Every finding on record at Skyline Center Inc Home Health

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 1/8/26 through 1/14/26 and the home health agency was found to be operating out of compliance with the following standard requirements of the Establishment of Emergency Preparedness.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on review of agency's emergency preparedness plan/policies, the home health agency failed to include the verbiage an individualized emergency plan must be included as part of the comprehensive patient assessment. Failure to ensure the agency completed an individualized emergency plan developed as part of the comprehensive assessment and failure to ensure the patient has knowledge of the identified Plan placed patients at risk for staff being unaware and unprepared to respond in a timely and effective manner to potential health and safety hazards the patient may encounter. Findings include: During an interview on 1/13/26 at 9:12 AM, Staff A, Administrator, reported she had reviewed the emergency preparedness policy and was unable to find the verbiage regarding the emergency plan being part of the comprehensive assessment. The agency failed to include required verbiage in the agency emergency preparedness policy. The findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals and Licensing from 1/8/26 through 1/14/26 and the home health agency was found to be operating out of compliance with the following standard level regulatory requirements. The agency reported a census of 88 patients at the time of the survey.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on staff interview, agency policy review and clinical record review, the agency failed to ensure the comprehensive assessment was completed in a timely manner consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care for 2 of 4 sampled patients (Patients #2 and #6) with start of care assessments after the last survey date of 12/1/22. Failure to complete the 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 agency policy, titled Comprehensive Assessment and OASIS Data Collection Start of Care, dated 07/2025, identified the initial (start of care) comprehensive assessment will be completed within 5 days after start of care. During an interview on 1/8/26 at 10:45 AM, Staff A, Administrator, reported initial assessments are scheduled in advance, if patient requests a later time frame, skilled nurse will notify the physician and document in the clinical record the reason why the assessment is outside the 5 day window. 1. Patient #6 had a start of care date of 7/29/24 and a discharge date of 1/10/25. Clinical record review revealed: a. Plan of Care, dated 7/29/24 to 9/26/24, included primary diagnosis of mild intellectual disabilities and interim physician orders for skilled nursing services. b. Start of care comprehensive assessment, dated 7/29/24, included documentation of an electronic signature on 8/7/24, 9 days after start of care, 4 days late. 3. Patient #2 had a start of care date of 1/6/25. Clinical record review revealed: a. Plan of Care, dated 1/6/25 to 3/6/25, included primary diagnosis of Schizoaffective disorder, unspecified, and interim physician orders for skilled nursing services. b. Start of care comprehensive assessment, dated 1/6/25, included documentation of an electronic signature on 1/12/25, 6 days after start of care, 1 day late. Skilled nurse failed to complete start of care comprehensive assessments within 5 days as required by regulation and per agency policy. The above findings were reviewed with Staff A, Administrator and Staff B, 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 agency staff interviews, clinical record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 1 of 7 sampled patients (Patient #7). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings include: According to the agency policy, titled Medication Administration/Drug Regimen Review, dated 12/2024, a drug regimen review will be completed with every comprehensive assessment and for OASIS patients with every Start of Care, Resumption of Care, Recertification, other follow up, and discharge assessments. All medications will be monitored by nursing personnel to determine: significant side effects, interactions, ineffective medications, duplicate medications and compliance. During an interview on 1/8/26 at 11:15 AM, Staff B, Clinical Manager, reported drug regimen review is completed at start of care, resumption of care, recertification and discharge assessments. Patient #7 had a start of care date of 6/9/25. Clinical record review revealed: a. Plan of Care, dated 8/8/25 to 10/6/25, included primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for skilled nurse services. b. Recertification comprehensive assessment, dated 8/6/25, included documentation of medication side effects and compliance but lacked documentation of interactions, ineffective medications and duplicate medications. The registered nurse failed to complete a drug regimen review at the time of the recertification comprehensive assessment as regulated. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.

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 1 of 7 sampled patients. (Patient #1) 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 Supervision of Service, dated 12/2024, assure that all services provided are in accordance with established plan of care. During an interview on 1/8/26 at 10:37 AM, Administrator reported communication with physicians is documented in an electronic physician notification, printed out and faxed to the physician. Patient #1 had a start of care date of 8/3/21. Clinical record review revealed: a. Plan of Care, dated 11/9/25 to 1/7/26, included primary diagnosis of mild intellectual disability and physician orders for skilled nursing services one time per week and home health aide services seven times per week. b. There was no home health aide visit note, dated 12/7/25, 12/13/25 or 12/14/25, or documentation notifying the physician why no visit was completed on 12/7/25. 12/13/25 or 12/14/25. c. There was no home health aide note, dated 1/3/26, or documentation notifying the physician why no visit was completed on 1/3/26. The agency failed to provide home health aide services as ordered in the plan of care or notify the physician why the services were not provided as ordered. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.

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 failed to obtain physician orders for physical therapy services and treatment using heat and or ice for 1 of 7 sampled patients (Patient #7). Failure to ensure staff obtain physician orders for all services and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Patient #7 had a start of care date of 6/9/25. Clinical record review revealed: a. Plans of Care, dated 6/9/25 to 8/7/25, 8/8/25 to 10/6/25, and 10/7/25 to 12/5/25, included primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for physical therapy services twice a week for 6 weeks, to start week of 7/7/25 (and ending 8/16/25). b. Physical therapy visit notes, dated 8/19/25, 8/21/25, 9/2/25, 9/9/25, 9/11/25, 9/17/25, 9/23/25, 9/25/25, 9/29/25, 10/6/25, 10/10/25, 10/13/25 and 10/17/25, identified services provided and documentation completed. The agency failed to obtain interim physician order for physical therapy services to cover the time frame after 8/16/25. c. Plan of Care, dated 8/8/25 to 10/6/25, included primary diagnosis of COPD and physician orders for skilled nurse services to assist with medication: setup, compliance, education and/or changes; monitor and educate on: changes in health status, pain, fall precautions and safety issues; general assessment with vitals. d. Skilled nurse visit note, dated 8/27/25, included documentation the patient reported right knee pain. Skilled nurse educated patient on use of heat/ice to help alleviate pain. Skilled nurse failed to obtain an interim physician order for the use of heat/ice for pain management. During an interview on 1/14/26 at 8:45 AM, Staff A, Administrator, reported skilled nurse probably forgot to change the order for physical therapy and Staff A was not aware of the need for a physician order for heat/ice. The surveyor reviewed the above findings with Staff A, Administrator and Staff B, Clinical Manager.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review and agency staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services (Patient #3 and #1). The agency reported 18 patients received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: According to the policy, titled Home Health Aide Services, dated 12/2024, home health aide will provide only the care/services listed on the assignment sheet and not alter, add to, or change the plan of care in any way without authorization from the supervisor. 1. Patient #3 had a start of care date of 1/26/04. Clinical record review revealed the following: a. Plan of Care, dated 12/3/25 to 1/31/26, included primary diagnosis of Apert Syndrome and physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 12/1/25, identified the task trim fingernails weekly on Wednesdays for the aide to complete. c. Aide visit notes, dated Wednesday 12/10/25, 12/17/25, 12/24/25, 12/31/25 and 1/7/26, included documentation the task trim fingernails weekly on Wednesdays was marked not needed per client. d. Aide visit notes, dated Saturday 12/13/25, Tuesday 12/30/25 and Friday 1/2/26, included documentation the task trim fingernails weekly on Wednesdays was marked as done. e. Aide visit note, dated 12/19/25, included handwritten documentation toe nails and was marked as done. The task toe nails was not assigned on the care plan. During an interview on 1/12/26 at 3:10 PM, Staff B, Clinical Manager reported agency may have to remove specific days from the aide care plan. The aide failed to complete tasks as assigned by the registered nurse. 2. Patient #1 had a start of care date of 8/3/21. Clinical record review revealed the following: a. Plan of Care, dated 11/9/25 to 1/7/26, included primary diagnosis of mild intellectual disability and physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 11/3/25, identified the task assist client with washing as needed for the aide to complete. c. Aide visit note, dated 1/6/26, included documentation the task assist client with washing as needed was not marked as completed or a reason why the task was not completed. The aide failed to complete tasks as assigned by the registered nurse. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 5 sampled patients who received hands on personal care services in conjunction with skilled service provision (Patient #7). The agency reported 18 patients who received personal care assistance by a home health aide while also receiving skilled service provision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency policy titled, Supervision of Services, dated 12/2024, agency professional/administrative staff will provide supervision for all Home Health Aide cases. Supervision includes initial evaluation and periodic supervision of performance. Patient #7 had a start of care date of 6/9/25. Clinical record review revealed: a. Plan of Care, dated 8/8/25 to 10/6/25, included primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit note, dated 9/16/25, included home health aide supervision. c. Skilled nursing visit note, dated 10/2/25, included home health aide supervision, 16 days after the last home health aide supervision, 2 days late per regulation. The registered nurse failed to complete home health aide supervision every 14 days as regulated. The above findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure the clinical record included weekly wound measurements for 1 of 2 sampled patients (Patient #6) with wounds. Failure of the agency to ensure the clinical record included accurate wound measurements placed agency patients at risk to receive inappropriate care. Findings include: According to the agency policy, titled Wound Assessment, dated 07/2025, skilled nurse will obtain wound measurements and document in patient chart at a minimum of weekly. Size including depth, length and width. During an interview on 1/8/26 at 11:15 AM, Staff B, Clinical Manager, reported wound measurements are obtained weekly, usually the first visit of the week, and includes length, width and depth. Patient #6 had a start of care date of 7/29/24 and a discharge date of 1/10/25. Clinical record review revealed: a. Plan of Care, dated 9/27/24 to 11/25/24, included primary diagnosis of mild intellectual disabilities and interim physician orders for skilled nursing services for wound care, measure wounds every Monday. b. Plan of Care, dated 11/26/24 to 1/24/25, included primary diagnosis of congestive heart failure and interim physician orders for skilled nursing services for wound care, measure wounds every Monday. c. Skilled nurse visit note, dated Monday 11/18/24, included wound measurements for 5 wounds, left lateral leg, right medial leg, left anterior leg, left knee and left medial leg. d. Skilled nurse visit note, dated Wednesday 11/27/24, included wound measurements for 1 wound, left lower leg. Documentation failed to identify the other 4 wounds. e. Skilled nurse visit note, dated Monday 12/2/24, included wound measurements for 3 wounds, left lateral leg, left medial leg and left lower anterior leg; and documentation 3 wounds were healed, right medial leg, left anterior leg and left knee. The skilled nurse failed to measure all documented wounds on Monday per physician orders or document a reason why wound measurements were not completed. The above findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.

A recertification survey was conducted by the Department of Inspections and Appeals from 11/28/2022 through 12/1/2022. The recertification survey found the agency operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

A recertification survey was conducted by the Department of Inspections and Appeals from 11/28/2022 through 12/1/2022. The recertification survey found the agency operating out of compliance with the following standard level regulatory deficiencies: The agency reported a census of 62 patients at the time of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to identify medication discrepancies when completing a drug regimen review with each comprehensive assessment within the allowed time frames for 5 of 7 sampled patients. (Patients #1, #4, #5, #6 and #7). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. According to the agency policy, titled Medication Administration/Drug Regimen Review and dated 9/19/22, a drug regimen review will be completed with every comprehensive assessment and for OASIS (Outcome and Assessment Information Set) patients with every start of care, resumption of care, recertification, transfer or discharge. All medications will be monitored by nursing personnel to determine: significant side effects or interactions, duplicate medications, ineffective medications, and compliance. On 11/28/22 at 9:50 AM, Staff B, Clinical Manager, reported RNs (registered nurses) complete a drug regimen review (DRR) at the time of start of care, resumption of care, recertification, and discharge. The drug regimen review is documented on the plan of care addendum form in the EMR (electronic medical record), printed out, sent to the physician with the plan of care, and kept in the paper chart or the visit note in the EMR. 1. Patient #1 had a start of care date of 12/31/19. Clinical record review revealed: a. Plans of care, dated 8/17/22 to 10/15/22 and 10/16/22 to 12/14/22, included orders for acetaminophen 500 milligram (mg) caplet every 6 hours as needed for pain or fever and ibuprofen 600 mg tablet 3 times daily for pain at morning, noon and bedtime. b. The plan of care addendum Patient Summary form, dated 10/10/22, included DRR components: duplicate medications and drug interactions but failed to include components: ineffective drug therapy, side effects or noncompliance. Duplicate medications were documented as: no duplicates noted. The documentation failed to identify the duplicate pain medications of acetaminophen and ibuprofen. c. Follow up comprehensive assessment completed at recertification, dated 10/11/22, lacked documentation of a DRR. 2. Patient #4 had a start of care date of 10/6/22. Plan of care, dated 10/6/22 to 12/4/22, included orders for medications. Clinical record review revealed: a. Comprehensive assessment completed at start of care, dated 10/6/22, lacked documentation of a DRR. b. The plan of care addendum Patient Summary form, dated 10/13/22, included DRR components: duplicate medications and drug interactions but failed to include components: ineffective drug therapy, side effects or noncompliance. 3. Patient #5 had a start of care date of 12/17/19. Clinical record review revealed: a. Plans of care, dated 6/4/22 to 8/2/22, 8/3/22 to 10/1/22, and 10/2/22 to 11/30/22, included orders for medications. b. The plan of care addendum Patient Summary forms, dated 8/3/22 and 9/26/22, included DRR components: duplicate medications and drug interactions but failed to include components: ineffective drug therapy, side effects or noncompliance. c. Follow up comprehensive assessments completed at recertification, dated 8/3/22 and 9/26/22, lacked documentation of a DRR. 4. Patient #6 had a start of care date of 9/7/22 and a discharge date of 10/25/22. Clinical record review revealed: a. Plan of care, dated 9/7/22 to 11/5/22, included orders for medications. b. The transfer/discharge comprehensive assessment, dated 10/25/22, lacked documentation a DRR was completed. c. The discharge summary, dated 11/2/22, lacked documentation a DRR was completed. 5. Patient #7 had a start of care date of 4/22/22 and a discharge date of 6/17/22. Clinical record review revealed: a. Plan of care, dated 4/22/22 to 6/20/22, included orders for medications. b. The comprehensive assessment completed at the time of discharge, dated 6/17/22, lacked documentation a DRR was completed. c. The discharge summary, dated 6/17/22, lacked documentation a DRR was completed. During an interview on 11/30/22 at 10:15 AM, Staff B, Clinical Manager reported DRR was not completed for Patients #6 and #7. Staff A, Administrator and Staff B, Clinical Manager, received the above findings and the agency provided no further information prior to the end of the survey.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 3 of 4 sampled patients requiring a recertification assessment (Patients #1, #2 and #5). Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. According to the agency policy, titled Comprehensive Assessment and OASIS (Outcome and Assessment Information Set) Data Collection Start of Care, dated 9/19/22, all adults, eighteen years of age and older, non-maternity patients receiving skilled care from a Medicare certified agency are to receive the comprehensive assessment and OASIS at specified time points. According to the agency policy, titled Follow Up Comprehensive Assessment and OASIS Data Collection, dated 9/19/22, the agency staff will complete the follow-up comprehensive assessment for recertification within 5 calendar days of each 2 month intervals after the start of care utilizing day 56 through day 60 or the last 5 days of the recertification period. 1. Patient #1 had a start of care date of 12/31/19. Clinical record review revealed: a. Plans of care, dated 6/18/22 to 8/16/22 and 8/17/22 to 10/15/22. b. Follow up comprehensive assessment completed at recertification, dated as initiated on 8/15/22 (day 59 of the certification period) was electronically signed as completed on 8/17/22, the first day of the new certification period, 1 day late. The assessment was not completed by day 60 as required by regulation. On 11/30/22 at 2:05 PM, Staff B, Clinical Manager agreed the recertification assessment was completed late. 2. Patient #2 had a start of care date of 3/3/15. Clinical record review revealed: a. Plans of care, dated 5/26/22 to 7/24/22, 7/25/22 to 9/22/22, 9/23/22 to 11/21/22 and 11/22/22 to 1/20/23, included interim physician orders for skilled nursing, physical therapy and home health aide services. b. Comprehensive assessments at recertification, dated 7/21/22, 9/19/22 and 11/21/22, lacked documentation of OASIS (Outcome and Assessment Information Set) data, required for patients receiving skilled services, skilled nursing and physical therapy services. The agency failed to complete follow up comprehensive assessments at recertification within the 5 day recertification window (days 56 to 60 of the certification period). 3. Patient #5 had a start of care date of 12/17/19. Clinical record review revealed: a. Plans of care, dated 6/4/22 to 8/2/22 and 8/3/22 to 10/1/22. b. Follow up comprehensive assessment completed at recertification, dated as initiated on 8/2/22 (day 60 of the certification period) was electronically signed as completed on 8/3/22, the first day of the new certification period, 1 day late. The assessment was not completed by day 60 as required by regulation. On 11/30/22 at approximately 2:05 PM, Staff B agreed the recertification assessment was completed late. Staff A, Administrator and Staff B, Clinical Manager, received the above findings and the agency provided no further 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 clinical record review and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including information related to advance directives and frequency of services to be provided for 3 of 7 sampled patients (Patients #1, #4 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 1. Patient #1 had a start of care date of 12/31/19. Clinical record review revealed Plans of Care, dated 6/18/22 to 8/16/22, 8/17/22 to 10/15/22 and 10/16/22 to 12/14/22, lacked documentation of information related to any advance directives. During an interview on 11/29/22 at 9:20 AM, Staff B, Clinical Manager reported the patient has a guardian the advance directives section on the plan of care is not completed. During an interview on 11/29/22 at 1:45 PM, Staff A, Administrator reviewed another plan of care that had advance directives section completed and marked as not applicable, patient has a guardian. Staff A agreed the advance directives section should be completed when patient's have a guardian. 2. Patient #7 had a start of care date of 4/22/22 and a discharge date of 6/17/22. Clinical record review revealed: a. Plan of Care, dated 4/22/22 to 6/20/22, lacked documentation of information related to any advance directives. During an interview on 11/30/22 at 10:15 AM, Staff B, Clinical Manager reported it is easy to miss this section on the plan of care. 3. Patient #4 had a start of care date of 10/6/22. Clinical record review revealed: a. Plan of Care, dated 10/6/22 to 12/4/22, included interim physician orders for skilled nursing visit 1 time every 60 days for comprehensive assessment and supervision of home health aide, skilled nursing visit 1 time every 14 days for supervision of home health aide services and home health aide visits 2 times a week for 9 weeks. b. Home health aide visit notes, dated 10/6/22, 10/11/22 and 10/13/22. c. The home health aide services were not provided 2 times a week for the first week of services, 10/6/22 to 10/8/22. The clinical record lacked documentation of skilled nursing visits every 14 days for home health aide supervision. The agency failed to provide services as ordered in the Plan of Care. Staff A, Administrator and Staff B, Clinical Manager, received the above findings and the agency provided no further information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 1 of 2 sampled patients with therapy only interim orders. (Patients #6). Failure to update the Plan of Care increased the potential for inaccurate provision of care. During an interview on 11/28/22 at 9:50 AM, Staff B, Clinical Manager reported the electronic medical record creates an updated plan of care after the orders are entered. This plan of care is printed out and kept in the paper chart, the word updated is printed on the top of the plan of care to identify it. The new orders added are marked with a dash to identify the added item easily. Patient #6 had a start of care date of 9/7/22 and a discharge date of 10/25/22. Record review revealed: a. Plan of Care, dated 9/7/22 to 11/5/22, included orders for physical and occupational therapy services to be determined by therapy. b. Physical therapy evaluation, dated 9/7/22, identified a frequency of 1 time a week for 1 week, 2 times a week for 4 weeks, and as needed thereafter. c. Occupational therapy evaluation, dated 9/8/22, identified a frequency of 2 times a week for 6 weeks. The agency failed to update the plan of care with the physical and occupational therapy orders. Staff A, Administrator and Staff B, Clinical Manager, received the above findings and the agency provided no further information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. 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 authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature and electronic signatures were completed according to agency policy for 3 of 7 sampled patients (Patients #2, #3 and #6). Failure to maintain timely, accurate and appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. According to agency policy, titled Electronic Signature, dated 9/19/22, all electronic signatures will be completed within 48 hours, locked and signed. During an interview on 11/28/22 at 9:50 AM, Staff B, Clinical Manager reported all documentation is to be completed within 48 hours. During an interview on 11/29/22 at 2:38 PM, Staff A, Administrator reported the agency had stopped dating the home health aide care plans. The aide care plans are created in windows computer program and would have a date when the updated is saved. On review of the patient record, Staff A reported the most current aide care plan had not been placed in the paper chart. Staff A printed an updated aide care plan and placed in the paper record. 1. Patient #2 had a start of care date of 3/3/15. Clinical record review revealed: a. Plans of care, dated 9/23/22 to 11/21/22 and 11/22/22 to 1/20/23, included interim physician orders for skilled nursing, physical therapy and home health aide services. b. The home health aide care plan, dated as revised 4/2019, included the task file/trim fingernails and a handwritten signature from the nurse. The aide care plan lacked a date and time when the care plan was signed. c. The home health aide visit notes, dated 9/28/22 through 11/25/22, included the task trim fingernails weekly on Wednesdays. The clinical record failed to include an updated home health aide care plan with the addition of the new task trim fingernails weekly on Wednesday. On 11/30/22 at 2:20 PM, Staff A provided the surveyor with the updated care plan that included the task trim fingernails weekly on Wednesdays and a revised date of 12/2019. The skilled nurse failed to authenticate her handwritten signature with date and time on the home health aide care plans. 2. Patient #3 had a start of care date of 1/14/2004. Clinical record review revealed: a. Plans of care, dated 8/8/22 to 10/6/22 and 10/7/22 to 12/5/22, included interim physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated as revised 12/2019, included the task trim fingernails and a handwritten signature from the nurse. The aide care plan lacked a date and time when the care plan was signed. c. The home health aide visit notes, dated 10/5/22 through 11/24/22, included the task trim fingernails weekly on Wednesdays. The clinical record failed to include an updated home health aide care plan with the addition of the new task trim fingernails weekly on Wednesdays. On 11/30/22 at 2:20 PM, Staff A provided the surveyor with the updated and undated care plan that included the task trim fingernails weekly on Wednesdays. The skilled nurse failed to authenticate her handwritten signature with date and time on the home health aide care plans. d. Skilled nursing visit note, dated 9/27/22, included documentation the note was electronically signed 10/5/22, 6 days late per agency policy. 3. Patient #6 had a start of care date of 9/7/22 and a discharge date of 10/25/22. Clinical record review revealed: a. The transfer/discharge comprehensive assessment, dated 10/25/22, lacked an electronic signature to complete the assessment. During an interview on 11/30/22 at 10:15 AM, Staff B, Clinical Manager reported she was unsure why the discharge assessment had not been completed/locked, she will check electronic medical record. On 11/30/22 at 2:00 PM, Staff B confirmed discharge assessment had not been completed/locked. Staff B reported locking assessment today. On 11/30/22 at 2:30 PM, Staff A provided the surveyor with discharge assessment, generated date 11/30/22 at 11:01 AM, 34 days late per agency policy. Staff A and Staff B, Clinical Manager received the above findings and no further information was provided prior to the end of the survey.