Every finding on record at Visiting Nurse Services of Iowa

Were not able to link the two surveys together. See complaint # 98572 survey for citations. Both complaint investigations were done at the same time.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, patient, family and agency staff interview, the agency failed to ensure agency staff: 1) accepted patients for treatment on the expectation that the agency could meet the assessed needs of the patient in his or her place of residence through the provision of services per the patient's individualized Plan of Care established by a physician (or primary healthcare practitioner); and, 2) notified the patient's physician of services agency staff were unable to provide to the patient in order to allow the physician the ability to decide whether the service could not be provided, or if additional intervention needed to be provided due to the potential clinical impact on the patient. (see G0572) The effects of these practice resulted in the agency's failure to ensure the agency provided the services needed by the patients and promoted and supported the coordination of safe and effective delivery of care to patients.

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 clinical record review, agency policy review, patient, family and agency staff interview, the agency failed to ensure agency staff: 1) accepted patients for treatment on the expectation that the agency could meet the assessed needs of the patient in his or her place of residence through the provision of services per the patient's individualized Plan of Care established by a physician (or primary healthcare practitioner); and, 2) notified the patient's physician of services agency staff were unable to provide to the patient in order to allow the physician the ability to decide whether the service could not be provided, or if additional intervention needed to be provided due to the potential clinical impact on the patient. 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. Review of the agency's policy, titled Plan of Care (POC), dated 2/3/23, revealed each patient's needs are reflected in an individualized POC specific to the assessed needs of the patient. Agency staff provide services based on the patient's assessed needs and physician (healthcare practitioner) orders. The POC includes the services and frequency of the delivery of those services. The patient has the right to participate in the development of their POC. Agency staff will promptly alert the physician to any changes that indicate a need to alter the POC. The clinician will immediately document care coordination in the clinical record and include the physician's response. Review of the agency's policy, titled Coordination of Care, dated 2/23/22, revealed the Registered Nurse (RN) Case Manager is responsible for communication with members of the health care team, including the patient's physician, to inform/discuss changes. The RN Case Manager will inform/discuss with members any changes in condition, Plan of Care, physician's orders and patient and family preferences/requests. On 6/20/23 at 1:31 PM, during an interview, the Administrator reported the RN Case Manager was responsible for scheduling skilled nursing visits with the patients and the Intake Scheduling Coordinator was responsible for scheduling the home health aide visits. When the RN completes the admission process for a patient, the RN sends an email to the Administrator, Clinical Manager and Intake Scheduling Coordinator. The Intake Scheduling Coordinator reviews the service and frequency order to confirm and completes the scheduling of the home health aides. If home health staff miss a scheduled visit for a patient, the home health staff complete a missed visit form and alert the Intake Scheduling Coordinator of the need to send notification to the patient's physician. On 6/20/23 at 1:49 PM, during an interview, the Administrator reported the home health have been having difficulty with staffing home health aide services. The licensed practical nurse (LPN) had also been assisting with providing home health aide services. On 6/20/23 at 2:05 PM, during an interview, Staff N, RN, reported the agency continued to admit patients that needed home health aide services and had physician orders for home health aide services, but the agency did not have enough staff to provide the home health aide services. On 6/20/23 at 4:00 PM, during an interview, the Intake Scheduling Coordinator confirmed she was responsible for scheduling the home health aides in the patients' homes. The Intake Scheduling Coordinator explained that once the RN Case Manager admits a patient, the RN Case Manager send an email to the Intake Scheduling Coordinator which identifies the services and frequency for the services the patient needs. For patients needing therapy services, the Intake Scheduling Coordinator receives an email notification from the RN Case Manager. The Intake Scheduling Coordinator then sends a notification to therapy and therapy staff schedule visits themselves. The Intake Scheduling Coordinator reported she was responsible for sending missed visit notifications to the physician for each patient and she sent out the notifications once a month. The Intake Scheduling Coordinator reported the agency has been short-staffed for home health aides since January 2023. On 6/21/23 at 8:08 AM, during an interview, the Administrator reported that the home health agency had not been taking all of the referrals the agency received. For the patients that the home health have been accepting that need home health aide services, the admitting nurse informs the patients the agency is short-staffed and that the home health agency will not be able to provide all of the home health aide services. The nurse also informs the patient’s physician on admit about the inability to provide home health aide services as ordered. The Administrator reported that staff needed to be documenting when staff informed the patient and physician about the agency not being able to provide home health services as ordered by the physician. The Administrator explained that any patient the home health agency are not able to provide home health aide services should not have the home health aide service and frequency orders on the Plan of Care. 1. Patient #2 had a start of care date of 6/2/23. Review of the clinical record revealed the following: a. The POC, dated 6/2/23 to 7/31/23, included a diagnosis of hypertensive heart with heart failure and physician orders by the patient's primary care physician (PCP) on 6/2/23 at 2:40 PM for skilled nursing, home health aide, physical therapy and occupational therapy services. The physician ordered the agency to provide home health aide services 2 times per week for 8 weeks. b. The comprehensive assessment completed by Staff E, RN, at the start of care, dated 6/2/23, included documentation Staff E assessed the patient lived alone and required assistance with the following activities of daily living (ADLs): bathing, dressing, grooming, ambulation, transferring from one surface to another and eating. Staff E, RN, assessed the patient had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the patient did not have a cognitive deficit or memory issues. Staff E, RN, assessed the patient had shortness of breath with minimal exertion, generalized swelling/fluid retention due to heart failure, and chronic, intermittent pain which was exacerbated by movement, walking and prolonged standing. c. The agency financial responsibility form, dated and signed on 6/2/23 by the patient and Staff E, RN, included documentation the agency would provide home health aide services 2 times per week for 8 weeks. d. The home health aide care plan, documented on the Team Care Plan, dated 6/2/23, included the following instructions for the home health to complete each visit: assist with ambulation with a walker, shower, shampoo, clean and file toenails, assist with dressing both top and bottom, apply lotion to dry skin areas, report skin changes to the nurse and perineal care with the shower. e. Review of the clinical record on 6/20/23 revealed the lack of documentation of any home health aide visits or missed visit notifications to the PCP, since the admission on 6/2/23. On 6/20/23 at 1:31 PM, during an interview, the Administrator and Quality Management Director confirmed the patient did not receive any home health aide visits since admission on 6/2/23, but they did not know why. On 6/20/23 at 2:30 PM, the Quality Management Director provided evidence of a missed visit notification sent to the physician on 6/20/23 at 2:10 PM (agency staff sent notification to the physician after the surveyor notified the Administrator of the missed home health aide visits) for the following services, dates and reasons: a. Missed home health aide visits, dated 6/6/23 and 6/9/23, due to the patient's request to not have the visits. b. A missed physical therapy visit, dated 6/14/23, due to the patient's request to not have the visit. c. A missed skilled nursing visit, dated 6/16/23, and missed home health aide visits on 6/16/23 and 6/20/23, due to the patient being in the hospital (however, the patient discharged from the hospital on 6/16/23). On 6/20/23 (Tuesday) at 3:16 PM, during an interview, the person identified as the primary family member contact, reported the patient was in the hospital 6/13/23 to 6/16/23, due to excessive fluid retention and had discharged from the hospital on 6/16/23. The family member explained the patient lived by himself/herself. The family member reported the patient did not refuse home health aide services prior to the recent hospitalization. The family member reported the patient needed home health aide services and the family member did not know why the patient did not receive the service since the home health admission on 6/2/23 . On 6/20/23 at 3:45 PM, during an interview, Staff I, Physical Therapist, reported he went to the patient’s home on 6/14/23, no one was home and no one answered the phone (the patient was in the hospital for this visit; agency staff incorrectly informed the physician the patient missed the visit due to the patient's request not to have a visit). On 6/20/23 at 4:00 PM, during an interview, the Intake Scheduling Coordinator explained Staff E, RN, sent notification that Patient #2 needed a home health aide. The Intake Scheduling Coordinator reported Staff E, RN, let the patient's family know that the home health agency was short-staffed on home health aides and the home health agency would get a home health aide in the patient's home as soon as possible. The Intake Scheduling Coordinator stated, "The patient wasn’t really wanting a home health aide, or needing one." On 6/21/23 at 8:08 AM, during an interview, the Administrator reported she had spoken with Staff E, RN, the admission nurse for Patient #2. The Administrator explained that Staff E, RN, informed her that Staff E spoke with both the patient and patient’s physician about the agency’s inability to provide home health aide services. Staff E further explained the patient was not really sure the patient needed home health aide services and the patient was fine with not receiving home health aide services. The Administrator reported that Staff E, RN, had not documented the conversation with the patient and with the physician, so the Administrator had Staff E, RN, complete a "late entry" in the clinical note. On 6/21/23 at 8:59 AM, during an interview, Staff E, RN, reported Staff E put clinical notes in the patient’s chart to explain the home health aide staffing issue for the patient after talking with management. Staff E, RN, reported the patient told Staff E that the patient was not sure he/she needed a home health aide to help with bathing. Staff E, RN, did not think that she notified the physician of the patient not getting home health aide services due to staffing issues at the start of care. Staff E, RN, reported agency staff were unaware the patient had been discharged from the hospital on 6/16/23, because the hospital did not notify the agency of the patient’s discharge. Staff E, RN, confirmed the agency had been having difficulty staffing home health aide services since January 2023. Staff E, RN, explained she has been telling patients/families that the home health agency are short-staffed for home health aides and she has been asking the patients and their families if the patient really need the service. Staff E, RN, reported that management is telling the staff to tell patients the home health agency do not have home health aide staff available. On 6/21/23 at 2:10 PM, during an interview, Staff K, Occupational Therapist, reported during her initial visit with the patient on 6/10/23, she assessed the patient's ability to complete ADLs. The patient reported he/she had already bathed and dressed prior to Staff K, Occupational Therapist, entering the home. Staff K, Occupational Therapist, reported that she assessed the patient was very winded after completing their bathing, dressing and a few household chores. The patient reported being worn out and having to rest the remainder of the day. Staff K, Occupational Therapist, explained the patient had a diagnosis of heart failure and any activity was extremely hard for the patient. Staff K, Occupational Therapist, thought Patient # 2 would benefit from home health aide services. Staff K, Occupational Therapist, reported she assessed the patient's legs were very swollen. The patient was able to take off their shoes and compression hose (a type of tight-fitting lower leg were used to help treat fluid retention in the lower extremities) with effort. Staff K, Occupational Therapist, reported the patient had been able to take his/her pants off, but Staff K had to help with putting the patient's pants back on due to the patient being so short of breath. Staff K, Occupational Therapist, reported the patient was "very oriented" and had no cognition issues. On 6/21/23 at 3:06 PM, during an interview, the nurse representative for the patient's PCP reported the physician did not have any correspondence from the agency that indicated the agency would not be providing home health aide services prior to 6/20/23 communication. On 6/22/23 at 8:04 AM, during an interview, the patient reported when the patient asked Staff E, RN, that he/she needed help with a shower, Staff E, RN, told the patient, " it isn’t my department to give a shower". The patient reported Staff E, RN, did not inform the patient he/she could not get home health aide services due to the agency being short-staffed. The patient reported he/she did not tell Staff E, RN, or any other agency staff that he/she did not need or want home health aide services. Agency staff failed to provide home health aide services after the nurse assessed the patient needed the service, the patient's PCP ordered the service and the agency agreed to provide the service (based on the agency's financial responsibility form). Agency staff failed to notify the physician of the correct reason for the missed home health aide visits, dated 6/6/23 and 6/9/23, and the missed physical therapy visit, dated 6/14/23. 2. Patient #3 had a start of care date of 4/13/23. Review of the clinical record revealed the following: a. The POCs, dated 4/13/23 to 6/11/23 and 6/12/23 to 8/10/23, included physician orders by the patient's PCP for skilled nursing services 1 time per week and home health aide services 2 times per week. Specific physician orders related to the skilled nursing services included orders for the skilled nurse to assess/instruct the patient/caregiver on the following: signs and symptoms to report the RN and physician; respiratory disease management/complications and appropriate interventions for chronic obstructive pulmonary disease (COPD); measures to decrease dyspnea (difficulty breathing) episodes; signs and symptoms of hypoxia (not enough oxygen), hydration and hemoptysis (bloody sputum); respiratory treatments including oxygen, nebulizers and inhalers; cardiovascular disease management/complications and interventions; and, medication dose, use, action and side effects. b. On 6/20/23, the clinical record included documentation of only one home health aide visit the week of 5/7/23, dated 5/9/23, and one home health visit the week of 5/28/23, dated 6/2/23. The clinical record lacked documentation for a reason why agency staff failed to provide a second home health aide visit the weeks of 5/7/23 and 5/28/23, and lacked documentation of notification to the patient's PCP of the missed home health aide visits. c. On 6/20/23, the clinical record lacked documentation of a skilled nursing visit the week of 6/11/23 (last documented skilled nursing visit was on 6/7/23, the previous week). The clinical record lacked documentation for a reason why agency staff failed to provide a visit the week of 6/11/23 and lacked documentation of notification to the patient's PCP of the missed skilled nursing visit. On 6/20/23 at 1:42 PM, during an interview, the Administrator reported the agency had proof of documentation that agency staff sent a missed visit notification to the patient's PCP for the missed skilled nursing visit the week of 6/11/23. The Administrator agreed to provide this evidence. On 6/20/23 at 2:07 PM, the Quality Management Director provided documentation agency staff notified the physician on 6/20/23 at 1:40 PM of the missed visits, dated 5/12/23 (visit the week of 5/7/23) and 5/30/23 (visit the week of 5/28/23) for home health aide services and 6/14/23 (visit the week of 6/11/23) for skilled nursing services. Agency staff documented the reason for all of the missed visits was due to the patient's request to not have the visit. On 6/20/23 at 2:19 PM, during an interview, the patient’s spouse reported last week (the week of 6/11/23) that the nurse did not show up. The nurse was supposed to call the patient and never called or showed. The patient's spouse did confirm that the patient refused the home health aide visits, dated 5/9/23 and 5/30/23. Agency staff failed to notify the patient's PCP of the correct reason for missed a skilled nursing visit the week of 6/11/23. 3. Patient #5 had a start of care date of 4/7/23 and discharged from agency services on 4/26/23 due to changing home health agency providers. On 6/20/23 at 2:38 PM, during an interview, the patient's spouse reported while the patient was receiving home health services from the agency, both the skilled nurse and home health aide did not call and did not show up to provide services as scheduled. The patient's spouse explained the home health agency was supposed to provide skilled nursing services one time per week and home health aide services twice per week. The patient's spouse reported the agency staff did not tell them when they started services that the agency was short-staffed on home health aides and the patient would get less than 2 home health aide visits per week. The patient's spouse reported they did not request to cancel either home health aide or skilled nursing services at any time and did not agree to receive less services. The patient's spouse reported Staff G, RN, was the patient's nurse and Staff H, (former) Home Health Aide, provided home health aide services. The patient's spouse reported they changed home health agencies due to not receiving the care the agency told them would provide. The patient's spouse reported they called and complained to the Clinical Manager about the problem with services, but nothing was done about it. The patient reported the home health agency staff did not show up when scheduled and the patient would not recommend the agency to others. Review of the agency's complaint log since January 1, 2023 revealed no complaints made by Patient #5 or Patient #5's spouse. The complaint log did not include any complaints related to patients not getting home health aide or skilled nursing services. Review of the clinical record revealed the following: a. The POC, dated 4/7/23 to 6/5/23, included physician orders by the patient's PCP for skilled nursing services one time per week for 9 weeks and home health aide services 2 times per week for 9 weeks. The POC included a primary diagnosis of legal blindness and other diagnoses of chronic obstructive pulmonary disease and peripheral vascular disease. Specific physician orders related to the skilled nursing services included orders for the skilled nurse to set up the patient's medication planner every 2 weeks, assess physical status and vital signs including the patient's pulse oximetry (device used to measure a patient's blood oxygen saturation levels) and assess/instruct the patient/caregiver on the following: signs and symptoms to report the RN and physician; signs and symptoms of infections and infection control methods; respiratory disease management/complications and appropriate interventions; respiratory treatments and response; cardiovascular disease management/complications and interventions; edema (fluid retention) and how to decrease edema; fall risk; and, medication dose, use, action and side effects. b. The comprehensive assessment completed by Staff G, RN, at the start of care, dated 4/7/23, included documentation Staff G assessed the patient lived alone and required assistance with the following activities of daily living (ADLs): bathing, dressing, grooming, ambulation and transferring from one surface to another. c. The agency financial responsibility form, dated and signed on 4/7/23 by the patient and Staff G, RN, included documentation the agency would provide to the patient skilled nursing services one time every one or two weeks. The number in front of the weeks had been written over and was not clearly legible whether the patient would receive skilled nursing services one time per week or one time every 2 weeks. The agency financial responsibility form included documentation the agency would provide home health aide services 1 to 2 times per week. d. The home health aide care plan, documented on the Team Care Plan, dated 4/7/23, included the following instructions for the home health to complete each visit: shave, shower, partial bath if no shower, shampoo with shower, haircare each visit, assist with dressing, assist with perineal care, assess the skin for changes and report any skin changes to the RN. e. The clinical record lacked documentation of a skilled nursing visit the week of 4/9/23. The clinical record lacked documentation of physician notification of the missed visit and lacked documentation of a reason why the patient did not receive a skilled nursing visit as ordered by the PCP. f. The clinical record included documentation of only one home health aide visit the week of 4/9/23, dated 4/11/23, and documentation of one health aide visit the week of 4/16/23, dated 4/18/23. The clinical record lacked documentation of physician notification of the missed visits and lacked documentation of a reason why the patient did not receive home health aide visits as ordered by the PCP. On 6/20/23 at 1:49 PM, during an interview, the Administrator reported Staff G, RN, was off work on leave and had been for some time. They terminated Staff H, Home Health Aide, in April 2023 after a patient/family complaint. The Administrator agreed to provide documentation of physician notification of missed visits for Patient #5. On 6/20/23 at 2:30 PM, the Quality Management Director provided evidence of the missed visit notification sent to the patient's PCP on 6/20/23 at 2:10 PM for the skilled nursing visit, dated 4/13/23 and home health aide visits, dated 4/7/23, 4/8/23, 4/13/23 and 4/20/23. Agency staff notified the patient's PCP that all missed visits were due to the patient's request to not have a visit. On 6/20/23 2:59 PM, during an interview, the Quality Management Director confirmed the agency's missed visit notification to the physicians for Patients #2, #3 and #5 did not occur until today until after the surveyor started to request the evidence of documentation. On 6/21/23 at 8:25 AM, during an interview, the Clinical Manager reported that they had spoken with the spouse of Patient #5 multiple times, but the spouse never called to complain about services. The Clinical Manager reported the spouse would call frequently about the schedule to find out when a staff person was coming to the home, or to inform them of the need to change the schedule. The Clinical Manager reported the spouse expressed being very happy with Staff H, former home health aide. The Clinical Manager reported the week the nurse did not provide a visit, Staff G, RN, documented that the wife canceled the visit. The Clinical Manager explained they informed the spouse upon admission that they would only be able to provide home health aide services one time per week to the patient, and the spouse was agreeable to this. On 6/21/23 at 8:37 AM, during an interview, the Intake Scheduling Coordinator, explained the agency had 3 home health aides for 120 patients and that they had been short-staffed since January 2023. The Intake Scheduling Coordinator reported they had been even more short-staffed since Staff H, former Home Health Aide, left the agency in April 2023. They explained agency staff tell the referral source prior to admission that they are short-staffed. The Intake Scheduling Coordinator explained that they send missed visit notification to the physician for the patients once a month. The Intake Scheduling Coordinator reported that they had spoke with the spouse of Patient #5, but the spouse never complained about services. The Intake Scheduling Coordinator explained the spouse would call about scheduling questions or to ask for a change in the schedule. The spouse called when they switched home health aides from Staff H, former Home Health Aide, to Staff J, Home Health Aide, just to make sure Staff J was competent. The Intake Scheduling Coordinator explained that the patient’s spouse knew when the patient was admitted that the agency could not provide home health aide services as ordered, and the spouse was fine with this. When asked how the Intake Scheduling Coordinator knew the spouse was aware and okay with getting less home health aide services, they responded, “the admitting RN would have told (the spouse) they would be getting only one day a week for now.” The surveyor attempted, but was unable to reach Staff G, RN (and admitting nurse), Staff H, (former) Home Health Aide, and the patient's PCP for interview. On 6/21/23 at 1:58 PM, during an interview, Staff L, Home Health Aide, reported patients have been complaining about not getting services and the home health agency keeps admitting people. Staff L, Home Health Aide, reported patients are saying, for example, “Well you've admitted me but I haven’t had a bath yet in 2 weeks." Staff L, Home Health Aide, reported Staff M, RN, admitted someone 3 weeks ago and they wanted to know why the had not received help with bathing. Staff L, Home Health Aide, thought this was a problem with the newer people admitted for services, but did not provide any patient names that had been affected. On 6/21/23 at 2:56 PM, during an interview, Staff M, RN, denied being aware of any patients not receiving home health aide services as ordered by the patient's physician. Agency staff failed to provide services to meet the assessed needs of the patient and per the patient's PCP orders. On 6/21/23 at 3:59 PM, during an interview, the Administrator explained that missed home health aide visits were not fully due to being short-staffed. The Administrator reported their was some problems with miscommunication and scheduling, as well, and felt that they have now identified and fix the communication and scheduling issues. They reviewed the physician orders for all of the patients and have ensured they are now providing services to all patients at the physician ordered frequencies. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.