Every finding on record at Taylor County Public Health Agency

The Iowa Department of Inspections, Appeals and Licensing conducted a Recertification Survey on 12/15/25 through 12/17/25. The home health agency was found to be operating in compliance with the regulations of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 12/15/25 through 12/17/25. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 18 patients at the time of the survey, including 13 patients in the parent Bedford office and 5 patients in the Corning branch office.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview review the agency failed to ensure accurate and thorough completion of a comprehensive assessment of wounds for 1 of 1 sampled patients with wounds (Patient #4). Failure to accurately and thoroughly complete a thorough comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition. Findings include: According to the undated agency policy, titled Wound Measurement, three-dimensional measurement includes the length, width, and depth. For undermining, there may be a larger area, measure the location of undermining and the area covered. May document as follows: 3 cm of undermining form 12 to 3 o'clock, 2 cm of undermining from 4 to 6 o'clock, etc. Accuracy and consistency are most important. Wound measurements are done with routine wound care procedures at minimum of weekly. If possible, the same person should do the measurements for consistency. During an interview on 12/16/25 at 9:15 AM the Clinical Manager stated the wound measurements are documented weekly and include the length, width and depth of the wound. Patient #4 had a start of care date of 3/9/15. Clinical record review revealed the following: a. The plans of care (POCs), dated 9/12/25 to 11/10/25 and 11/11/25 to 1/9/25, identified the patient had a diagnosis of sepsis. The POCs included orders for skilled nurse services and wound care. b. The comprehensive assessment at resumption of care, dated 11/26/25, Staff C, Registered Nurse (RN) documented the patient had a wound on the midline inner buttock rectal area, right ischial decubitus ulcer. The wound documentation included measurements of 2 centimeters (cm) length by 5.2 cm width with 1.3 cm depth. The wound included undermining located at 11 o'clock. Staff C failed to include documentation of measurements of the undermining. b. The skilled nurse visit notes, dated 12/3, 12/5, 12/8, 12/10 and 12/12/25, Staff C, RN documented the patient had a wound on the midline inner buttock rectal area, right ischial decubitus ulcer. The wound documentation included measurements of length, width and depth. The wound identified undermining located at 11 o'clock. Staff C failed to include documentation of measurements of the undermining. The agency failed to document complete wound assessments. The above findings were reviewed with the 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, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 2 of 3 sampled patients with home observation visits (Patients #1 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Drug Regimen Review, revised 10/2/25, the comprehensive drug regimen review (DRR) assessment completed at the time of admission and at least every 60 days as part of and at the time of the comprehensive assessment, the Registered nurse (RN) will review with the patient/caregiver all medications, prescribed as well as over-the-counter, that the patient is taking in order to identify: medication orders discrepancies between patient understanding, RN initial orders, discharge orders and/or hospital discharge summaries and addition or discontinuance of medication. During an interview on 12/16/25 at 9:15 AM, the Clinical Manager stated the DRR is completed on admission, with each comprehensive assessment, resumption of care and at discharge. 1.Patient #1 had a start of care date of 7/18/22. Clinical record review revealed: a. The Plan of Care (POC), dated 11/9/25 to 1/7/26, identified the patient had a diagnosis of atherosclerosis and included physician orders for medications and skilled nursing services. Medication orders included Magnesium 400 milligrams (mg) with calcium 1000 mg and zinc 25 mg daily. b. The recertification comprehensive assessment, dated 11/4/25, completed by Staff C, Registered Nurse (RN), included documentation a DRR was completed. c. During a home observation visit on 12/2/25 at 11:15 AM with Staff D, RN, the surveyor noted the RN set up the patient's medications. The patient's bottle identified the magnesium 500 mg and observed to be 1/2 empty. The DRR failed to include an accurate review of all medications taken by the patient. 2.Patient #3 had a start of care date of 1/3/25. Clinical record review revealed: a. The POC, dated 10/30/25 to 12/28/25, identified the patient had a diagnosis of diabetes mellitus and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 10/27/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 12/17/25 at 10:00 AM with Staff C, RN, the surveyor identified a bottle of Acetaminophen 500 mg tablets on the table next to the recliner. During the same observation visit, the patient stated he/she takes 2 tablets 1 time a day as needed for pain. The DRR failed to include an accurate review of all medications taken by the patient. The above findings reviewed with the Clinical Manager.

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 observations, staff and patient interviews, clinical record review and policy review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient for 2 of 3 sampled patients with surveyor home visit observation (Patients #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 physician orders. Findings include: According to agency policy titled Home Health Clinical Record, dated 10/2/25, the original plan of care is signed and dated by the physician who is responsible for the care of the patient and incorporated into the clinical record in a timely manner. Total plan of care will be reviewed as frequently as the patient's condition dictates, but at least every sixty (60) days. 1.Patient #1 had a start of care date of 12/5/25. Clinical record review and home observation revealed the following: a. The plan of care (POC) dated 1/15/25 to 3/16/25, included a diagnosis of collapsed vertebrae thoracic region. Services, supplies, and equipment utilized by the patient included bedside commode, hand-held shower, grab bars/safety rails, reacher/grabber, medication reminder boxes, incontinence pads, shower wand and 2 wheeled walker. b. During a home observation visit 12/17/25, at 8:30 AM with Staff D, Registered Nurse (RN), the surveyor also noted the patient stated he/she also had a heating pad he/she had used following the admission for home health services. The agency failed to include all of the services, supplies, and equipment the patient utilized to include the heating pad on the POC. 2. Patient #3 had a start of care date of 1/3/25. Clinical record review and home observation revealed the following: a. The POC, dated 10/30/25 to 12/28/25, included a diagnosis of diabetes mellitus. Services, supplies, and equipment utilized by the patient included rolling walker, shower chair, hand-held shower, long handled sponge and grab bars/safety rails. b. During a home observation visit 12/17/25, at 10:00 AM with Staff D, RN, the surveyor also noted the patient utilized a chair cushion, urinal, CPAP (continuous positive airway pressure), reacher, glucometer, and diabetic supplies. The agency failed to include all of the services, supplies, and equipment the patient utilized to include the chair cushion, urinal, CPAP, reacher, glucometer, and diabetic supplies on the POC. The above findings were reviewed with the 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 staff interview, policy review and clinical record review, 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 4 sampled patients receiving home health aide services (Patients #3 and #5). The agency reported 12 patients who 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 agency policy titled, Home Care Aide Services, dated 10/2/25, the supervising Registered Nurse (RN) prepares written instructions outlining the individualized care needed by the patient based on an assessment of the client's needs. Plan will be in accordance with physician orders for home care aide cases. Home Care Aide will provide only the care/services listed on the assignment sheet and not alter, add to, or change the tasks in any way without authorization form the supervisor. During an interview on 12/16/25 at 9:15 AM, the Clinical Manager reported aides are to document in the narrative portion of the document if the patient refused a task. The aides are to reach out to the nurse to report a patient request for a task not on the care plan. 1.Patient #3 had a start of care date of 1/3/25. Clinical record review revealed: a. The Plan of Care (POC), dated 10/30/25 to 12/28/25, included primary diagnosis of diabetes mellitus and physician orders for skilled nursing and home health aide services. b. The home health aide assignment, with an effective date of 10/30/25, directed the home health aides to ambulate the patient using assistive device, report to RN if no bowel movement, clean bathroom after patient care, assist patient with dressing, partial bath, shower chair, encourage to wear glasses/hearing aide, lotion to back and feet as requested with non-medicated lotion and universal precautions. c. The home health aide visit notes, dated 10/22, 10/24 and 10/27/25, Staff E, HCA, documented both partial bath and shower completed. The visit notes also included documentation a shampoo completed, not included in the assigned tasks. The HCA failed to follow the aide care plan as written. 2. Patient #5 had a start of care date of 10/24/25 and received services out of the Bedford parent office. Clinical record review revealed: a. The POC, dated 10/24/25 to 12/22/25, included primary diagnosis of pleural effusion and physician orders for skilled nursing and home health aide services. b. The home health aide assignment, with an effective date of 10/24/25, directed the home health aides to ambulate the patient using assistive device, assist patient with home exercise program, assist with dressing and undressing, partial sponge bath as requested, shower chair as requested, lotion as requested with non-medicated lotion as requested, perineal care shampoo as requested, remind to wear emergency call system and standard precautions. c. The home health aide visit notes, dated 11/10/25, Staff E, HCA, failed to documented the partial bath completed or not completed. d. The home health aide visit note, dated 11/18/25, Staff E, HCA, documented both partial sponge bath and shower chair completed. The HCA failed to follow the aide care plan as written. The above findings were reviewed with the Clinical Manager.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. 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 and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 3 of 3 sampled patients with transfers/ discharges (Patients #4, #6 and #7). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy titled, Discharge/Transfer Criteria for Home Health Services, dated 5/21/24, within 2 business days of when the agency becomes aware that a client is transferred to another health care facility or moves out of the agency's geographic service area, but still needs care, a written referral/transfer form will be completed and sent to the new agency. During an interview on 12/17/25 at 12:30 PM the Clinical Manager stated the agency did not have documentation a transfer summary sent to the receiving facility. 1.Patient #4 had a start of care date of 4/4/25. Clinical record review revealed: a. The plans of care (POCs), dated 10/1/25 to 11/29/25 and 11/30/25 to 1/28/25, identified the patient had a diagnosis of sepsis. The POC included orders for skilled nursing services. b. An interim physician's order, dated 9/29/25, ordered to place services on hold due to transfer to the hospital. c. A home health transfer summary, dated 10/7/25, Staff C, RN documented the patient transferred to the hospital (6 business days after the transfer and 4 days late per policy) and the transfer summary sent to the primary care physician. The agency failed to complete the transfer summary within 2 business days and failed to send the transfer summary to the receiving hospital. 2. Patient #6 had a start of care date of 10/10/25 and discharge date of 11/12/25. Clinical record review revealed: a. The POCs, dated 10/10/25 to 12/8/25, identified the patient had a diagnosis of B-cell lymphoma. The POC included orders for skilled nursing services and aide. b. An interim physician's order, dated 10/29/25, ordered to place services on hold due to transfer to the hospital. c. A home health transfer summary, dated 11/13/25, Staff D, RN documented, 9 business days after the visit and 7 days late (per agency policy), the patient transferred to the hospital and the transfer summary sent to the primary care physician. The agency failed to complete the transfer summary within 2 business days and failed to send the transfer summary to the receiving hospital. 3. Patient #7 had a start of care date of 11/5/25 and discharge date of 11/17/25. Clinical record review revealed: a. The POC, dated 11/4/25 to 1/3/26, identified the patient had a diagnosis of hepatic encephalopathy. The POC included orders for skilled nursing services. b. A home health transfer summary, dated 11/17/25, Staff D, RN documented the patient transferred to the hospital on 11/14/25 and the transfer summary sent to the primary care physician. The agency failed to send the transfer summary to the receiving hospital. The above findings reviewed with the Clinical Manager.

The Department of Inspections and Appeals conducted a recertification survey, dated 11/13/22 to 11/17/22, and found the following standard level deficient practice under the Emergency Preparedness Condition of Participation.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of emergency preparedness training documentation and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles initially and annually thereafter for 2 of 2 sampled staff employed by contract (Staff E, Occupational Therapist, and Staff F, Physical Therapist). The agency reported a total of 5 contract employees. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: On 11/16/22, the surveyor requested to review of emergency preparedness staff training documentation for Staff E, Occupational Therapist (hired 11/29/21), and Staff F, Physical Therapist (hired 9/2017). On 11/16/22 at 11:40 AM, during an interview, the Clinical Manager reported they had not provided training on EP for any of the contracted staff since the last survey (dated 11/21/19). The agency failed to provide and maintain documentation of training for new and existing staff provided agency services under contract. Agency staff provided no further information prior to the end of the survey.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 11/13/22 to 11/17/22. The survey identified the following standard level deficient practices. The agency reported a census of 20 patients, including 12 patients receiving services from the parent office in Bedford and 8 patients receiving services from the branch office in Corning.

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, home visit observation, patient interview and staff interview, the agency failed to ensure agency staff accurately completed a drug regimen review, including completion of all required components within the required time frames as part of the comprehensive assessment for 2 of 7 records reviewed (Patients #3 and #5). 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: Review of the agency's policy, titled Drug Regimen Review (DRR), dated 11/1/22, the registered nurse is responsible for completing the DRR at the start of care and at least every 60 days as part of the comprehensive assessment. The DRR will include a review of all medications for potential adverse effects, significant drug interactions, duplicate drug therapy, ineffective drug therapy and non-compliance. On 11:15 at 4:07 PM, during an interview, the Clinical Manager reported the registered nurse was responsible for completing the DRRs with the comprehensive assessment and each update to the comprehensive assessment. 1. Patient #3 had a start of care date of 11/6/22 and received home health agency services from the agency's parent office. Review of the clinical record revealed the following; a. The Plan of Care (POC), dated 11/6/22 to 1/4/23, included physician orders for skilled nursing, occupational and physical therapy services. The POC included the following medication orders: Amlodipine Besylate 5 milligrams (mg) oral tablet, 1 tab oral once a day; Fluconazole 200 mg oral tablet 1 tab oral once a day; Fluconazole 100 mg oral tablet 2 tabs oral once a day; and, Protonix 40 mg oral delayed release tablet 1 tab oral once a day. b. The comprehensive assessment completed by the nurse at the start of care, dated 11/6/22, included documentation the nurse completed a drug regimen review. On 11/16/22 at 10:35 AM, during a home visit observation, Staff E, OT, the patient and patient’s spouse reported the spouse set up the patient’s medications. They both reported the following medication discrepancies: a. The POC included medication orders for Amlodipine, Fluconazole and Protonix. Both the spouse and patient reported the patient did not have these medications in the home and had not been taking them. b. The patient’s spouse reported the patient had been taking Lisinopril for a long time and prior to the start of agency services. Observation of the patient’s medications revealed a medication bottle for Lisinopril 40 milligrams one tablet every day and a prescription date of 11/10/22. The DRR contained inaccurate and incomplete medication information. 2. Patient #5 had a start of care date of 8/1/22 and received home health services through the agency's parent office. Review of the clinical record revealed the following: The POCs, dated 8/1/22 to 9/29/22 and 9/30/22 to 11/28/22, included orders for medications and nursing services one time every 60 days. a. The comprehensive assessment completed by the nurse at the start of care, dated 8/1/22, included documentation the nurse completed a DRR based on the patient's medication profile. The nurse documented there were no identified concerns. b. Review of the medication interactions generated by the agency's electronic medical record revealed the following major medication interactions between medications ordered by the physician for the patient: Atenolol and Amlodipine; Atenolol and Glimepiride; Atenolol and Insulin Glargine; Aspirin and Amlodipine; Aspirin and Lisinopril; Aspirin and Glimepiride; Aspirin and Insulin Glargine; Amlodipine and Atorvastatin; Lisinopril and Metformin; Lisinopril and Glimepiride; Lisinopril and Insulin Glargine; Metformin and Glimepiride; Metformin and Insulin Glargine; and, Glimepiride and Insulin Glargine. The patient took duplicate medications to treat high blood sugar and high blood pressure. The DRR performed by the nurse with the comprehensive assessment failed to identify potential drug interactions and duplicate medication therapy taken by the patient. c. The update to the comprehensive assessment completed at the time of recertification, dated 9/28/22, included documentation the nurse completed a DRR and found no changes. On 11/16/22 at 3:11 PM, during an interview, Staff D, RN, reported when she completed the patient's DRR, it was in the agency's new electronic medical record, and she did not know at the time where to put DRR information. Now, they usually type a narrative paragraph at the bottom of the assessments which specifically identifies any concerns found during the review. She confirmed the patient did not have a DRR which identified information related to all of the required components of a DRR. The Clinical Manager received the above findings and agency staff 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, agency clinicians failed to complete updates to the comprehensive assessment at recertification in the last 5 days of each certification period for 2 of 3 sampled patients requiring a recertification assessment (Patients #1 and #2). Failure to complete the updates to the comprehensive assessment at recertification in a timely manner increased the potential that patients might not receive services in a timely manner according to assessed needs. Findings include: Review of the agency's policy, titled OASIS (Outcome and Assessment Information Set) Data, dated 11/1/22, identified agency staff will complete a comprehensive assessment at the start of care and then not less than every 60 days. 1. Patient #1 had a start of care date of 3/25/22 and received home health services from the branch office. Review of the clinical record revealed the following. The Plans of Care (POCs), dated 5/24/22 to 7/22/22, 7/23/22 to 9/20/22 and 9/21/22 to 11/19/22, included orders for skilled nursing services. a. The update to the comprehensive assessment completed by the nurse at the time of recertification, dated 7/18/22, included documentation of a signature of completion, dated 7/26/22. Review of the electronic medical record (EMR) audit system revealed the nurse had not locked the assessment as complete until 7/26/22, 4 days late. b. The update to the comprehensive assessment completed by the nurse at the time of recertification, dated 9/16/22, included documentation of a signature of completion, dated 9/21/22. Review of the EMR audit system revealed the nurse had not locked the assessment as complete until 9/21/22, 1 day late. On 11/16/22 at 2:40 PM, during an interview, the Clinical Manager explained the agency started a new electronic medical record (EMR) in July 2022. She reported staff did not know the process for reviewing and locking documents. She confirmed staff locked the updates to the comprehensive assessment completed at the time of recertification late. 2. Patient #2 had a start of care date of 3/28/2003 and received home health services from the agency's parent office. Review of the clinical record revealed the following: The POCs, dated 6/18/22 to 8/14/22, 8/15/22 to 10/13/22 and 10/14/22 to 12/12/22, included orders for skilled nursing services. a. The update to the comprehensive assessment completed by the nurse at the time of recertification, dated 8/11/22, included documentation of a signature of completion, dated 8/26/22. Review of the EMR audit system revealed the nurse had not entered the visit initially until 8/15/22 and locked the assessment as complete on 8/26/22, 12 days late. On 11/16/22 at 3:11 PM, during an interview, Staff D, Registered Nurse, explained there was a problem with the EMR not letting her pull the assessment up. She explained staff had entered the patient's date of birth incorrectly, and the system would not let her enter the assessment information. b. The update to the comprehensive assessment completed by the nurse at the time of recertification, dated 10/13/22, included documentation of a signature of completion, dated 10/14/22. Review of the EMR audit system revealed the nurse had entered the visit initially on 8/26/22 and locked the assessment as complete on 10/14/22, 1 day late. The Clinical Manager received the above findings and agency staff 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, agency policy review and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 2 of 7 sampled patients (Patients #1 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive treatments according to assessed needs and physician orders. Findings include: Review of the agency's policy, titled Home Care Admission Criteria/Continuation of Care, dated 3/10/15, identified agency staff will provide services based on a Plan of Care (POC) that is directed and signed by a physician. 1. Patient #1 had a start of care date of 3/25/22 and received services from the branch office. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 7/23/22 to 9/20/22, included a physician order for the skilled nurse to change the patient's suprapubic urinary catheter every month. The POCs lacked an order which specified the size of the catheter and bulb (balloon like device inserted into the bladder to hold the catheter in place) inflation amount. b. The skilled nursing visits, dated 9/23/22 and 10/21/22, included documentation the nurse changed the patient's suprapubic catheter using 20 French Foley catheter with 10 milliliter bulb. On 11/15/22 at 9:00 AM, during a home visit observation, Staff C, Registered Nurse (RN), assessed the patient's catheter and told the patient she would be changing the catheter next week. On 11/16/22 at 2:40 PM, during an interview, the Clinical Manager confirmed the POCs lacked an order which specified the catheter size and bulb inflation amount the nurse should use when changing the patient's catheter. 2. Patient #7 had a start of care date of 3/31/22, received home health services from the agency's branch office and discharged from agency services on 5/3/22. Review of the clinical record revealed the following: a. The POC, dated 3/31/22 to 5/29/22, identified a primary diagnosis of emphysema (disease associated with the lungs and difficulty with breathing), included orders for skilled nursing services one time per week and identified the patient used oxygen. The POC lacked orders which specified the flow rate per minute of oxygen use and a route of delivery of the oxygen, such as a mask or nasal cannula. b. The comprehensive assessment completed by a nurse at the start of care, dated 3/31/22, identified the patient used oxygen continuously at a rate of 2.5 liters per minute via nasal cannula. c. A skilled nursing visit, dated 4/7/22, identified the patient was using 2.5 liters of oxygen. d. A skilled nursing visit, dated 4/14/22, identified the patient was using 2.1 liters of oxygen. e. A skilled nursing visit, dated 4/21/22, identified the patient was using 2 liters of oxygen. f. A skilled nursing visit, dated 4/28/22, identified the patient was not using oxygen during the visit. On 11/16/22 at 3:11 PM, during an interview, the Clinical Manager and Staff D, RN, confirmed an inability to find an order for the patient's oxygen use that specified a flow rate per minute and route of delivery. The Clinical Manager received the above findings and agency staff reported provided no further information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, patient, patient's significant other and agency staff interview, the agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 1 of 3 sampled patients receiving home health aide services (Patients #1). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: Review of the agency's policy, titled Home Care Aide Services, dated 11/1/22, identified the supervising registered nurse (RN) was responsible for creating written instructions of care based on the patient's assessed needs. The home health aide will provide services only as listed on the assignment. On 11:15 at 4:07 PM, during an interview, the Clinical Manager reported the supervising RN was responsible for creating the home health aide assignment, reviewing and updating the assignment with changes. Patient #1 had a start of care date of 3/25/22 and received home health services from the agency's branch office. Review of the clinical record revealed the following: a. The updates to the comprehensive assessment completed by the nurse at the time of recertification, dated 7/18 and 9/16/22, included documentation the nurse assessed the patient needed assistance with upper and lower body dressing. b. The Plan of Care (POC), dated 9/21/22 to 11/19/22, included physician orders for skilled nursing and home health aide services. The POC included directions for the home health aide to complete the following tasks every visit: ambulate only with assistance, ambulate patient using assistive device (cane, crutches, walker, O2), bath, shower, perineal care, shampoo and shave. c. The home health aide visit notes, dated 9/26, 10/11, 10/31 and 11/14/22, included documentation the home health aide assisted the patient with undressing and/or dressing. On 11/15/22 at 9:00 AM, in an interview, during a home visit observation with Staff C, Registered Nurse (RN), the patient reported the home health aides assisted the patient with dressing. The patient explained the patient could do it without help, but the help made it easier. The home health aide assignment failed to include instruction to the home health aide to assist the patient with dressing per the patient's assessed needs. The Clinical Manager received the above findings and agency staff provided no further assistance 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 clinical record review, agency policy review, patient, patient's significant other and 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 in writing by the skilled professional assigning the home health aide to the patient for 1 of 3 sampled patients receiving home health aide services (Patient #1). 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: Review of the agency's policy, titled Home Care Aide Services, dated 11/1/22, identified the supervising registered nurse (RN) was responsible for creating written instructions of care based on the patient's assessed needs. The home health aide will provide services only as listed on the assignment. On 11:15 at 4:07 PM, during an interview, the Clinical Manager reported home health aide staff are required to document a reason why they are unable to complete assigned tasks. Patient #1 had a start of care date of 3/25/22 and received home health services from the agency's branch office. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 9/21/22 to 11/19/22, included physician orders for skilled nursing and home health aide services. The POC included directions for the home health aide to complete the following tasks every visit: ambulate only with assistance, ambulate patient using assistive device (cane, crutches, walker, O2), bath, shower, perineal care, shampoo and shave. b. The home health aide visit note, dated 10/17/22, included documentation the home health aide completed a visit and wore personal protective equipment, but lacked documentation of the completion of any tasks or a reason why the home health aide did not complete assigned tasks. On 11/16/22 at 2:40 PM, during an interview, the Clinical Manager confirmed the 10/17/22 home health aide visit note lacked documentation of any tasks the home health aide had completed during the visit. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.