Every finding on record at Regional Health Services of Howard County

The Iowa Department of Inspections, Appeals and Licensing conducted a Recertification Survey on 12/1/25 through 12/3/25 and the home health agency was found to be operating in compliance with the regulations of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 12/1/25 through 12/3/25. The recertification survey identified the home health agency was operating out of compliance with the following standard level hospice regulations. The home health agency reported a current census of 31 patients at the time of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview review the agency failed to ensure accurate and thorough completion of a comprehensive assessment of wounds for 1 of 1 sampled patients with wounds. (Patient #4) Failure to accurately and thoroughly complete a thorough comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition. Findings include: According to agency policy, titled Wound Measurement and Documentation, dated 8/27/25, agency staff complete wound measurement using centimeter measuring device. Use different measuring device with each wound. (Length is measured from patient's head to toe; width is measured from one side of the patient to the other). Head to toe and side to side may not indicate longest and widest parts of wound. During an interview on 12/2/25 at 3:16 PM the Director of Nursing stated wounds are expected to be measured weekly and include length, width and depth. Patient #4 had a start of care date of 3/9/15. Clinical record review revealed the following: a. The plans of care (POCs), dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/25, identified the patient had a diagnosis of pressure ulcer of the left buttock. The POCs included orders for skilled nurse services and wound care. The POC included orders for wound care and skilled nurse to check with the wound clinic for measurements of all wounds after wound clinic visits. b. The comprehensive assessment at resumption of care, dated 11/3/25, Staff D, Registered Nurse (RN) documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. d. The comprehensive assessment at recertification, dated 1163/25, Staff D, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. b. The skilled nurse visit note, dated 11/14/25, Staff D, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. c. The skilled nurse visit notes, dated 11/17/25 and 11/20/25 Staff , C, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. d. The skilled nurse visit notes, dated 11/26/25, Staff G, RN documented the patient had a wound on the left lower posterior leg, ischial tuberosity pressure area stage 4 and left posterior leg ischial tuberosity pressure wound stage 4. The note identified family provided wound care and the document failed to include wound assessments including measurements of the wounds. c. The clinical record lacked documentation of collaboration with the wound clinic for wound assessments including measurements. Agency failed to document wound assessments. The above findings were reviewed with the Administrator and Director of Nursing.

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 observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 3 of 3 sampled patients with home observation visits (Patients #1, #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 3. Patient #3 had a start of care date of 8/12/25. Clinical record review revealed: a. The POC, dated 10/11/25 to 12/9/25, identified the patient had a diagnosis of Diabetes Mellitus and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 10/7/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 12/2/25 at 10:00 AM with Staff C, RN, interview with the patient stated he/she sets up medication in a medication planner. The following medication discrepancy identified: 1) Glipizide (diabetic medication) bottle in the home says 5 mg tablets with instructions to take 1/2 tablet by mouth 2 daily in the morning. Agency medication list says Tramadol 5 mg tablets with instructions to take 0.5 mg orally daily in the morning. 2) The surveyor observed a bottle of opened Niquil on the kitchen counter. Instructions listed Aceteminiphen 650 mg, dextromethorphan 30 mg and doxylamine succinate 12.5 mg, take 30 milliliters (ml) evvery 6 hours as needed. During the same home visit the patient stated he/she takes the medication every once in a while and had it in the home quite a while. The DRR failed to include an accurate review of all medications taken by the patient. The above findings reviewed with the Administrator and Director of Nursing. According to the agency Drug Regimen Review policy, revised 2/2022, the comprehensive drug regimen review (DRR) assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including effective/ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. During an interview on 12/2/25 at 3:16 PM, Staff B, Clinical Manager stated the DRR is completed on admission, with each comprehensive assessment and when medication is added or changed. 1.Patient #1 had a start of care date of 7/29/25. Clinical record review revealed: a. The Plan of Care (POC), dated 9/27/25 to 11/25/25, identified the patient had a diagnosis of Compression of the brain and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 11/25/25, completed by Staff C, Registered Nurse (RN), included documentation a DRR was completed. c. During a home observation visit on 12/2/25 at 9:00 AM with Staff D, RN, interview with the patient stated he/she sets up his/her own medication with supervision from the skilled nurse. The following medication discrepancy identified: Tramadol bottle in the home says 50 milligram (mg) tablets with instructions to take 2 tablets by mouth 2 times daily as needed. Agency medication list says Tramadol 50 mg tablets with instructions to take 2 tablets orally in the morning and 1 tablet at 2:00 PM. The patient identified he/she takes Tramadol 1 tablet 3-4 times a day spaced out as needed. The DRR failed to include an accurate review of all medications taken by the patient. 2.Patient #2 had a start of care date of 7/23/25. Clinical record review revealed: a. The POC, dated 11/20/25 to 1/18/26, identified the patient had a diagnosis of Radiculopathy lumbar region and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 11/18/25, completed by Staff C, RN, included documentation a DRR was completed, medications were verified with spouse, bottles in the home and agency medication list. c. During a home observation visit on 12/2/25 at 12:35 PM with Staff F, Physical Therapy Assistant (PTA), the patient's spouse stated he/she sets up patient's medication. The following medication discrepancies were identified: 1) Melatonin bottle in the home contains 5 mg tablets and the spouse gives the patient 1 tablet at bedtime. Agency med list says Melatonin 10 mg oral capsule with instructions to take 1 capsule at bedtime. 2) Agency medication list identifies patient takes Tamsulosin 0.4 mg oral capsule;1 capsule at bedtime. Interview with patient's spouse identified patient has not taken this medication for greater than 3 weeks. The DRR failed to include an accurate review of all medications taken by the patient.

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 observations, patient interviews, clinical record reviews and agency policy review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and advanced directives used by the patient for 2 of 7 sampled patients (Patients #1 and #4). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 2.Patient #1 had a start of care date of 7/29/25. Clinical record review revealed: a. The POC, dated 9/27/25 to 11/25/25, identified the patient had a diagnosis of Compression of the brain. The POC included the following medical equipment and supplies used by the patient: cane, grab bars/safety rails, oral medication trays, heating pad and rolling walker. b. During a home observation visit on 12/2/25 with Staff D, RN, the surveyor observed the patient to have a pill cutter. The patient identified he/she has a medication that gets cut in half and he/she uses the pill cutter to cut the medication. The patient also identified he/she uses a Cefaly device (external trigeminal nerve stimulation device) for migraine relief and has utilized this device for 3-4 years. The agency failed to include all medical equipment and supplies used by the patient on the POC. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Home Health Plan of Care (POC), dated 10/29/25, all home health care services furnished to patinets must follow an individualized written plan of care that identifies patient-specific measureable outcomes and goals, established in collaboration with the physician, the patient, the Registered Nurse (RN) case manager, and in accordance with the patinet's needs. 1.Patient #4 had a start of care date of 3/9/15. Clinical record review revealed: a. The POCs, dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/25, identified the patient had a diagnosis of Pressure ulcer of the right buttock. The POC included the physician's order to do not resusitate (DNR). b. Client Bill of Rights Form, dated 3/9/15, revealed the patient had a Doctor's order for no cardiopulmonary resusitation (CPR). c. The discharge summary, dated 10/3/25, Staff D, RN, documented the patient transfered to the hospital on 9/30/25 and requested full code status (perform CPR). d. The skilled nurse visit at resumption of care, dated 10/9/25, Staff D, RN failed to document discussion of wishes for code status. e. Review of the electronic medical record failed to include discurssion of code wished following the hospital admission on 9/30/25. The agency failed to ensure correct code status per the patient's wishes listed on the POC.

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 patient interview, clinical record review and agency policy review, the agency failed to provide services only as ordered by the physician for 3 of 7 sampled patients (Patients #1, #5 and #7). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed patients at risk for inconsistent care/treatment and possible harm. Findings include: 3. Patient #4 had a start of care date of 3/9/15. Clinical record review revealed: a. The POCs, dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/25, identified the patient had a diagnosis of Pressure ulcer left buttock and inherited spinal muscular atrophy, identified the patient utilized a heating pad and included orders for skilled nursing services every two weeks. b. Review of the clinical record failed to include physician orders for heat therapy. Agency staff failed to include physician orders for treatments administered including heat therapy. The above findings reviewed with the Administrator and Director of Nursing. According to the agency policy, titled Home Health Plan of Care, revised 11/2022, all home health care services furnished to patients must follow an individualized written Plan of Care (POC) that identifies patient-specific measurable outcomes and goals, established in collaboration with the physician, the patient, the Registered Nurse (RN) case manager and in accordance with the patient needs. The POC must reflect patient and family goals and interventions, physician orders and problems identified in the initial, comprehensive and updated comprehensive assessments. 1.Patient #1 had a start of care date of 7/29/25. Clinical record review revealed: a. The POC, dated 9/27/25 to 11/25/25, identified the patient had a diagnosis of Compression of the brain, identified the patient utilized a heating pad and included orders for skilled nursing services every two weeks. b. During a home observation visit on 12/2/25 at 9:00 AM with Staff D, RN, the patient identified he/she utilizes a heating pad for pain relief. c. Review of the clinical record failed to include physician orders for heat therapy. Agency staff failed to include physician orders for treatments administered including heat therapy. 2.Patient #5 had a start of care date of 7/3/2013. Clinical record review revealed: a. The POC, dated 10/28/25 to 12/26/25, included diagnoses of Schizophrenia and hypertensive heart disease without heart failure and included an order for skilled nursing to assess orthostatic blood pressure sitting to standing each visit. b. Skilled nurse visit notes, dated 10/28/25, 11/11/25 and 11/25/25, completed by Staff D, RN, included documentation of blood pressure sitting at rest but failed to include blood pressure standing. The skilled nurse failed to follow physician orders and assess orthostatic blood pressure sitting to standing each visit.

The recertification survey conducted from 10/17/22 through 10/20/22, found the agency in substantial compliance with the emergency preparedness regulations with no deficiencies.

The recertification survey conducted from 10/17/22 through 10/20/22, identified the following standard level deficient practices. The agency identified a current census of 32 patients.

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, home visit observation, caregiver/patient interviews, and agency staff interviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 5 of 8 sampled patients (Patient #1, Patient #2, Patient #4, Patient #5 and Patient #6). Failure to maintain complete and accurate Plans of Care placed the patients at risk for not receiving home health services and treatments and correctly identifying their needs and current orders. Findings include: During interview on 10/20/22 at 10:42 AM, the Administrator revealed the agency did not have a Plan of Care policy or a policy regarding physician orders. Patient #2 had a start of care date of 1/9/91 and was diagnosed with disorder of urea metabolism and epilepsy. Clinical record review revealed: a. The Plans of Care, dated 5/26/22 to 7/24/22, 7/25/22 to 9/22/22 and 9/23/22 to 11/21/22, identified the following equipment and supplies were used to meet the patient's needs: wheelchair, adult diapers, nonsterile gloves, urinal, bedside commode, wheelchair cushion, gait belt, shower chair, hand held shower, grab bars/safety rails, lift chair stair lift, pill cutter, syringes, and wheelchair ramp. During a home visit observation on 10/18/22 at 10:00 AM with Staff C, Registered Nurse (RN), the surveyor reviewed the patient's medication with the caregiver and the caregiver retrieved a medication planner used to set up the medications. The caregiver revealed setting up medications for the patient for years using the medication planner. The Plans of Care lacked identification of the medication planner as a supply used to meet the patient's needs. b. During the same home visit observation on 10/18/22 at 10:00 AM with Staff C, RN, the surveyor observed a bed rail on the patient's bed. The caregiver revealed having the bed rail for 4 to 5 months. Interview with Staff H, Home Care Aide (HCA), on 10/20/22 at 9:14 AM revealed the patient did have a bed rail and the aide was unsure how long the patient had it, but would guess about six months. The Plans of Care lacked identification of the bed rail as a supply to meet the patient's needs. c. During the same home visit observation on 10/18/22 at 10:00 AM with Staff C, RN, the surveyor reviewed the patient's medication with the caregiver and the caregiver retrieved a bottle with 10 tablets of Furosemide 20 mg with instructions to take 1 tablet daily, date of dispense 7/26/22, originally with a 90 day supply. The caregiver revealed setting up medications and daily use of the Furosemide. The nurse revealed on the Medication Profile, Furosemide was discontinued back in February 2022. The caregiver did not remember the Furosemide being discontinued and the patient was receiving the Furosemide daily. Interview with Staff C, RN on 10/20/22 at 8:47 AM revealed the nurse contacted the physician and the physician did not have the Furosemide on the patient's medication list. The provider planned to make a home visit to the patient to visit with family regarding the Furosemide. The Plans of Care lacked identification of the current medications used by the patient. 2. Patient #5 had a start of care date of 7/22/22 and was diagnosed with morbid obesity. Clinical record review revealed: a. The Plans of Care, dated 7/22/22 to 9/19/22 and 9/20/22 to 11/18/22, identified the following equipment and supplies were used to meet the patient's needs: raised toilet seat, walker, reacher, hand held shower, grab bars/safety rails, lift chair and seated walker. b. The initial comprehensive assessment, dated 7/22/22, documented the patient used the following supplies: disposable chux pads, BIPAP, gait belt, bedside table, humidifier, pill planner, pill splitter, lymphedema machine, long handled shoe horn, back scratcher, incentive spirometer, sitz bottle, wash basin x3, cleansing wipes, urine graduates and urine pail. c. The update to the comprehensive assessment, dated 9/16/22, documented the patient used the following supplies: disposable chux pads, BIPAP, gait belt, bedside table, humidifier, pill planner, pill splitter, lymphedema machine, long handled shoe horn, back scratcher, incentive spirometer, sitz bottle, wash basin x3, cleansing wipes, urine graduates and urine pail. The Plans of Care lacked identification of disposable chux pads, BIPAP, gait belt, bedside table, humidifier, pill planner, pill splitter, lymphedema machine, long handled shoe horn, back scratcher,incentive spirometer, sitz bottle, wash basin x3, cleansing wipes, urine graduates and urine pail used to meet the patient's needs. 3. Patient #6 had a start of care date of 9/3/19 and was diagnosed with multiple sclerosis. Clinical record review revealed: a. The Plan of Care, dated 4/20/22 to 6/18/22, identified the following equipment and supplies were used to meet the patient's needs: overbed table, nonsterile gloves, trapeze, wheelchair, pressure release mattress, wheelchair cushion, gait belt, bed rails, reacher, shower chair, shoe/sock aides, hand held shower, long handled sponge, grab bars/safety rails, hospital bed, compression stockings, bike, leg lift, blood pressure cuff, emergency response system, straight catheter and supplies, incontinence briefs, and a 4 wheeled walker. b. The Plan of Care, dated 6/19/22 to 8/17/22, identified the following equipment and supplies were used to meet the patient's needs: overbed table, nonsterile gloves, trapeze, wheelchair, pressure release mattress, wheelchair cushion, bed rails, reacher, shower chair, shoe/sock aides, hand held shower, long handled sponge, grab bars/safety rails, hospital bed, compression stockings, bike, leg lift, ramp, blood pressure cuff, emergency response system, straight catheter and supplies, and a 4 wheeled walker. Interview with Staff H, HCA, on 10/20/22 at 9:14 AM revealed the patient did have incontinence supplies and a gait belt for use, but only used incontinence supplies for long trips and infrequently used the gait belt due to decreased mobility. The Plan of Care lacked identification of incontinence briefs and gait belt as equipment used by the patient. c. The Plan of Care, dated 8/18/22 to 10/16/22, identified the following equipment and supplies were used to meet the patient's needs: overbed table, nonsterile gloves, trapeze, wheelchair, pressure release mattress, bed rails, reacher, shower chair, shoe/sock aides, hand held shower, long handled sponge, grab bars/safety rails, hospital bed, compression stockings, bike, leg lift, ramp, blood pressure cuff, emergency response system, straight catheter and supplies, and a 4 wheeled walker. Interview with Staff H, HCA, on 10/20/22 at 9:14 AM revealed the patient did have a trapeze on the hospital bed and a wheelchair cushion still in use The Plan of Care lacked identification of trapeze and wheelchair cushion as equipment used by the patient. 4. Patient #1 had a start of care date of 9/2/22. Review of the clinical record revealed the following: The Plan of Care (POC), dated 9/2/22 to 10/31/22, included orders for skilled nursing, home health aide, occupational and physical therapy services. The POC included an order for Calcium 600 milligrams (mg) plus Vitamin D one tablet daily. On 10/18/22 at 12:40 PM, during a home visit observation with Staff G, Physical Therapy Assistant, the surveyor reviewed the patient's medications and observed the patient had a bottle of Calcium 600 mg plus Vitamin D 400 mg and a hand-written medication list which identified the patient took Calcium 600 mg plus Vitamin D 400 mg one tab daily. In an interview, during the same home visit observation, the patient reported family set up the patient's medications and created the hand-written medication list. The handwritten medication list identified the patient had been taking the Calcium 600 mg plus Vitamin D 400 mg tablets since prior to the start of agency services. The POC failed to identify a specific dose amount for the Vitamin D. 5. Patient #4 had a start of care date of 3/18/22. Review of the clinical record revealed the following: a. The POCs, dated 7/16/22 to 9/13/22 and 9/14/22 to 11/12/22, identified the patient had a diagnosis of pressure ulcer to the left buttock and included orders for skilled nursing and home health aide services. The POCS included orders for the skilled nurse to assess pressure ulcer status including signs and symptoms of healing and complications, to teach the home health aide/caregiver regarding wound care regimen, including procedure, aseptic technique, complications, disposal of old dressings and changes to report. 1) The POC, dated 7/16/22 to 9/13/22, identified the patient had 4 different abdominal surgical wounds with instructions to the home health aide to wash surgical wounds with soap and water during shower, pat dry and leave open to air. The POC included orders for the skilled nurse to complete a skilled nursing visit one time per week and measure the patient's wounds at least one time every 7 days. 2) The POC, dated 9/14/22 to 11/12/22, identified the patient continued to have unhealed abdominal wounds. The POC included included instructions to the home health aide to wash surgical wounds with soap and water during shower, pat dry and leave open to air. The POC included orders for the skilled nurse to complete a skilled nursing visit one time every other week starting the week of 9/27/22, and a conflicting order for the skilled nurse to provide the skilled nursing services of measuring the patient's wounds at least one time every 7 days. 3) The clinical record included documentation of weekly skilled nursing visits for the weeks of 9/18/22, dated 9/20, the week of 9/25/22, dated 9/27, the week of 10/2/22, dated 10/4, the week of 10/9/22, dated 10/11, and the week of 10/16/22, dated 10/18. On 10/20/22 at 8:55 AM, during a phone interview, the Administrator reported the skilled nurse did weekly wound assessment, but otherwise, completed a full visit every other week. The nurse provided supervision of home health aide services weekly, and did not do a skilled service. They did not bill for the weekly wound assessment. On 10/20/22 at 10:09 AM, during a phone interview with the Administrator and Clinical Manager, the Clinical Manager reported they did not realize they were doing something incorrect in the skilled nursing frequency order. b. The POCs, dated 7/16/22 to 9/13/22 and 9/14/22 to 11/12/22, included an intervention for the social worker to review the patient's behavior contract for compliance, provide encouragement and praise when appropriate and share any concerns with social worker and/or home health lead. The POCs included a social worker goal to make progress towards items outlined in behavior contract and a target date of completion, dated 11/12/2022. The POCs lacked a frequency and duration for social worker services. On 10/20/22 at 10:09 AM, during a phone interview with the Administrator and Clinical Manager, the Clinical Manager reported the social worker services should not have been on the 2 POCs and staff should have removed the goal and intervention for this service. The Administrator and Clinical Manager 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 clinical record review and agency staff interview, the agency staff failed to provide medications and treatments only as ordered by the physician for 1 of 8 sampled patients (Patients #4). Failure to ensure staff obtain/follow physician orders for administration of medications and treatments placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Patient #4 had a start of care date of 3/18/22. Review of the clinical record revealed the following: The Plans of Care (POCs), dated 7/16/22 to 9/13/22 and 9/14/22 to 11/12/22, identified a primary diagnosis of an unhealed pressure ulcer to the left buttocks and included orders for skilled nursing and home health aide services. a. The POC, dated 7/16/22 to 9/13/22, the POC identified the patient had 4 abdominal surgical wounds, included orders for the skilled nurse to complete a skilled nursing visit one time per week, measure the patient's wounds at least one time every 7 days and assess the patient's blood sugar reading and trends with each skilled nursing visit. 1) The POC, dated 9/14/22 to 11/12/22, identified the patient continued to have unhealed abdominal wounds. The POC included included instructions to the home health aide to wash surgical wounds with soap and water during shower, pat dry and leave open to air. The POC included orders for the skilled nurse to complete a skilled nursing visit one time every other week starting the week of 9/27/22, and a conflicting order for the skilled nurse to provide the skilled nursing service of measuring the patient's wounds at least one time every 7 days. The POC continued to have an order for the skilled nurse to assess the patient's blood sugar reading and trends with each skilled nursing visit. 2) The skilled nursing visit, dated 9/6/22, lacked documentation the nurse assessed the patient's blood sugar reading and trends per POC orders. 3) The clinical record included documentation of weekly skilled nursing visits for the weeks of 9/18/22, dated 9/20, the week of 9/25/22, dated 9/27, the week of 10/2/22, dated 10/4, the week of 10/9/22, dated 10/11, and the week of 10/16/22, dated 10/18. The skilled nursing visits, dated 9/6, 9/20, 10/4 and 10/18/22, lacked documentation the nurse assessed the patient's blood sugar readings and trends. b. The POCs included orders for the skilled nurse to trim and file toenails once a month (around mid-month). The skilled nursing visits, dated 9/9, 9/13 and 9/27/22, included documentation the skilled nurse completed the task of trimming and filing the patient's toenails. The nurse provided the intervention 3 times in the month of September, exceeding the physician's order of one time per month. c. The POCS included orders for the skilled nurse to assess pressure ulcer status including signs and symptoms of healing and complications, to teach the home health aide/caregiver regarding wound care regimen, including procedure, aseptic technique, complications, disposal of old dressings and changes to report. The POCs included the following orders for the home health aide: apply skin barrier cream/Calmoseptine to redness in skin folds or buttocks per client request; and, cleanse buttocks with soap and water, allow to dry and mix equal parts of Silvadene 1 percent cream and Calmoseptine and apply to buttocks. 1) A home health aide visit, dated 9/9/22 at 11:15 AM, identified the patient had the beginning of an open wound on the right buttock. Staff D, Home Health Aide, documented she completed a communication note to notify the nurse. 2) An update to the comprehensive assessment completed by Staff F, Registered Nurse (RN) at the time of recertification, dated 9/9/22 at 1:15 PM, identified the patient did not have any pressure ulcers on the buttocks. 3) The POC, dated 9/14/22 to 11/12/22, included documentation the nurse completed the POC on 9/12/22 and sent the document for physician signature. The POC included documentation of a summary by the nurse which identified the patient did not have any pressure ulcer wounds at the time of the recertification visit. 4) A skilled nursing visit, dated 9/13/22, included documentation Staff F, RN, assessed the patient had an open pressure ulcer wound on the right inner buttocks. 5) A verbal physician order, dated 9/13/22, included the following order: "decubitus/pressure ulcer stage II / right inner buttocks coccyx; perform wound care/dressing change; cleanse with mild soap and water; apply Silver Alginate to wound bed, cover with Mepilex border foam dressing; change 2x week after showers and PRN (as needed) if dressing falls off or becomes soiled, continue until healed (home health aide will be changing dressing on bath days)" effective 9/13/2022. 6) The multidisciplinary care plan in the electronic record included intervention instructions for the home health aide and skilled nurse. The multidisciplinary care plan included the verbal physician order for wound care to the right inner buttocks, dated 9/13/22. 7) The home health aide visit notes, dated 9/16, 9/20, 9/23, 9/27, 9/30, 10/4 and 10/6/22, lacked documentation the home health aide applied Silver Alginate and Mepilex to the right inner buttock wound per physician orders. 8) The skilled nursing visit note, dated 9/20/22, included documentation Staff F, RN, washed the right inner buttock wound with soap and water and applied Calmoseptine. The visit note lacked documentation the nurse applied Silver Alginate and Mepilex. 9) The skilled nursing visit, dated 9/27/22, included documentation Staff F, RN, did not apply a Mepilex dressing due to the patient not having any in the home. 10) The skilled nursing visits, dated 10/4 and 10/11/22, included documentation the skilled nurse completed wound care to the right inner buttock wound per POC orders. On 10/19/22 at 12:09 PM, during an interview, Staff D, Home Health Aide (HHA), reported on 9/9/22, she observed the patient had the beginning of an open area on the right buttock, but the area was not open yet. She explained she had been applying half Silvadene cream and half Calmoseptine to the buttocks wounds. She denied ever applying Mepilex or Silver Alginate to the right inner buttock wound. On 10/19/22 at 12:19 PM, during an interview, Staff E, HHA, reported she applied half Silvadene cream and half Calmoseptine to the buttocks wounds. She has never applied Silver Alginate or Mepilex to any of the wounds. She explained she follows the care plan and this was not on the care plan. On 10/19/22 at 1:15 PM, during an interview, Staff F, RN, reported on 9/9/22 she must not have seen the wound on the patient’s buttock, but she did assess the patient’s buttocks every time. She reported the patient did not have Mepilex, so it was not put on the wound. She reported she did not contact the physician to notify the physician about not having Mepilex. She reported she did not instruct the home health aides to apply Silver Alginate and Mepilex to the right buttock wound. The skilled nurse failed to follow wound care orders and failed to provide instructions/teach the home health aides on wound care treatment to the right inner buttock wound per POC and physician orders. On 10/20/22 at 8:55 AM, during a phone interview, the Administrator reported the skilled nurse did weekly wound assessment, but otherwise, completed a full visit every other week. The blood sugar readings were not required every week. The nurse provided supervision of home health aide services weekly, and not a skilled service. They did not bill for the wound assessment weekly. On 10/20/22 at 10:09 AM, during a phone interview with the Administrator and Clinical Manager, the Clinical Manager reported they did not realize they were doing something incorrect in the skilled nursing frequency order. They thought the nurse only needed to assess the patient’s blood sugars every 2 weeks. She confirmed the nurse documented trimming the patient’s toenails 3 visits in September, and the nurse could not remember which visit she trimmed the toenails. She was marking complete to indicate she was following this per the POC orders. The patient did not purchase the Mepilex dressing, so this was why the nurse was unable to cover the right inner buttock wound with it. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to report changes in patient clinical findings to the physician for 1 of 4 sampled patients (Patient #4) with wounds. 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: Patient #4 had a start of care date of 3/18/22. Review of the clinical record revealed the following: The Plans of Care (POCs), dated 7/16/22 to 9/13/22 and 9/14/22 to 11/12/22, identified a primary diagnosis of an unhealed pressure ulcer to the left buttocks and included orders for skilled nursing and home health aide services. The POCS included orders for the skilled nurse to assess pressure ulcer status including signs and symptoms of healing and complications, to teach the home health aide/caregiver regarding wound care regimen, including procedure, aseptic technique, complications, disposal of old dressings and changes to report. The POCs included the following orders for the home health aide: apply skin barrier cream/Calmoseptine to redness in skin folds or buttocks per client request; and, cleanse buttocks with soap and water, allow to dry and mix equal parts of Silvadene 1 percent cream and Calmoseptine and apply to buttocks. a. An update to the comprehensive assessment completed by Staff F, Registered Nurse (RN) at the time of recertification, dated 9/9/22 at 1:15 PM, identified the patient did not have any pressure ulcers on the buttocks. 1) The POC, dated 9/14/22 to 11/12/22, included documentation the nurse completed the POC on 9/12/22 and sent the document for physician signature. The POC included documentation of a summary by the nurse which identified the patient did not have any pressure ulcer wounds at the time of the recertification visit. 2) A skilled nursing visit, dated 9/13/22, included documentation Staff F, RN, assessed the patient had an open pressure ulcer wound on the right inner buttocks. 3) A verbal physician order, dated 9/13/22, included the following order: "decubitus/pressure ulcer stage II / right inner buttocks coccyx; perform wound care/dressing change; cleanse with mild soap and water; apply Silver Alginate to wound bed, cover with Mepilex border foam dressing; change 2x week after showers and PRN (as needed) if dressing falls off or becomes soiled, continue until healed (home health aide will be changing dressing on bath days)" effective 9/13/2022. 4) The multidisciplinary care plan in the electronic record included intervention instructions for the home health aide and skilled nurse. The multidisciplinary care plan included the verbal physician order for wound care to the right inner buttocks, dated 9/13/22. 5) The home health aide visit notes, dated 9/16, 9/20, 9/23, 9/27, 9/30, 10/4 and 10/6/22, lacked documentation the home health aide applied Silver Alginate and Mepilex to the right inner buttock wound per physician orders. 6) The skilled nursing visit note, dated 9/20/22, included documentation Staff F, RN, washed the right inner buttock wound with soap and water and applied Calmoseptine. The visit note lacked documentation the nurse applied Silver Alginate and Mepilex. 7) The skilled nursing visit, dated 9/27/22, included documentation Staff F, RN, did not apply a Mepilex dressing due to the patient not having any in the home. 8) The skilled nursing visits, dated 10/4 and 10/11/22, included documentation the skilled nurse completed wound care to the right inner buttock wound per POC orders. On 10/19/22 at 12:09 PM, during an interview, Staff D, Home Health Aide (HHA), denied ever applying Mepilex or Silver Alginate to the right inner buttock wound. On 10/19/22 at 12:19 PM, during an interview, Staff E, HHA, reported has never applied Silver Alginate or Mepilex to any of the patient's wounds. On 10/19/22 at 1:15 PM, during an interview, Staff F, RN, reported the patient did not have Mepilex, so it was not put on the wound. She reported she did not contact the physician to notify the physician about not having Mepilex. b. A skilled visit note, dated 9/20/22, included documentation Staff F, RN, assessed the patient had 2 new pressure ulcer open wounds to the left buttock. The visit note included documentation the nurse completed wound care per POC orders. The clinical record lacked documentation the nurse contacted the physician about the new wounds. c. A skilled nursing visit note, dated 10/18/22, included documentation Staff F, RN, assessed the patient had 2 new pressure ulcer wounds, one on the right buttock and one on the left buttock. The nurse documented she completed wound care per the POC orders. The clinical record lacked documentation the nurse contacted the physician about the new wounds. On 10/19/22 at 1:15 PM, during an interview, Staff F, RN, explained she did not remember if she reported the 2 new left buttock wounds on 9/20/22, but thought she probably did not and did not see it charted. She planned to contact the physician to notify of the 2 open wounds currently on the patient’s buttocks from the 10/18/22 visit and clarify orders. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

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 review, agency policy review and agency staff interview, the agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 2 of 6 sampled patients receiving home health aide services (Patient #4 and Patient #5). The agency reported 19 out of 32 patients received home health aide services at the time of the survey. Findings include: 2. Patient #4 had a start of care date of 3/18/22. Review of the clinical record revealed the following: The POCs, dated 7/16/22 to 9/13/22 and 9/14/22 to 11/12/22, identified the patient had a diagnosis of pressure ulcer to the left buttock and included orders for skilled nursing and home health aide services. The POCs included the following orders for the home health aide: apply skin barrier cream/Calmoseptine to redness in skin folds or buttocks per client request; and, cleanse buttocks with soap and water, allow to dry and mix equal parts of Silvadene 1 percent cream and Calmoseptine and apply to buttocks. The directions to the home health aide included 2 different orders for care of the patient's buttocks. On 10/20/22 at 10:09 AM, during a phone interview with the Administrator and Clinical Manager, the Clinical Manager confirmed there were 2 orders for the home health aides for care to the buttocks. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. According to agency policy, titled Home Care Aide and Homemaker Services, dated 5/23/22, ....home care aide services are are under the supervision of medical staff and provides health related services for person care or rehabilitative therapies, such as: observation of self-administration of oral medications, checking the pulse rate, temperature, and respiration rate, helping with simple prescribed exercises, keeping consumer's rooms neat, simple wound care and dressing changes, assisting with braces and artificial limbs, assisting the consumer in using medical equipment, other tasks as assigned and the agency follows medicare benefits to include aide supervision guidelines. Interview on 10/17/22 at 11:24 AM with the Clinical Manager revealed the admitting nurse creates the home health aide care plan with the patient and/or family. Patient #5 had a start of care date of 7/22/22 and a diagnosis of morbid obesity. Clinical record review revealed: a. The Plans of Care, dated 7/22/22 to 9/19/22 and 9/20/22 to 11/18/22, included orders for weekly skilled nursing visits and twice weekly home care aide services. The Plans of Care ordered the aide to perform the following tasks: ask patient to perform therapy home exercise program during visit for accountability and assist with bed bath including perineal care. b. The home health aide visit notes, dated, 8/22/22, 9/7/22, and 9/9/22, documented the task of asking the patient to perform therapy home exercise program during visit was not applicable this visit. Interview on 10/20/20 with Staff H, Home Care Aide, (HCA) revealed the aide was unsure why not applicable was documented. The aide care plan was not specific if the charting of done meant the patient completed the exercises during the visit or if the aide simply asked the patient to perform the exercises during the visit. c. The skilled nurse visit note, dated 8/15/22, documented the nurse visited the patient with Staff H, HCA and the patient suggested the aide use the sink to wash the patient's hair so a wound could be measured while standing. Interview with Staff I, Registered Nurse, (RN) on 10/19/22 at 1:17 PM revealed the nurse remembered visiting the patient with the aide and the aide washing the patient's hair. d. The aide visit note, dated 8/15/22, documented the aide assisted with a bed bath, including perineal cares. Interview with Staff H, HCA on 10/20/20 at 9:14 AM revealed the aide performed the shampoo to the patient's hair during the visit. The aide stated not charting the bath as the aide thought it was part of the bed bath. The aide further stated the patient's hair is only shampooed on request of the patient. The written patient care instructions were not specific and individualized 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 agency policy review, clinical record review and staff interview, 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 nursing professional assigning the home health aide to the patient for 3 of 6 sampled patients receiving home health aide services (Patient #2, Patient #4, and Patient #5). The agency reported 19 patients currently received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law,and/or as directed by the skilled nursing professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: 3. Patient #4 had a start of care date of 3/18/22. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 7/16/22 to 9/13/22 and 9/14/22 to 11/12/22, identified a primary diagnosis of an unhealed pressure ulcer to the left buttocks and included orders for skilled nursing and home health aide services. The POCS included the following orders for the home health aide: apply skin barrier cream/Calmoseptine to redness in skin folds or buttocks per client request; and, cleanse buttocks with soap and water, allow to dry and mix equal parts of Silvadene 1 percent cream and Calmoseptine and apply to buttocks. b. The POC, dated 9/14/22 to 11/12/22, included documentation the nurse completed the POC on 9/12/22 and sent the document for physician signature. The POC included documentation of a summary by the nurse which identified the patient did not have any pressure ulcer wounds at the time of the recertification visit. c. A skilled nursing visit, dated 9/13/22, included documentation Staff F, Registered Nurse (RN), assessed the patient had an open pressure ulcer wound on the right inner buttocks. d. A verbal physician order, dated 9/13/22, included the following order: "decubitus/pressure ulcer stage II / right inner buttocks coccyx; perform wound care/dressing change; cleanse with mild soap and water; apply Silver Alginate to wound bed, cover with Mepilex border foam dressing; change 2x week after showers and PRN (as needed) if dressing falls off or becomes soiled, continue until healed (home health aide will be changing dressing on bath days)" effective 9/13/2022. e. The multidisciplinary care plan in the electronic record included intervention instructions for the home health aide and skilled nurse. The multidisciplinary care plan included the verbal physician order for wound care to the right inner buttocks by the home health aide 2 times per week on bath days, dated 9/13/22, under the skilled nursing portion of the plan. f. The clinical record included documentation of home health aide visits two times per week the week of 9/12 through the week of 10/2/22. The home health aide visit notes, dated 9/16, 9/20, 9/23, 9/27, 9/30, 10/4 and 10/6/22, included documentation the home health aide applied both Calmoseptine and a combination of one-half Calmoseptine and one-half Silvadene cream to the patient's buttocks. The visit notes lacked documentation the home health aide applied Silver Alginate and Mepilex to the right inner buttock wound per physician orders. On 10/19/22 at 12:09 PM, during an interview, Staff D, Home Health Aide (HHA), explained she applied half Silvadene cream and half Calmoseptine to the buttocks wounds. She denied ever applying Mepilex or Silver Alginate to the right inner buttock wound. On 10/19/22 at 12:19 PM, during an interview, Staff E, HHA, reported she applied half Silvadene cream and half Calmoseptine to the buttocks wounds. She has never applied Silver Alginate or Mepilex to any of the wounds. She explained she follows the care plan and this was not on the care plan. On 10/19/22 at 1:15 PM, during an interview, Staff F, RN, explained the patient did not have Mepilex, so it was not put on the wound. She reported she did not instruct the home health aides to apply Silver Alginate and Mepilex to the right buttock wound. On 10/20/22 at 10:09 AM, during a phone interview with the Administrator and Clinical Manager, the Clinical Manager reported she was unsure if the home health aides had access to the multidisciplinary care plan in the electronic medical record or what they were able to see when they viewed the home health aide care plan. The home health aide failed to follow the agency's multidisciplinary care plan which included wound care orders to the right buttock for the home health aide to follow. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. According to agency policy, titled Home Care Aide and Homemaker Services, dated 5/23/22, ....home care aide services are are under the supervision of medical staff and provides health related services for person care or rehabilitative therapies, such as: observation of self-administration of oral medications, checking the pulse rate, temperature, and respiration rate, helping with simple prescribed exercises, keeping consumer's rooms neat, simple wound care and dressing changes, assisting with braces and artificial limbs, assisting the consumer in using medical equipment, other tasks as assigned and the agency follows medicare benefits to include aide supervision guidelines. Interview on 10/17/22 at 11:24 AM with the Clinical Manager revealed the admitting nurse creates the home health aide care plan with the patient and/or family. Patient #2 had a start of care date of 1/9/91. Clinical record review revealed: a. The Plan of Care, dated 7/25/22 to 9/22/22, included orders for skilled nursing services every 2 weeks and home health aide services 2 times per week from the agency to provide assistance with the assigned tasks, including apply barrier cream to any reddened areas on patient's skin. b. The aide visit note, dated 8/22/22, documented the task was not applicable this visit as caregivers requested the aide use the Nystatin powder as no barrier cream was available and the aide will leave a communication note for the nurse. Interview on 8/19/22 at 12:15 PM with Staff D, Home Care Aide (HCA) revealed the aide did not speak to the nurse and only left the nurse a communication note after the Nystatin powder was used per the caregivers request as the caregivers did not have any cream. The home health aide failed to provide services as written in the aide care plan. 2. Patient #5had a start of care date of 7/22/22. Clinical record review revealed: a. The Plan of Care, dated 7/22/22 to 9/19/22, included orders for skilled nursing services weekly and home health aide services 2 times per week from the agency to provide assistance with the assigned tasks, including asking the patient to perform therapy home exercise program during visit for accountability b. The aide visit notes, dated 8/22/22, 9/7/22 and 9/9/22, documented the task was not applicable this visit with no reason why the task was not applicable. Interview on 8/20/22 at 9:14 AM with Staff H, HCA revealed the aide was not sure what not applicable this visit for the task meant. The home health aide failed to provide services as written in the aide care plan.