Every finding on record at Sanford Health Network

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 1/15/26 through 1/22/26 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 1/15/26 through 1/22/26. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a census of 32 current patients.

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 staff interview, clinical record reviews and agency policy review, the agency failed to provide a complete comprehensive assessment for patients with wounds during start of care, recertifications, resumption of care and discharge assessments for 1 of 1 sampled patient with wounds (Patient #3). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency policy, titled Documentation of Wound Care, reviewed 9/23/25, wounds will be measured in centimeters (length by width by depth) at least weekly unless covered with a non-removable dressing during the nurse visit. During Interview on 1/22/25 at 10:30 AM, the Administrator concured the documentation failed to include measurement of the wounds depth. Patient #3 had a start of care date of 12/19/25. Clinical record review revealed: a. The Plan of Care (POC), dated 12/19/25 to 2/16/26, identified the patient had a diagnosis of infection of a surgical site. Orders included skilled nurse services 2 times a week. b. The skilled nurse comprehensive visit note at start of care, dated 12/19/25, Staff D, Resgistered Nurse (RN) identified the patient had an open wound on the left dorsal foot. The wound measured 3.1 centimeters (cm) (length) by 1.9 cm (width). The assessment failed to include documentation of measurements of wound depth. c. The skilled nurse assessment, dated 12/24/25, Staff D, RN documented the patient had an open wound of the left dorsal foot. The wound measured 3.1 cm by 1.9 cm. The assessment failed to include documentation of measurements of wound depth. d. The skilled nurse assessments, dated 12/29/25, 1/7, 1/12, and 1/20/26, Staff D, RN documented the patient had an open wound of the left dorsal foot. The wound measured 3.3 cm by 2.3 cm at each visit. The assessments failed to include documentation of measurements of wound depth. The agency nurses failed to provided complete skilled nurse services. The above findings were reviewed with the Administrator and Clinical Manager.

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 1 of 3 sampled patients with home observation visits (Patient #1). 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: According to the agency policy titled Medication Management, dated 11/12/25,a drug regimen review in post-acute care is generally considered to include medication reconcilliation, a review of all medications and a review of the drug regimen to identify and prevent potential medicataion issues. During an interview on 1/22/26 at 10:10 AM the Clinical Manager stated the Registered Nurse (RN) responsible to complete the Drug Regimen Review (DRR) at admission, recertification and discharge. Patient #1 had a start of care date of 8/12/2020. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/13/25 to 3/13/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney discease with heart failure and included physician orders for medications and skilled nursing services. b. The comprehensive assessment at recertification, dated 1/12/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 1/20/26 at 10:00 AM with Staff D, RN, the patient interview revealed the following medication discrepancies orders and patient stated medication schedule: 1) Anoro/Ellipta 62.5-25 microgram inhaler, 1 puff daily. The patient identified the medication not used in over 6 months. 2) Triamcinolone 0.1% cream. Apply 3 times a week to arms and legs. The patient stated the medication not utilized in over 1 year. The DRR failed to include an accurate review of all current medications taken by the patient. The above findings were reviewed with the Administrator and Clinical Manager.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #6). The agency performed 5 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled OASIS (Outcome and Assessment Information Set), dated 7/30/25, at the resumption of care (ROC), the comprehensive assessment must be completed within 48 hours of returning home after discharge from an inpatinet facility or a physician ordered resumption of care. Patient #6 had a start of care date of 8/29/25. Clinical record review revealed the following: a. The OASIS transfer document, dated 9/19/25, Staff C, Registered Nurse (RN) documented the patient transfered to the hospital. b. The Communication note, dated 9/27/25, Staff E, RN documented the patient discharge to home on 9/26/25 and a visit made to the home. The documentation lacked an assessment of the patient. c. The updateded comprehensive assessment at resumption of care, dated 10/1/25, completed by Staff C, RN, 5 days following discharge from the hospital and 3 days late. The agency failed to complete the update to the comprehensive assessment completed at resumption of care within 48 hours of the patient’s discharge from the hospital. The above findings were reviewed with the Administrator and Clinical Manager.

The Department of Inspections and Appeals conducted a recertification survey, dated 1/5/23 to 1/12/23, and found the agency to be operating in substantial compliance with regulations found under the Emergency Preparedness Condition of Participation.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 1/5/23 to 1/12/23. The survey identified the following standard level deficient practices. The agency reported a census of 46 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 policy review, clinical record review and agency staff interview, 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 7 sampled patients (Patients #3 and #7). 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 Skilled Nursing Service Policy and dated 6/2014, the skilled nurse will regularly reevaluate the Plan of Care and the patient's needs; coordinate all services; and notify the physician if changes may be needed to the Plan of Care. During agency staff interview on 1/9/22 during entrance conference, the Administrator/Clinical Manager reported if the frequency of visits if varied from the Plan of Care, the physician would be notified. 1. Patient #3 had a start of care date of 12/31/22. Clinical record review and associated patient and agency staff interviews revealed the following: a. The Plan of Care, dated 12/31/22 to 1/6/23, included physician orders for home health aide services beginning 1/1/23 1 to 2 times per week for assistance with shower, activities of daily living, and light tidying. b. The clinical record lacked documentation of any home health aide visits for the week of 1/1/23. During a home visit observation on 1/10/23 at 3:00 PM with Staff E, Occupational Therapist, the patient confirmed to the surveyor no home health aide visits have occurred. The therapist did state the agency may have been waiting for the therapist to contact them to notify the patient was ready to start the aide services. The clinical record lacked documentation of initiation of aide services or notification to the physician that the services were not initiated. 2. Patient #7 had a start of care date of 6/30/22 and date of discharge of 7/25/22. Clinical record review revealed the following: a. The Plan of Care, dated 6/30/22 to 8/28/22, included physician orders for home health aide services 1 to 3 visits every week for assistance with shower, activities of daily living, and light tidying. b. The clinical record lacked documentation of any home health aide visits for the week of 7/17 through 7/16/22. The clinical record lacked documentation of notification to the physician that the services were not completed the week of 7/17 through 7/16/22. The above findings were reviewed with the agency Administrator/Clinical Manager and Clinical Supervisor. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review, home visit observation and patient and staff interviews, the agency failed to ensure the accurate completion of all components compromising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 sampled patients with surveyor home visit observation (Patient #1, #2, and #3). 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 physicians orders. Findings include: 2. Patient #1 had a start of care date of 2/28/22. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 12/25/22 to 2/22/23, included the following Durable medical equipment (DME) required to meet the patient needs: bath chair, grab bars, hand held shower and walker. During a home visit observation on 1/9/23 at 11:00 AM, with Staff C, Registered Nurse (RN), the patient revealed the walker no longer required and had not been required for at least 4 months. Agency staff failed to remove the equipment no longer used or required form the patient's plan of care. 3. Patient #2 had a start of care date of 12/15/21. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 8/12/22 to 10/10/22, 10/11/22 to 12/9/22 and 12/10/22 to 2/7/22, included the following DME required to meet the patient needs: walker, electric wheelchair, wound supplies, incontinence supplies, diabetic supplies, bedrais, hospital bed, raised toilet seat, reacher, braces, grab bars and hand held shower. During a home visit observation on 1/9/23 at 1:00 PM, with Staff D, RN, the identified the patient required the use of a shower chair. During the same home visit the patient revealed the shower chair had been in use since the beginning of home health services. The Plan of Care lacked identification of the shower chair as equipment needed to meet the patient's needs. The above findings were reviewed with the agency Administrator/Clinical Manager and Clinical Supervisor. The agency provided no additional information prior to the end of the survey. According to agency policy, titled Care Planning and Care Coordination, dated 3/30/22, ...the plan of care should be patient specific and include the following:patient diagnoses and individual needs, services and disciplines involved, along with frequency and duration of each, measurable outcomes and goals, including interventions, medications, treatments, equipment, supplies and limitations (functional, notrional, and Safety needs), and advance directives information... 1. Patient #3 had a start of care date of 12/31/22. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 12/31/22 to 1/6/23, included orders for Novolog 8 units daily with meals plus sliding scale insulin. b. The Medication list included orders for Novolog 8 units daily with meals plus sliding scale insulin. During a home visit observation on 1/10.23 at 3:00 PM, with Staff E, Occupational Therapist (OT), the patient revealed only takes sliding scale insulin and does not take 8 units of Novolog plus the sliding scale insulin dosages ordered. The Plan of Care included Novolog 8 units which was not in use by the patient. c. The Plan of Care, dated 12/31/22 to 1/6/23 identified the following equipment and supplies were needed to meet the patient's needs: walker, wheelchair, braces, bath bench/chair, mediset, continuous positive airway pressure device, and diabetic supplies. During the same home visit observation on 1/10.23 at 3:00 PM, with Staff E, OT, the surveyor observed a stool riser on the toilet in the patient's bathroom. The patient revealed use of the stool riser since returning home from the hospital in December. The Plan of Care lacked identification of the stool riser as equipment needed to meet the patient's needs.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 2 of 7 sampled patients with new verbal/interim orders. (Patient #4 and #7). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 1. Patient #7 had a start of care date of 6/30/22 and discharge date of 7/25/22. Clinical record review revealed: The Plan of Care, dated 6/30/22 to 8/28/22, included physician orders for torsemide (diuretic) 10 milligram (mg) tablet. Take 10 mg by mouth 1 time per day. The update to the plan of care included a hand written note to discontinue the order of torsemide 10 mg daily on 6/30/2022. No further orders included. Review of the Physician's order, dated 7/11/22, included identification the patients current order had been torsemide 20 mg tablet. Take 20 mg by mouth 2 times a day. The order changed to torsemide 20 mg tablet. Take 30 mg in the morning as the patient's weight was up. During an interview on 1/11/23 at 9:55 AM, the Office Manager stated she hand writes new orders on the paper plan of care. She concurred the order for torsemide not included on the updated plan of care. The agency lacked an updated Plan of Care with the changes in orders to include torsemide 20 mg twice a day or the 7/11/23 order to increase the morning dose to 30 mg every morning. The above findings were reviewed with the agency Administrator/Clinical Manager and Clinical Supervisor. The agency provided no additional information prior to the end of the survey. According to agency policy, titled Care Planning and Coordination of care, dated 3/30/22, ...The Plan of Care must be reviewed and revised by the provider and team as frequently as the patient's condition requires, but no less frequently than once every 60 days beginning with the start of care date. On 1/5/23 at 2:00 PM, interview with the Administrator/Clinical Manager revealed an updated Plan Of Care is completed and staff document on the Plan Of Care changes that have been ordered and the document is located in with the charting in the Electronic Health Record. 1. Patient #4 had a start of care date of 10/7/22. Clinical record review revealed: a. The Plans of Care, dated 10/7/22 to 12/5/22 and 12/6/22 to 2/3/23 included physician orders for the nurse to notify the physician for several blood sugars above 250 milligrams (mg) per deciliter (dl) or below 70 in the same day or at the same time of day, unexplained low blood sugars or symptomatic reaction. b. The skilled nursing visit notes, dated 11/16, 11/28, 11/30, 12/5, 12/14, 12/16, 12/19, 12/23, 12/28, 12/30, 1/4, and 1/6/22 lacked documentation of assessment of the patient's blood sugars. Interview on 1/11/23 on 10:13 AM with Staff F, Registered Nurse, RN revealed on December 21st the Veteran's Administration (VA) took over monitoring the patient’s medications and blood sugars and the nurse does an assessment of blood sugar weekly and the other times performs wound care only. The nurse revealed not updating the Plan of Care as the nurse should have, but the VA was aware and the nurse was following the VA’s orders. Interview on 1/10/23 at 10:26 AM with the Administrator/Clinical Manager revealed the Administrator/Clincal Manager remember getting notified the VA would take over the patient’s medications. The clinical record lacked documentation of communication or orders from the VA regarding the agency no longer needed to assess the patient’s blood sugars. The agency lacked an updated Plan of Care with the changes in orders reported by agency staff.