiting as the former nurse on a medical leave of absence resigned, family cancelled on Memorial Day, and on 6/2/22 a nurse was ill. The total hours provided for the week was 22.5. f. Skilled nursing visit notes for the week of 6/5/22, included documentation of 1 skilled nursing visits, dated 6/10/22. The notes identified the patient received only 10.37 hours of service on 6/10/22 . The patient lacked receiving the ordered number of hours and 2 days of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/11/22, documented for the week of 6/5/22 through 6/11/22 the patient caregiver was notified and the physician was notified on 7/11/22. The report noted the nurse was on vacation from 6/6/22 through 6/9/22 and the total hours provided for the week was 10.5. g. Skilled nursing visit notes for the week of 6/12/22, included documentation of 3 skilled nursing visits, dated 6/13/22, 6/14/22 and 6/16/22. The notes identified the patient received only 11.27 hours of service on 6/13/22, only 10.58 hours of service on 6/14/22 and only 8.48 hours of service on 6/16/22. The patient lacked receiving the ordered number of hours of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/11/22, documented for the week of 6/12/22 through 6/18/22 the patient caregiver was notified and the physician was notified on 7/11/22. The report noted the agency was recruiting and the patient was hospitalized on 6/16/22 and 6/17/22 and the total hours provided for the week was 30.25. h. Skilled nursing visit notes for the week of 6/19/22, included documentation of 5 skilled nursing visits, dated 6/20/22, 6/21/22, 6/22/22, 6/23/22 and 6/24/22. The notes identified the patient received only 7.88 hours of service on 6/20/22, only 10.43 hours of service on 6/21/22 and only 10.38 hours of service on 6/23/22. The patient lacked receiving the ordered number of hours of skilled nursing services as ordered on the Plan of Care. i. Skilled nursing visit notes for the week of 6/26/22, included documentation of 1 skilled nursing visit, dated 6/27/22. The notes identified the patient received only 9.62 hours of service on 6/27/22. The patient lacked receiving the ordered number of hours and 2 days of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/11/22, documented for the week of 6/5/22 through 6/11/22 the patient caregiver was notified and the physician was notified on 7/11/22. The report noted the nurse was on a leave of absence and the total hours provided for the week was 9.75. j. Skilled nursing visit notes for the week of 7/3/22, included documentation of 3 skilled nursing visits, dated 7/6/22, 7/7/22 and 7/8/22. The notes identified the patient received only 11.13 hours of service on 7/6/22 and only 9.75 hours of service on 7/7/22. The patient lacked receiving the ordered number of hours of skilled nursing services as ordered on the Plan of Care. Interview with patient caregiver on 7/12/22 at 12:50 PM reported the agency has been having issues with staffing the ordered number of hours since last September. A registered nurse left so at that time only had the one registered nurse for the home. The agency did not find a replacement for the nurse until December. In January the patient received services three days per week. The patient caregiver has had to use Family Medical Leave Act (FMLA) to provide cares during this time period. The patient caregiver reported the patient is now staffed Monday through Friday. The clinical record lacked timely documentation of physician notification for the variance in the tasks ordered on the Plan of Care. 2. Patient #2 had a start of care date of 9/12/13. The patient received private duty nursing services and had a diagnosis of Trisomy 18. Clinical record review and associated agency staff interviews revealed the following: a. The Plans of Care, dated 5/10/22 to 7/8/22, included physician orders for skilled nursing visits 14 hours per day for 5-7 days per week for complex skilled nursing services. b. The Clinical record lacked documentation of any skilled nursing visits for the weeks of 5/8/22, 5/15/22, 5/22/22, 5/29/22, and 6/5/22. The Missed Services and Physician Notification Reports, dated 6/8/22, documented for the week of 5/8/22 through 5/14/22, 5/15/22 through 5/21/22, 5/22/22 through 5/28/22, and 5/29/22 through 6/4/22, documented the physician was notified on 6/8/22. The report noted the agency was recruiting and the total hours provided for the week was 0. The patient lacked receiving the ordered number of hours and days of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/11/22, documented for the week of 6/5/22 through 6/11/22, documented the physician was notified on 7/11/22. The report noted the agency was recruiting and the total hours provided for the week was 0. c. Skilled nursing visit notes for the week of 6/12/22, included documentation of 1 skilled nursing visit, dated 6/16/22. The note identified the patient received only 5.7 hours of service. The patient lacked receiving the ordered number of hours and 4 days of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/11/22, documented for the week of 6/12/22 through 6/18/22, documented the physician was notified on 7/11/22. The report noted the agency was recruiting and the total hours provided for the week was 13.75. d. Skilled nursing visit notes for the week of 6/19/22, included documentation of 2 skilled nursing visits, dated 6/20/22 and 6/216/22. The notes identified the patient received only 7.82 hours of service on 6/20/22 and only 8 hours of service on 6/21/22. The patient lacked receiving the ordered number of hours and 3 days of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/11/22, documented for the week of 6/19/22 through 6/25/22 the physician was notified on 7/11/22. The report noted the agency was recruiting and the total hours provided for the week was 15.75. e. Skilled nursing visit notes for the week of 6/26/22, included documentation of 2 skilled nursing visits, dated 6/27/22 and 6/28/22. The notes identified the patient received only 8 hours of service on 6/27/22 and 8 hours of service on 6/28/22. The patient lacked receiving the ordered number of hours and 3 days of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/11/22, documented for the week of 6/26/22 through 7/2/22 the physician was notified on 7/11/22. The report noted the agency was recruiting and the total hours provided for the week was 16. f. Skilled nursing visit notes for the week of 7/3/22, included documentation of 2 skilled nursing visits, dated 7/4/22 and 7/5/22. The notes identified the patient received only 8 hours of service on 7/4/22 and 8 hours of service on 7/5/22 . The patient lacked receiving the ordered number of hours and 3 days of skilled nursing services as ordered on the Plan of Care. Interview with the patient caregiver on 7/12/22 at 1:03 PM reported the patient's staffing has not been great. The patient is receiving eight hours a couple of days per week. The patient caregiver is available to provide services for the patient. The clinical record lacked timely documentation of physician notification for the variance in the tasks ordered on the Plan of Care. The above findings were reviewed with the agency Administrator and Clinical Manager for home health services, Staff F, AVP of Operations for PDN, Staff G, Area VP of Operations for PDN, and Staff H, Area VP of Clinical Operations for PDN. The agency provided no additional 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 medications, treatments or services only as ordered by the physician for 1 of 3 sampled home health patients (Patient #6). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to home health agency policy, titled Client's Plan of Care (POC), dated 12/18/17, the client'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. Patient #6 had a start of care date of 5/11/22, received home health services and was discharged from the agency on 5/11/22. Clinical record review revealed the following: a. The Plans of Care, dated 2/1/22 to 4/1/22 and 4/2/22 to 5/31/22, included orders for oxygen 3 liters every night. b. The skilled nursing visit notes, dated 3/16/22 and 3/24/22, documented the patient's use of 2 liters of oxygen at bedtime. c. The update to the comprehensive assessment at the time of recertification, dated 3/30/22, documented the patient's use of 2 liters of oxygen at bedtime. d. The skilled nursing visit notes, dated 4/13/22, 4/20/22, 4/27/22, and 5/4/22, documented the patient's use of 2 liters of oxygen at bedtime. Interview with the home health Clinical Manager reported the physician was not notified of the patient's use of 3 liters per nasal canula to obtain an order to decrease the patient's oxygen. The Clinical Manager called the registered nurse for the patient and the nurse confirmed the patient was using 2 liters of oxygen at bedtime and stated the nurse confirmed the physician was not notified of this to obtain new orders. The above findings were reviewed with the agency Administrator and Clinical Manager for home health services, Staff F, AVP of Operations for PDN, Staff G, Area VP of Operations for PDN, and Staff H, Area VP of Clinical Operations for PDN. The agency provided no additional information prior to the end of the survey.