Every finding on record at Tama County Public Health & Home Care

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 11/18/24 through 11/20/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 11/18/24 through 11/20/24 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 47 patients at the time 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, and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including the types of services and the frequency and duration of visits to be made in 2 of 7 sampled patients ( Patient #1 and #6). 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. 2. Patient #6 had a start of care date of 5/6/24 and was discharged on 7/26/24. Review of the clinical record revealed: a. The POC, dated 5/6/24 to 7/8/24, included physician orders/interventions for skilled nursing services 1 time a week and home health aide services 1 to 2 times a week. b. The communication note, dated 5/20/24, revealed the skilled nurse clarified with the patient, the home health agency per the patient request with discontinue home health aide services. Personal care provider to be contacted for order. c. The clinical record lacked a physician's order to discontinue home health aide services. d. The POC, dated 7/9/24 to 9/6/24, included orders for home health aide interventions including: ambulate patient using assistive device walker, oxygen, leave dressings to bilateral heels intact, assist to toilet per patient request, clean bathroom after patient care, wipe wet surfaces with towel, take linens to laundry, assist patient with dressing, denture care, foot care-patient is diabetic, may trim or file any long or uneven finger nails, shampoo at sink, per patient request, shave per patient request, skin care, apply lotion to trunk, back, arms, legs every visit, sponge bath and fall precautions. The POC lacked frequency orders for a home health aide. e. The clinical record lacked documentation of home health aide interventions provided per order or a clarification order to discontinue home health aide interventions. The agency failed to ensure the POC accurately included the type, frequency and duration of the services the patient was receiving. The above findings shared with the Director, Assistant Director and Clinical Manager. According to the agency policy, titled Plan of Care Policy, dated 4/2022, the individualized plan of care must specify the care and services necessary to meet the patient specific needs, including identification of the responsible disciplines and the measurable outcomes. The individualized plan of care must include the frequency and duration of visits to be made and patient specific interventions and measurable outcomes and goals. All patient orders including verbal orders must be recorded in the plan of care. 1.Patient #1 had a start of care date of 5/1/2019. Review of the clinical record revealed: a. The Plan of Care (POC), dated 8/2/24 to 9/30/24, included physician orders/interventions for skilled nursing services 1 time a week and home health aide services 2 to 3 times a week. b. Verbal order, dated 9/30/24, Staff D, RN notified the physician the patient no longer wanted home health aide services. c. The POC, dated 10/1/24 to 11/29/24, included orders for home health aide interventions including: apply lotion to back, arms and legs, assist patient with dressing, assist patient with a sponge bath or shower, foot care, trim or file any long or uneven finger and toe nails, perineal care, shampoo, shave and fall precautions, but lacked an order for home health aide frequency or duration. d. The clinical record lacked documentation of home health aide interventions provided, or a clarification order to discontinue home health aide interventions. e. Interview on 11/20/24 at 9:00 AM, Clinical Manager reported a verbal physicians order was taken by Staff D, Registered Nurse (RN), to discontinue the home health aide service effective 9/30/24, but acknowledged the interventions the home health aide was ordered to perform remained on the updated POC. The agency failed to ensure the POC accurately included the type, frequency and duration of the services the patient was receiving.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observations, clinical record reviews, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 3 of 4 sampled patients (Patients #2, #4 and #7) with wounds. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: 3. Patient #7 had a start of care date of 6/12/24 and a discharge date of 7/31/24. Clinical record review revealed the following: a. The POC dated 6/12/2024 to 8/10/2024, included physician orders for skilled nursing services 1-2 times weekly for observation, assessment and education for wound management related pressure ulcers and to perform wound care/dressing change. b. The initial comprehensive assessment, dated 6/12/24, by Staff D, RN, identified a skin tear wound on the penis and included a description of the wound, but lacked measurements of the wound. c. The skilled nurse visit note, dated 6/21/24, by Staff F, RN, identified the wound on the penis as dime sized and included a description of the wound, but lacked measurements. d. The skilled nurse visit notes, dated 6/27/24, 7/3/24, 7/10/24 and 7/17/24, by Staff D, RN, included description of the wound on the penis, but lacked measurements. The skilled nurse failed to document wound measurements for the wound to the penis. The above findings shared with the Director, Assistant Director and Clinical Manager According to the agency policy titled Wound Monitoring Guidelines, dated 1/2023, agency staff are directed to document procedure, including the following, in the patient's record: condition of wound or pressure ulcer, length, width, depth, drainage, if any, odor, if any, patient's tolerance of procedure, condition of surrounding tissue, any tissue granulation noted, instructions provided and photo as available to support documentation with patient name and date of picture. During an interview on 11/19/24 at 3:40 PM, the Clinical Manager stated wound measurements to include length, width and depth every 7 days, unless seen by a physician or the wound clinic. 1.Patient #2 had a start of care date of 8/5/24. Clinical record review revealed the following: a. The Plans of Care (POC), dated 8/17/24 to 10/15/24 and 10/16/24 to 12/14/24, included physician orders for skilled nursing services 1-2 times weekly for physical assessment, education or wound management. b. Skilled Nurse visit notes, dated 9/17/24, 10/1/24 and 11/12/24, Staff D, Registered Nurse (RN), included documentation of a diabetic ulcer on the right posterior foot with an onset date of 6/18/23. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient's right posterior foot. 2. Patient #4 had a start of care date of 9/13/24. Clinical record review revealed the following: a. The POC, dated 11/12/24 to 1/10/25, included physician orders for skilled nursing services 2 to 3 times a week to provide wound care/monitoring and management/education related to new onset type 2 diabetes. b. The POC, dated 11/12/24 to 1/10/25, lacked orders for skilled nurse frequency and included orders to provide dressing changes to the right anterior foot amputation surgical incision site. b. Skilled Nurse visit notes, dated 9/20/24, Staff E, RN, included documentation of a right anterior foot amputation surgical incision with an onset date of 9/13/24. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient's right posterior foot.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 1/24/2022 through 1/26/2022. At the time of the survey, the agency reported a current census of 51 patients. The survey found the agency operating in substantial compliance with the requirements of the Appendix Z Establishment of Emergency Preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 1/24/2022 through 1/26/2022. At the time of the survey, the agency reported a current census of 51 patients. The survey found the agency operating in substantial compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The survey found the agency operating out of compliance with the following standard level regulatory requirements:

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to, prior to initiation of a service, ensure staff advised the patient of the planned frequency of the service; extent to which payment for agency services may be expected; charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency; and the charges the individual may have to pay for the service for 2 of 3 sampled patients who had additional services added after admission (Patients #1 and #4). Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: The agency form, titled Patient Bill of Rights and Statement of Responsibility included a section for the agency to identify the planned services; the frequency of such services; and the funding source that will be billed for the identified services. The form included a service agreement statement allowing the agency to provide care for the identified services, documented the payer the agency planned to bill for the services and identified an estimated patient financial responsibility for such services. During agency staff interview on 1/24/2022 at 9:00 AM, the Administrator reported no paper charts were kept for agency patients. All documentation was either completed electronically directly into the electronic medical record system or completed on paper and then scanned into the electronic medical record system. Consent forms, drug regimen review forms and therapy visit notes were all documents completed on paper and then scanned into the electronic clinical record. 1. Patient #1 had a start of care date of 1/5/2022. Clinical record review and associated agency staff interviews revealed the following: a. The patient's electronic clinical record included a copy of the Patient Bill of Rights and Statement of Responsibility, dated as signed by the patient on 1/5/2022. The form identified a planned frequency of once weekly for skilled nurse visits; 1-2 times weekly for physical therapy visits; and 1-2 times weekly for occupational therapy visits. The form documented a plan to bill the patient's private insurance for the skilled nursing, physical therapy and occupational therapy services for Patient #1 with no expected out of pocket expense to the patient. b. The Plan of Care, dated 1/5/2022 to 3/5/2022, included physician orders for skilled nursing visits weekly; physical therapy visits 1-2 times weekly and occupational therapy 1-2 times weekly. c. The Plan of Care Update, dated 1/10/2022, added a physician's order for home health aide services once weekly to the patient's planned services. d. The clinical record included home health aide visit notes, dated 1/11/2022 and 1/18/2022, each documenting the provision of home health aide services. The electronic clinical record lacked documentation of an updated Patient Bill of Rights and Statement of Responsibility form prior to the initiation of home health aide services. The electronic clinical record lacked any other documentation indicating the agency notified Patient #1 of the planned frequency of home health aide visits; the funding source billed for the home health aide visits; or the patient's estimated financial responsibility for the home health aide services prior to initiation of the first home health aide visit. e. During agency staff interview on 1/24/2022 at 2:00 PM, the Clinical Manager reported she reviewed Patient #1's electronic clinical record and found only the original Patient Bill of Rights and Statement of Responsibilities. The Clinical Manager reported finding no written documentation given to Patient #1 at the time of initiation of the added service of home health aide. 2. Patient #4 had a start of care date of 12/14/2021. Clinical record review and associated agency staff interviews revealed the following: a. The patient's electronic clinical record included a copy of the Patient Bill of Rights and Statement of Responsibility, dated as signed by the patient on 12/14/2021. The form identified a planned frequency of once weekly for skilled nurse visits and 1-2 times weekly for home health aide visits. The form documented a plan to bill the Veteran's Administration, for the skilled nursing and home health aide services for Patient #4 with no expected out of pocket expense to the patient. b. The Plan of Care, dated 12/14/2021 to 2/11/2022, included physician orders for skilled nursing visits weekly; and home health aide 1-2 times weekly. c. The Plan of Care Update, dated 12/22/2021, added physician orders for physical therapy evaluation with continued services 1-2 times weekly beginning 12/28/2021 ending 1/8/2022; and added physician orders for occupational therapy evaluation with continued services 1-2 times weekly beginning 12/28/2021 ending 1/8/2022. d. The electronic clinical record included physical therapy visit notes, dated 12/28/2021, 12/31/2021, 1/3/2022 and 1/6/2022, each documenting the provision of physical therapy services. e. The electronic clinical record included occupational therapy visit notes, dated 12/27/2021, 12/29/2021, 1/4/2022 and 1/6/2022, each documenting the provision of occupational therapy services. The electronic clinical record lacked documentation of an updated Patient Bill of Rights and Statement of Responsibility form prior to the initiation of physical therapy and occupational therapy services. The electronic clinical record lacked any other documentation indicating the agency notified Patient #4 of the planned frequency of physical therapy and occupational therapy visits; the funding source billed for the physical and occupational therapy visits; or the patient's estimated financial responsibility for either service prior to initiation of the first physical and occupational therapy visits. f. During agency staff interview on 1/25/2022 at 3:45 PM, the Clinical Manager reported she reviewed Patient #4's electronic clinical record and found only the original Patient Bill of Rights and Statement of Responsibilities. The Clinical Manager reported finding no written documentation given to Patient #4 at the time of initiation of the added service of physical therapy and occupational therapy. The above stated findings were reviewed with the Clinical Manager and the Assistant Director/Chief Financial Officer. The agency provided no additional information prior to the end 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 agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part of the initial and/or update to the comprehensive assessment for 3 of 8 sampled patients (Patients #3, #7 and #8). 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 Drug Regimen Review and dated 7/2018, the registered nurse (RN) will complete the drug regimen review at the time of every comprehensive assessment completed at start of care, within the last 5 days of the current 60 day certification period, within 48 hours of resumption of care following hospitalization; at the time of significant change in condition and at discharge. The nurse must assess the patient's medication regimen to determine ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and patient non-compliance. The nurse will complete the agency's drug regimen review form and file the completed form in the patient's clinical record. During agency staff interview on 1/24/2022 at 9:00 AM, the Administrator reported no paper charts were kept for agency patients. All documentation was either completed electronically directly into the electronic medical record system or completed on paper and then scanned into the electronic medical record system. Consent forms, drug regimen review forms and therapy visit notes were all documents completed on paper and then scanned into the electronic clinical record. During agency staff interview on 1/24/2022 at 9:40 AM, the Clinical Manager reported the clinicians assess all medications at the time of admission/recertification/significant change in condition/resumption of care/discharge; enter the results of the medication review on a paper form titled Drug Regimen Review and scan the completed form into the patient's electronic medical record and send the form to the patient's physician along with any documented variances. Each drug regimen review will include a reconciliation of the patient's medications at the time of the assessment and a review of the medications to determine duplication of medication, ineffective medication therapy, side effects, medication interactions and patient non-compliance with medication use. The agency's form, titled Drug Regimen Review, included the following sections: a. Potential Adverse Effects and Drug Reactions b. Side Effects Patient is Experiencing c. Contraindications d. Duplicate Therapy e. Potential/Actual Significant Drug Interactions f. Ineffective Drug Therapy g. Non-compliance and/or lack of understanding of the medication regimen The form included a statement "Federal rules and regulations require home health agencies to perform a drug regimen review every 60 days. This was done on the above client with the following results." The agency policy, titled Documentation/Visit Time Frames for RNs and dated 6/26/2018, directed the RN to complete a drug regimen review with every comprehensive assessment, except homemaker only patients, at start of care, resumption of care, recertification, discharge and significant change in condition. 1. Patient #3 had a start of care date of 8/17/2021. Clinical record review revealed the following: a. The patient's Plans of Care, dated 10/16/2021 to 12/14/2021 and 12/15/2021 to 2/12/2022, included physician orders for skilled nursing services. b. The electronic clinical record included an update to the comprehensive assessment at the time of recertification, dated 12/13/2021. c. The electronic clinical record included a scanned copy of the Drug Regimen Review Form. The form was signed by the RN as completed on 12/15/2021, the first day of the new certification period, making the review outside of the last five days of the 10/16/2021 to 12/14/2021 certification period. The clinical record lacked documentation of any drug regimen review completed in the last five days of the 10/16/2021 to 12/14/2021 certification period as required by regulation and agency policy. d. During agency staff interview on 1/25/2022 at 11:30 AM, the Clinical Manager reported she reviewed the patient's electronic clinical record and was unable to find any other drug regimen reviews during the last five days of the certification period of 10/16/2021 to 12/14/2021. 2. Patient #7 had a start of care date of 12/3/2021 and was discharged from agency services on 12/30/2021. Clinical record review revealed the following: a. The Plan of Care, dated 12/3/2021 to 1/31/2022, included physician orders for skilled nursing, home health aide and physical therapy services. b. The patient's clinical record included an initial comprehensive assessment completed at the time of admission, dated as begun on 12/3/2021 and completed on 12/8/2021. c. The patient's clinical record lacked documentation of a scanned copy of the agency's Drug Regimen Review Form associated with the initial comprehensive assessment. The only Drug Regimen Review form found in the clinical record was completed at the time of the patient's discharge from agency services on 12/30/2021. d. During agency staff interview on 1/26/2022 at 10:00 AM, the Clinical Manager reported she reviewed the patient's electronic clinical record and was unable to find a drug regimen review form completed at the time of admission. The Clinical Manager concurred the only documentation of a drug regimen review found in the electronic clinical record was completed at the time of discharge on 12/30/2021. 3. Patient #8 had a start of care date of 7/7/2020. Clinical record review revealed the following: a. The patient's Plans of Care, dated 10/30/2021 to 12/28/2021 and 12/29/2021 to 2/26/2022, included physician orders for home health aide visits with skilled nursing supervisory visits every 60 days (no provision of skilled service). b. The electronic clinical record included an update to the comprehensive assessment at the time of recertification, dated 12/28/2021. c. The electronic clinical record lacked any scanned copy of the Drug Regimen Review Form associated with the update to the comprehensive assessment. The clinical record lacked documentation of any drug regimen review completed in the last five days of the 10/30/2021 to 12/28/2021 certification period as required by regulation and agency policy. d. During agency staff interview on 1/25/2022 at 4:00 PM, the Clinical Manager reported she reviewed the patient's electronic clinical record and was unable to find a drug regimen review during the last five days of the certification period of 10/30/2021 to 12/28/2021. The above stated findings were reviewed with the Clinical Manager and the Assistant Director/Chief Financial Officer. The agency provided no additional information prior to the end of the survey.

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, surveyor observation, patient/caregiver interview and agency 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 professional assigning the home health aide to the patient for 1 of 5 sampled patients receiving home health aide services (Patient #1). The agency reported providing home health aide services to 35 patients at the time of the survey. 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 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 and safely met. Findings including: According to the agency policy, titled Home Health Aide Program Policy and dated 4/2019, a registered nurse (RN) will complete a comprehensive assessment to identify the needs of the patient, obtain a physician order to begin services and develop a Plan of Care detailing the scope, frequency and duration of home health aide services. The RN will develop a Home Health Aide Care Plan detailing the services the aide should provide in accordance with the physician's signed Plan of Care. Patient #1 had a start of care date of 10/2/2020. Clinical record review, home visit observation and associated patient/caregiver/agency staff interviews revealed the following: a. The Plan of Care, dated 1/5/2022 to 3/5/2022, included physician orders for skilled nursing, physical therapy and occupational therapy services. The Plan of Care Update, dated 1/10/2022, added home health aide services to the Plan to: assist with transfers; assist with showering the patient; shampoo the patient's hair; and run water over the patient's surgical incision on the neck without rubbing or scrubbing- pat dry. The Plan of Care documented the patient need for a cervical collar on at all times when out of bed. The Plan of Care included safety precaution "patient to wear C-collar (cervical collar/brace worn to keep the patient's cervical spine immobilized) to neck when out of bed. Has a special shower C-collar to wear when bathing- husband managers and will change/put on when the home health aide is present." b. The home health aide care plan, dated 1/10/2022, directed the home health aide to: assist with transfers; assist with showering the patient; shampoo the patient's hair; and run water over the patient's surgical incision on the neck without rubbing or scrubbing- pat dry. The assignment included safety precaution "patient to wear C-collar to neck when out of bed. Has a special shower C-collar to wear when bathing- husband managers and will change/put on when the home health aide is present." c. On 1/25/2022 at 9:00 AM, the surveyor accompanied Staff A, Physical Therapist, to the patient's home. During the home visit, the surveyor observed Patient #1 wore compression knee high stockings and had a cervical collar on. d. During patient interview while in the home, Patient #1 reported the home health aides had been removing the cervical collar, putting on the washable C-collar used for showering and putting the cervical collar back on after showering. The patient also reported "boy those aides sure have a special way to put on my compression stockings- she did it so easily." e. During patient caregiver interview while in the home, Patient #1's spouse concurred with the patient's report that the aide did remove and put on the two different types of C-collars while caring for the patient as "the aide said she had done it before" and put on the patient's compression stockings. f. The home health aide visit note, dated 1/11/2022, was signed by Staff D, Home Health Aide. The visit note did not document any compression stocking application or removal/application of the cervical collar during the visit. During agency staff interview on 1/25/2022 at 3:50 PM, Staff D, Home Health Aide, reported she had provided care to Patient #1. During the visit, the aide reported she had removed the patient's C-collar, put on the washable C-collar for showering, removed the washable C-collar and put the other C-collar back on. She also reported she had put on the patient's compression stockings during the visit. g. The home health aide visit note, dated 1/18/2022, was signed by Staff E, Home Health Aide. The visit note did not document any compression stocking application or removal/application of the cervical collar during the visit. During agency staff interview on 1/26/2022 at 8:15 AM, the Clinical Manager reported she had contacted Staff E, Home Health Aide to discuss care provided to Patient #1. Staff E, Home Health Aide reported she had removed the patient's C-collar, put on the washable C-collar for showering, removed the washable C-collar and put the other C-collar back on. She also reported she had put on the patient's compression stockings during the visit. The above stated findings were reviewed with the Clinical Manager and Assistant Director/Chief Financial Officer. The agency provided no additional information prior to the end of the survey.

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, review of the therapy contract for services, clinical record review and agency staff interview, the agency failed to ensure the clinical record included the patient's current documentation according to the agency's expectations/therapy contract for 5 of 5 sampled patients receiving contracted therapy services (Patients #1, #4, #5, #6 and #7). At the time of the survey, the agency reported providing contracted therapy services to 9 patients. Failure of the agency to ensure the clinical record included current documentation placed agency patients at risk to receive care or not receive care meeting the needs of the patient. Findings include: According to the agency policy, titled Therapy Services Policy and dated 7/2013, therapy services will be provided by the agency via contracted services; such services will be provided by qualified therapists licensed in the state of Iowa and shall maintain all current requirements of license as required by the licensing body; and will be provided according to the written contract between the agency and the contacted therapy company. According to the contract between the agency and the therapy company, dated 3/1/2011, the contracted therapists will provide documentation in accordance with regulations and guidelines of federal and state agencies. Initial evaluations, progress notes and discharge summaries along with daily time sheets will be emailed or faxed within one business day of the date of service. The original paper documents will then be mailed or carried to the agency office weekly at the end of the week. During agency staff interview on 1/24/2022 at 2:00 PM, the Administrator reported the expectation is the therapist will follow the contract requirements when completing patient care documentation and incorporating that documentation into the patient's home health clinical record. 1. Patient #1 had a start of care date of 1/5/2022. Clinical record review revealed the following: a. The Plan of Care Update (1/5/2022 to 3/5/2022), dated 1/10/2022, included physician orders for a physical therapy evaluation with continued visits 1-2 times weekly. b. The physical therapy evaluation, dated 1/6/2022, was not electronically signed as completed until 1/11/2022, 3 business days after the service date. The therapist would not have been able to send the above stated visit note to the home health agency by email or fax within one business day of the visit as required by the contract as the note had not yet been completed. 2. Patient #4 had a start of care date of 12/14/2021. Clinical record review revealed the following: a. The Plan of Care Update (12/14/2021 to 2/11/2022), dated 12/22/2021, included physician orders for a physical therapy evaluation with continued visits 1-2 times weekly. b. The physical therapy evaluation, dated 12/28/2021, was not electronically signed as completed until 1/3/2022, 3 business days after the service date. The therapist would not have been able to send the above stated visit note to the home health agency by email or fax within one business day of the visit as required by the contract as the note had not yet been completed. 3. Patient #5 had a start of care date of 1/4/2022. Clinical record review revealed the following: a. The Plan of Care, dated 1/4/2022 to 3/4/2022, included physician orders for a physical therapy evaluation with continued visits 1-2 times weekly. b. The physical therapy evaluation, dated 1/5/2022, was not electronically signed as completed until 1/11/2022, 4 business days after the service date. The therapist would not have been able to send the above stated visit note to the home health agency by email or fax within one business day of the visit as required by the contract as the note had not yet been completed. 4. Patient #6 had a start of care date of 11/3/2021 and was discharged from agency services on 12/14/2021. Clinical record review revealed the following: a. The Plan of Care, dated 11/3/2021 to 1/1/2022), included physician orders for a physical therapy evaluation with continued visits 1-2 times weekly. b. The physical therapy evaluation, dated 11/4/2021, was not electronically signed as completed until 11/8/2021, 3 business days after the service date. The physical therapy progress visit note, dated 11/17/2021, was not electronically signed as completed until 11/22/2021, 3 business days after the service date. The physical therapy progress visit note, dated 11/29/2021, was not electronically signed as completed until 12/2/2021, 3 business days after the service date. The therapist would not have been able to send the above stated visit notes to the home health agency by email or fax within one business day of the visit as required by the contract as the notes had not yet been completed. 5. Patient #7 had a start of care date of 12/3/2021 and was discharged from agency services on 12/30/2021. Clinical record review revealed the following: a. The Plan of Care, dated 12/3/2021 to 1/31/2022), included physician orders for a physical therapy evaluation with continued visits 1-2 times weekly. b. The physical therapy progress visit note, dated 12/24/2021, was not electronically signed as completed until 12/29/2021, 3 business days after the service date. The therapist would not have been able to send the above stated visit note to the home health agency by email or fax within one business day of the visit as required by the contract as the note had not yet been completed. The above stated finding were reviewed with the Clinical Manager and the Assistant Director/Chief Financial Officer. The agency provided no additional information prior to the end of the survey.