Every finding on record at Wayne County Treasury

A Recertification Survey was conducted by the Department of Inspections and Appeals from 1/29/24 through 1/31/24 and the home health agency was found to be operating out of compliance with the following standard level requirements of the Establishment of Emergency Preparedness.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the agency’s policies and procedures for their emergency preparedness plan and staff interview, the agency failed to ensure the development of a policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Failure to have a policy and procedure in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency’s emergency preparedness plan, updated most recently in March 2023, failed to include a policy/procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. During an interview on 1/31/24 at 10:30 AM, Staff A, RN, reported an inability to find a policy/procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The above information was shared with Staff A, RN and Staff B, RN. Agency staff provided no further information prior to the end of the survey.

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), §485.542(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, REHs at §485.542, "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 the agency’s emergency preparedness plan and agency staff interview, the agency failed to ensure training in emergency preparedness to existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 4 of 4 sampled employees (Staff A regular employee and Staff D, F, G contracted staff). Lack of emergency training for staff puts patients at an increased risk should an emergency situation arise and staff be needed to assist patients. Findings include: According to the agency’s emergency preparedness Training and Testing plan, dated March 2023, the agency will provide initial training in emergency preparedness policies and procedures to all new and existing staff and volunteers consistent with their expected roles. Provide emergency preparedness training at least annually either internally or externally with response partners. Maintain documentation of all training provided each fiscal year. Demonstrate staff knowledge of emergency procedures. Review of the agency’s emergency preparedness training revealed the following: 1. Staff A, Registered Nurse (RN), direct hire staff. The agency was unable to provide documentation of any emergency preparedness training. 2. Staff D, Home Care Aide, contracted staff. The agency was unable to provide documentation of any emergency preparedness training. 3. Staff F, Occupational Therapist, contracted staff. The agency was unable to provide documentation of any emergency preparedness training. 4. Staff G, Physical Therapist, contracted staff. The agency was unable to provide documentation of any emergency preparedness training. Interview with Staff A, Interim Administrator, on 1/30/24 at 3:30 PM, reported no documentation of staff trainings could be located for Staff A, D, F, and G. The above findings were shared with Staff A, RN, and Staff B, RN. No further information was provided prior to the end of survey.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the agency’s emergency preparedness plan and agency staff interview, the agency failed to conduct and/or document any exercises to test their emergency plan in 2022 and 2023. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: According to the agency’s emergency preparedness Training and Testing plan, dated March 2023, the agency would conduct training and testing that complies with federal and state laws. Review of the agency’s emergency preparedness testing and training information did not include any exercises in 2022 and 2023. Interview with Staff A, Registered Nurse, on 1/30/24 at 3:30 PM, reported no knowledge of when an event/exercise during 2022 and 2023. The above findings were shared with Staff A, RN, and Staff B, RN. No further information was provided prior to the end of survey.

The Iowa Department of Inspections and Appeals conducted a Recertification Survey from 1/29/24 through 1/31/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a census of 23 current patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, patient interview, and agency staff interview, the agency failed to ensure accurate and through completion of pertinent components of the initial comprehensive assessment for 2 of 3 sampled patients with wounds at start of care. (Patient #3 and #4.) Failure to accurately and thoroughly complete the comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. 2. Patient #4 had a start of care date of 3/21/23. a. The POC, dated 1/15/24 to 3/14/24, included orders for skilled nursing services. b. The update to the comprehensive assessment, dated 1?10/24, identified the patient had an abscess to the coccyx area. The assessment lacked documentation of an assessment of the abscess including measurements. c. The skilled nurse visit note, dated 1/25/24, included documentation the patient had a procedure on his/her abscess. The note lacked documentation of an assessment of the abscess area and provided no measurements.. The agency failed to complete an assessment including wound measurements for the patient's wound area. The above findings reviewed with Staff A, RN and Staff B, RN. The agency provided no further information prior to the end of the survey. Findings Include: During an interview with Staff A, Registered Nurse (RN), January 30, 2024 at 2 PM, She reported the agency does not have a current wound care policy in place, reported they were looking at 2 different policies, but had yet to implement one. Staff A, reported that the expectation for wound care assessment would be wound assessments be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment will include wound measurements (length x width x depth in centimeters). 1. Patient #3 had a start of care date, 1/11/24. Clinical record review revealed the following: a. The initial comprehensive assessment, dated 1/11/24, identified the patient had a wound with gangrene on the left foot and a diabetic ulcer on the right heel. The assessment lacked wound measurements for both wounds. b. Skilled nursing visit notes, dated 1/17/24, and 1/23/24, documented a general description of the wound on the left foot with gangrene, and the of the diabetic ulcer on the right heel, but lacked specific wound measurements of both wounds. c. During a home observation visit on 1-30-24, at 8:30 AM with staff B, surveyor observed wound care completed with no measurements obtained during the visit. During the home visit, a patient interview was completed with patient and spouse. The spouse reported the wound with gangrene is not improving, reported they were waiting on decision from physician on future treatment likely including partial amputation of the left foot. Agency failed to obtain baseline wound measurements on the initial comprehensive assessment and on subsequent skilled nurse visits.

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, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 8 sampled patients (Patients #1, #2, #4). 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: 3. Patient #2 had a start of care date of 12/28/2023. Home visit observation, clinical record review, and accompanying patient interviews revealed the following: a. The Plan of Care (POC), dated 12/28/23 - 2/25/24 included orders for skilled nursing services and medications for the patient. b. The Medication Profile, dated 1/5/24, included medications for the patient. c. During a home observation visit on 1-29-24, at 12:00 PM, with staff E, Physical Therapy Assistant, surveyor identified patient had medications beside his chair that were not included in the plan of care. Patient reported that he takes ibuprofen on a regular basis because the hydrocodone and tylenol were not controlling his pain, and that he used different analgesic muscle rubs and sprays to help with pain control. Patient also reported that on occasion he used melatonin to help him sleep. Agency failed to identify and document all medications on the plan of care and medication profile including ibuprofen, melatonin and analgesic muscle rubs and sprays the patient is self administering. The above findings were shared with staff A, RN and staff B, RN. No further information provided prior to the end of survey. 2. Patient #4 had a start of care date of 3/21/23. Clinical review revealed the following: a. The POC, dated 1/15/24 to 3/14/24, included the following DME: oxygen, wheelchair and bedside commode. b. The skilled nurse note, dated 1/10/24, included documentation the patient incontinent and required incontinent products. The agency failed to include the DME incontinent products to the POC> Patient #1 had a start of care date of 1/17/24. Clinical record review, home visit observation, and accompanying interviews revealed the following: a. The Plan of Care (POC), dated 1/17/24 to 3/16/24, included the following durable medical equipment (DME) used by the patient: Adult diapers, walker, cane, shower chair, hand-held shower, long handled sponge, and grab bars/safety rails. b. During a home visit observation on 1/29/24 at 2:00 PM, with Staff A, Registered Nurse (RN), the surveyor identified the following additional DME in the home: Medication cassette, scale, pulse oximeter, urinal, and nebulizer. c. Interview with Staff A, RN, during the home visit observation revealed that agency provided the medication cassette at start of care for medication set up and the scale is utilized weekly to weigh the patient. d. Interview will Pt #1 revealed pulse oximeter, urinal, and nebulizer have been utilized for “a long time” due to his health issues. The POC failed to identify the DME medication cassette, scale, pulse oximeter, urinal, and nebulizer.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 4 of 4 sampled patients with new verbal/interim orders. (Patients #1, #4, #6 and #7) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 4. Patient #7 had a start of care date of 12/5/22 Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 12/5/22 to 2/2/23, included orders for skilled nursing services and medications for the patient. b. Physician's interim order dated,12/21/22, included a change in the dosage of the medication Valsartan (to lower blood pressure) Order changed the dosage from 40 mg once a day in the morning to 20 mg once a day in the morning. c. Physicians Interim order dated, 1/12/23, included a change in the time of day the medication Valsartan 20 mg, was to be taken from morning to evening. d. Physicians interim order, dated 1/12/23, included a change in the frequency of the medication, Glipizide Extended release,(diabetes medication to lower blood sugar) 2 mg from one tablet every day to one tablet every other day. e. Physicians interim order, dated 1/2/24, included frequency for Physical Therapy Visits, for two times a week for two weeks. The agency failed to ensure the POC was updated to include all interim patient care orders for medications and visit frequencies. The above findings were reviewed with Staff A, RN and Staff B, RN , the agency presented no additional information prior to the end of the survey. 3. Patient #1 had a start of care date of 1/17/24. Review of the clinical record revealed the following: a. The POC, dated 1/17/24 to 3/16/24, included orders for skilled nursing services, aide services, and medications for the patient. b. The physician's order, dated 1/26/24 at 11:42 AM, included Aspirin 81 mg oral tablet 1 time a day, Vitamin D3 25 micrograms (mcg) capsule 1 time a day, and discontinue Prednisone (steroid) 20 mg oral tablet once a day. c. The physician’s order, dated 1/26/24 at 11:45 AM, included Thermotabs 287mg-180mg 1 tablet orally 3 times a day for 7 days (Start 1/26/24 End 2/1/24). d. The physician’s order, dated 1/26/24 at 11:49 AM included discontinue effective 1/26/24: Xalatan 0.005% ophthalmic solution apply 1 drop in each eye once a day. e. The physician’s order, dated 1/26/24 at 3:58 PM included discontinue effective 1/26/24 rosuvastatin (high cholesterol) 10mg capsule orally once a day and start rosuvastatin 20mg oral tablet once a day. The agency failed to ensure the POC was updated to include all patient care orders to reflect new medications (Aspirin, Vitamin D3, Thermotabs), changed doses (rosuvastatin), and discontinued medications (Prednisone, Xalatan). During an interview on 1/30/24 at 8:40 AM Staff A, Registered Nurse (RN) stated the agency did not complete updates to the Plan of Care to include new physician orders. 1. Patient #4 had a start of care date of 3/21/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/15/23 to 3/14/24, included orders for skilled nursing services and medications for the patient. b. The physician's order, dated 11/30/23 included Doxycycline (antibiotic) 120 milligrams (mg) 2 times a day for 15 days. The agency filed to ensure the POC was updated to include all patient care orders to include Doxycycline. 2. Patient #6 had a start of care date of 6/1/23 and discharge date of 6/20/23. Review of the clinical record revealed the following: a. The POC, dated 6/1/23 to 7/30/23, included orders for skilled nursing services. b. The physician's order, dated 6/20/23 included orders to decrease skilled nursing services to weekly and as needed. The agency filed to ensure the POC was updated to include all patient care orders to include a decrease in skilled nursing services.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on agency policy review, personnel file review and staff interview, the agency failed to ensure 1 of 3 sampled home care aides (Staff D), completed a home health aide training program that addressed all areas identified in the Medicare Conditions of Participation. The agency provided Home Health Aide services to 11 patients at the time of the survey and employed 4 Home Health Aide under contract. Failure to ensure Home Health Aides successfully complete competencies in required basic skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: The Medicare Conditions of Participation require home health agencies to ensure all newly hired home health aides are competent in all of the basic home health aide skills by successfully demonstrating competency in the performance of all of the "hands on" basic home health aide skills with a home health patient, exactly as these tasks will be performed with an actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently. The list of "hands on" basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tub and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation, positioning, nutrition and fluid intake and range of motion. Basic home health aide competencies may not be demonstrated using a mannequin, pseudo-patient or volunteer or by using verbalization or simulation. According to the agency policy titled “Home Care Aide Service”, dated 2/2022, each home care aide will have completed the necessary training as outlined by the Iowa Department of Public Health. Staff D, Home Health Aide, had a hire date of 7/27/22. Staff D’s personnel file lacked documentation of successful completion of training for the basic skills of hair shampooing in sink, tub, and bed and sponge, tub, and shower bath. On 1/31/24 at 10:30 AM, during an interview, Staff A, Registered Nurse (RN), reported no evidence to show Staff D, HHA, had completed training for the basic skills of hair shampooing in sink, tub, and bed and sponge, tub, and shower bath. Staff A, RN, and Staff B, RN, received the above findings. The agency provided no further information prior to the end of the survey.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview and policy review the agency failed to authorize in writing by the administrator and the governing body a qualified pre-designated person who assumes the same responsibilities and obligations as the administrator. Failure to authorize a pre-designated person to assume the same responsibilities and obligations puts agency patients at risk for receiving inconsistent services. Findings include: During an interview on 1/29/23 at 1:40 PM Staff A, Registered Nurse (RN) stated the Administrator on vacation and considered the Clinical Manager as well. Staff A identified she would be the back-up for the Administrator if she is not in the office but had no title and not identified in writing. Review of the Governing Body Minutes, dated 3/13/19, included the Board of Health approval of the Administrator. The note failed to included a pre-designated person to assume the same responsibilities and obligations as the administrator. Staff A, RN, and Staff B, RN, received the above findings. The agency provided no further information prior to the end of the survey.

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 1 of 3 sampled patients with transfers/ discharges (Patients #8). 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: Patient #8 had a start of care date of 2/16/14. Clinical record review revealed: a. The Plan of Care, dated 11/25/23 to 1/26/24, included orders for skilled nursing services. b. The transfer assessment, dated 12/29/23, documented the patient was transferred to the hospital. c. Review of the medical record lacked documentation of a transfer summary. The agency failed to complete a transfer summary. The above information provided to Staff A, Registered Nurse (RN) and Staff B, RN. No further information provided prior to the end of the survey.

The recertification survey, dated 1/19/2021 through 1/21/2021, identified the home health agency was operating out of compliance with the following standard level emergency preparedness regulations.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and policies, clinical record review and agency staff interview, the agency failed to ensure the clinical record included documentation staff developed, reviewed and/or revised the patient's individualized emergency plan as part of each comprehensive assessment for 2 of 7 sampled patients (Patients #4 and #5), and the agency failed to ensure the emergency plan had a written policy and procedure that addressed the need to include the completion of an individualized emergency preparedness plan as part of each comprehensive assessment for the patient. The agency provided services to 36 patients at the time of the survey. Failure to ensure agency staff completed an individualized emergency preparedness plan as part of the comprehensive assessment for each agency patient based on policy and procedures found in the emergency preparedness plan, placed staff and patients at risk for being unaware and unprepared to respond in a timely and effective manner to potential natural or man-made disasters the patient may encounter. Findings include: According to the agency's policy, titled Home Care Program Emergency Preparedness Plan, dated 6/17/19, on admission, the admitting nurse will assign each patient a priority code, indicating that patient's emergency rating. Obtain a list of contact numbers, and discuss emergency planing options with the patient and family. All information will be kept in the patient's electronic chart. The policy failed to identify the individualized emergency plan must be included as part of the comprehensive assessments. On 1/20/21 at 10:57 AM, during an interview, the Clinical Manager reported staff should be reviewing the patient's individualized emergency preparedness plan with each update to the comprehensive assessment completed at recertification. He was not sure if this was happening all of the time or if staff were documenting they were doing it. 1. Patient #4 had a start of care date of 6/19/2020. Review of the clinical record revealed the following: The updates to the comprehensive assessment, completed at the time of resumption of care, dated 7/8 and 7/21/2020, and at the time of recertification, dated 8/13 and 10/15/2020, lacked documentation the nurse completing the comprehensive assessments reviewed the patient's individualized emergency preparedness plan. 2. Patient #5 had a start of care date of 7/23/2020. Review of the clinical record revealed the following: The update to the comprehensive assessment, completed at the time of recertification, dated 9/16/2020, lacked documentation the nurse completing the comprehensive assessment reviewed the patient's individualized emergency preparedness plan. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the agency emergency preparedness plan policy and staff interview, the agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The agency reported a current census of 36 patients. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed hospice patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: According to the agency's policy, titled Home Care Program Emergency Preparedness Plan, dated 6/17/19, if a patient requires transportation, staff may assist the patient with contacting friends or family to assist with transportation, or transportation can be arranged through the county emergency planners, If the patient is injured and needs transport, staff will contact an emergency supervisor through the emergency operations center. The policy failed to specify the need to inform State and local officials of homebound patients in need of evacuation in the event of an emergency situation. On 1/20/21 at 2:12 PM, during an interview, the Administrator confirmed the agency's emergency preparedness plan failed to include a policy and procedure to address informing State and local officials of homebound patients in need of evacuation in the event of an emergency situation. Agency staff provided no further information prior to the end of the survey.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the agency emergency preparedness plan and related policies and staff interview, the agency failed to ensure the written emergency preparedness plan included procedures to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The agency reported a current census of 36 patients. Failure to have procedures in place to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency staff and patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: According to the agency's policy, titled Home Care Program Emergency Preparedness Plan, dated 6/17/19, on duty agency staff must check in if there is an emergency situation or disaster, and agency staff must contact patients who are potentially effected by the emergency. The policy failed to include a procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. On 1/20/21 at 2:12 PM, during an interview, the Administrator confirmed the agency's emergency preparedness plan failed to include a policy and procedure to address informing State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Agency staff provided no further information prior to the end of the survey.

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 agency training documentation and staff interview, the agency failed to ensure training in emergency preparedness for 4 of 4 contracted therapy staff (all contracted since prior to the last survey, dated 1/3/18), 3 of 3 current contracted home health aide staff, 2 of 2 terminated contracted home health aide staff (both terminated in 2020) and 3 of 3 sampled hired employees ( Staff B, Staff I and Staff J). The agency reported a total of 9 hired 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 1/20/21 at 3:35 PM, during an interview with the Administrator, the surveyor asked to review emergency preparedness training for contracted therapy and home health aide staff. The Administrator reported she was unaware of the need to provide emergency preparedness training for contract staff and this had not been done. 1. Staff B, Clinical Manager, had a hire date of 11/29/16. Review of emergency preparedness training documentation revealed a lack of documentation of training since prior to 2018 for Staff B. 2. Staff I, Registered Nurse, had a hire date of 10/5/2020. Review of the emergency preparedness training documentation revealed a lack of documentation of any training for Staff I. 3. Staff J, Clerk, had a hire date of 6/11/19. Review of the emergency preparedness training documentation revealed a lack of documentation of any training for Staff J. On 1/20/21 at 3:56 PM, during an interview, the Administrator explained she had reviewed emergency plan policies and procedures with hired staff, but she did not maintain documentation of any of the trainings. She reported when she started in 2019, she could not find documentation of staff training on the agency's emergency preparedness plan. Agency staff provided no further information prior to the end of the survey.

The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 1/19/2021 through 1/21/2021. The recertification survey found the agency to be operating out of compliance with the following standard level home health regulations:

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff completed the comprehensive assessment at the start of care by the fifth day after the start of care for 2 of 7 sampled patients (Patients #3 and #6). The agency reported a current census of 36 patients. Failure to complete comprehensive assessments at the start of care 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 policy, titled Legal Aspects of the Clinical Record, dated 3/18/2020, identified agency staff will complete the comprehensive assessment in a timely manner and no later than 5 calendar days after the patient's start of care. On 1/20/21 at 8:32 AM, during an interview, the Clinical Manager reported Staff C, Registered Nurse (RN) or himself, typically take all new referrals to ensure the patient is seen timely and they complete the comprehensive assessment timely. 1. Patient #3 had a start of care date of 1/14/21. Review of the clinical record revealed the following: The comprehensive assessment completed at the start of care, dated 1/14/21, included documentation of a signature of completion by Staff C, RN, dated 1/20/21 (1 day late). On 1/21/21 at 8:12 AM, during an interview, Staff C, RN, reported there was a billing issue, and the agency's clerk told her not to lock the assessment. 2. Patient #6 had a start of care date of 9/15/2020 and discharged from agency services on 11/3/2020. Review of the clinical record revealed the following: The comprehensive assessment completed at the start of care, dated 9/15/2020, included a documentation of a signature of completion by Staff C, RN, dated 9/26/2020 (6 days late). On 1/20/21 at 12:45 PM, during an interview, Staff C, RN, reported she did not know why the comprehensive assessment was signed late. On 1/21/21 at 8:13 AM, during an interview, Staff C, RN, showed the surveyor in the system where she completed the OASIS (Outcome and Assessment Information Set) portion of the start of care comprehensive assessment on 9/16/2020. She could not explain why the comprehensive assessment visit note, which contained the patient's physical assessment information including pulse, blood pressure, respiration rate, temperature, blood oxygen saturation level, height and weight, was signed on 9/26/2020. She reported she should have signed both the OASIS and the comprehensive assessment visit note at the same time. The Administrator and Clinical Manager received the above findings and agency staff provided no further 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 clinical record review, agency policy review, home visit observation, patient interview and agency staff interview, the agency failed to perform complete and accurate drug regimen reviews with corresponding comprehensive assessments for 1 of 3 sampled patients (Patient #3) with a home visit observation. The agency reported a census of 36 patients at the time of the survey. Failure to perform the drug regimen review in a complete and accurate manner places the patient at risk for delayed identification of medication concerns. Findings include: Review of the agency's policy, titled Medication Policy, dated 7/15/2020, identified agency staff will review all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, ineffective drug therapy, significant side effects, drug allergies and contraindicated medications. On 1/20/21 at 8:32 AM, during an interview, the Clinical Manager reported a registered nurse (RN) completes a drug regimen review (DRR) with each comprehensive assessment. He reported agency staff documented the DRR on the Plan of Care (POC). Patient #3 had a start of care date of 1/14/21. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 1/14/21, included documentation the RN completed a DRR. The POC, dated 1/14/21 to 3/14/21, included physician orders for medications. The medications identified on the POC included orders for Cyclobenzaprine 10 milligrams (mg) 1 tab daily as needed by mouth, Tramadol 50 mg 1 tab every 6 hours as needed by mouth. The DRR documented on the POC identified a potential severe interaction between Tramadol and Cyclobenzaprine. On 1/21/21 at 10:55 AM, in an interview, during a home visit observation, the patient reported the patient's primary care physician took the patient off Cyclobenzaprine on 12/6/2020 and Tramadol 1/11/2021 (both prior to the start of care). The patient also reported the physician started the patient on Aspirin 81 mg twice per day by mouth on 1/13/21. The patient showed the surveyor the bottle of Aspirin with 81 mg tablets. The DRR completed with the comprehensive assessment at the start of care failed to include accurate information of the medications the patient was using. The Administrator and 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 and agency 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 #2 and #4). The agency reported a census of 36 patients at the time of the survey. 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: On 1/20/21 at 8:32 AM, during an interview, the Clinical Manager reported the electronic medical record system tracked and notified staff when patients were due for an update to the comprehensive assessment at the time of recertification. 1. Patient #4 had a start of care date of 6/19/2020. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 8/18/2020 to 10/16/2020 and 10/17/2020 to 12/15/2020, included orders for skilled nursing services. b. The update to the comprehensive assessment completed at the time of recertification, dated 10/15/19, included documentation of a signature of completion by the Clinical Manager, dated 10/19/2020 (3 days late). On 1/20/21 at 10:15 AM, during an interview, the Clinical Manager confirmed he signed the updated to the comprehensive assessment completed at the time of recertification 3 days after the new certification period had started. 2. Patient #2 had a start of care date of 9/3/2020. Clinical record review revealed the following: a. The Plans of Care, dated 11/2/2020 to 12/31/2020 and 1/1/21 to 3/1/21. b. The update to the comprehensive assessment at recertification, dated 12/28/2020, identified a document completion date of 1/6/21, 6 days after the new episode of care began. c. The communication log lacked documentation to identify the document was locked during the required time frame. During an interview on 1/21/21 at 10:00 AM, the Administrator agreed the assessment was completed late. The above stated findings were reviewed with the agency Administrator. The agency provided no additional information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician-ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure the timely completion of all pertinent components of the update to the comprehensive assessment at the resumption of care within 48 hours of the agency's knowledge of the patient's return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #4). The agency reported a current census of 36 patients, including 5 patients in the last 6 months (since 7/1/2020) with an update to the comprehensive assessment at the resumption of care. Failure to complete an update of the comprehensive assessment at the resumption of care in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: On 1/20/21 at 8:32 AM, during an interview, the Clinical Manager reported agency staff call the hospital and try to track the patients to ensure staff can go out immediately when the hospital discharges the patient. Patient #4 had a start of care date of 6/19/2020. Review of the clinical record revealed the following: a. A Plan of Care (POC), dated 6/19/2020 to 8/17/2020, included orders for skilled nursing and physical therapy services. b. A Transfer OASIS (Outcome and Assessment Information Set), dated 6/25/2020, included documentation a hospital admitted the patient on 6/23/2020. c. A Communication Log note, dated 6/29/2020, included documentation the Clinical Manager found out the hospital had discharged the patient on 6/25/2020. The patient's spouse did not want agency staff to come see the patient until 7/2/2020. The note lacked any documentation the Clinical Manager contacted the patient's physician about the need to delay the resumption of care. d. A Communication Log note, dated 7/2/2020, included documentation the Clinical Manager was unable to reach the patient or the patient's spouse. The note lacked any documentation the Clinical Manager contacted the patient's physician about the inability to complete the resumption of care. e. A Communication Log note, dated 7/6/2020, included documentation the Clinical Manager spoke with the spouse of the patient. The spouse did not want agency staff to visit until 7/8/2020. The note lacked any documentation the Clinical Manager contacted the patient's physician about the inability to complete the resumption of care. f. An update to the comprehensive assessment completed at the time of resumption of care, dated 7/8/2020, included a signature of completion, dated 7/9/2020 (8 days late). On 1/20/21 at 11:46 AM, during an interview, the Clinical Manager reported he thought he contacted the patient's physician to notify the physician of the delay in the resumption of care, but he did not have documentation of this. Agency staff failed to complete the update to the comprehensive assessment at the time of resumption of care within 48 hours of knowledge of the patient's discharge from the hospital or obtain an order from the physician to delay the resumption of care based on patient and family preference. The Administrator and 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 may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and patient interview, the agency failed to ensure agency staff accurately completed all components comprising the Plan of Care, including identifying all supplies/equipment used by the patient for 3 of 7 sampled patients (Patients #1, #3 and #4). The agency reported a current census of 36 patients at the time of the survey. 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: Review of the agency's policy, titled Registered Nurses Instructions for Plan of Care, dated 03/2020, identified the registered nurse was to list all durable medical equipment and supplies used on the plan of care. 1. Patient #1 had a start of care date of 1/7/21. Clinical record review revealed the following: The Plan of Care, dated 1/7/21 to 3/7/21, included crutches, grab bars, home blood glucose monitor, urinal, ramp, shower chair and toilet riser as medical equipment and supplies used by the patient. During a home observation visit on 1/20/21 at 10:10 AM, with Staff C, Registered Nurse (RN), the patient reported a concern with the walking boot that was obtained during the patients hospitalization prior to home health care services. The patient reported heel pain possibly increased from the walking boot and the plan to obtain sheepskin to pad the walking boot for comfort. The Plan of Care failed to identify all medical equipment and supplies used by the patient.2. Patient #3 had a start of care date of 1/14/2021. Review of the clinical record revealed the following: The Plan of Care (POC), dated 1/14/2021 to 3/14/2021, identified the patient used the following medical equipment and supplies: grab bars, ramp, shower chair, toilet riser and walker. On 1/21/21 at 10:55 AM, during a home visit observation, Staff L, Physical Therapist, directed the patient to walk with the patient's cane down and back up the front steps. In an interview, during the same home visit observation, the patient explained he/she was recently hospitalized due to hip replacement surgery reported having used the cane while at the hospital prior to discharging (just prior to the home health agency admission) in order to walk up and down steps. The patient also reported the use of a weekly medication box to set up the patient's medications. The POC failed to identify all medical equipment used by the patient. 3. Patient #4 had a start of care date of 6/19/2020. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 6/19/2020, and the updates to the comprehensive assessment completed at the time of recertification, dated 8/13, 10/15 and 12/15/2020, identified the patient was incontinent of urine. The updates to the comprehensive assessment completed at the time of recertification, dated 8/13 and 12/15/2020, also identified the patient used incontinent briefs. b. The POCs, dated 6/19/2020 to 8/17/2020, 8/18/2020 to 10/16/2020, 10/17/2020 to 12/15/2020 and 12/16/2020 to 2/13/2021, failed to identify the patient used incontinent briefs. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, family interview and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 4 of 6 sampled patients with interim/verbal orders. (Patients #3, #4, #5 and #6) The agency reported a census of 36 patients at the time of the survey. Failure to update the Plan of Care increased the potential for inaccurate provision of care. Findings include: Review of the agency's policy, titled Legal Aspects of Clinical Records, dated 3/18/2020, identified interim physician orders are created when there are order changes, which also creates a Plan of Care update; the interim physician order is completed and sent to the physician for signature and date. When the registered nurse completes a recertification the nurse will check that order changes have been reflected on the new Plan of Care.On 1/20/21 at 8:32 AM, during an interview, the Clinical Manager explained when agency nursing staff received an interim physician order (IPO), they put the order in the electronic medical record (EMR) and write "refer to the IPO" on the updated Plan of Care (POC). If a patient has therapy orders (physical, occupational or speech), the nurse is responsible for putting the order in the EMR and the update on the POC. The Clinical Manager reported IPOs were put in the computer as soon as staff received them. 1. Patient #3 had a start of care date of 1/14/21. On 1/20/21, review of the clinical record revealed the following: a. The POC, dated 1/14/2021 to 3/14/2021, included orders for skilled nursing services and physical therapy (PT) services to evaluate and treat. b. A PT evaluation note, dated 1/19/21, included documentation the therapist obtained a verbal physician order for PT services 2 times per week for 4 weeks for strengthening, transfers and gait training. The PT evaluation note included a faxed date to the home health agency of 1/20/21 at 8:08 AM. On 1/21/21 at 11:45 AM, the surveyor requested the updated POC from the Office Manager. She provided a POC the nurse had updated on 1/20/21. On 1/21/21, review of the updated POC revealed the nurse had not included the new PT services orders for 2 times per week for 4 weeks for strengthening, transfers and gait training. 2. Patient #4 had a start of care date of 6/19/2020. Review of the clinical record revealed the following: a. A POC, dated 10/17/2020 to 12/15/2020. b. An interim physician order, dated 10/23/2020, included an order for a change in medication from Carbidopa-Levodopa 25-250 milligrams (mg) three times per day orally to one time per day. An updated POC, dated 10/26/2020, included the following: "New orders: refer to IPO dated 10/23/2020". The updated POC included the an order for Carbidopa- Levodopa 25-250 mg 1 time per day, but failed to include the order for the discontinued dosage. c. An interim physician order, dated 11/13/2020, included an order for a change in medication from Spironolactone 25 mg daily orally to 12.5 mg daily. An updated POC, dated 11/17/2020, included the following: "New orders: refer to IPO dated 11/13/2020". The updated POC included an order for Spironolactone 12.5 mg daily, but failed to include the order for the discontinued dosage. d. An interim physician order, dated 11/23/2020, included an order to reduce skilled nursing services from 1 to 2 visits weekly to 1 to 2 every other week. An updated POC, dated 11/23/2020, included the following: "New orders: refer to IPO dated 11/23/2020". The updated POC failed to specify the new order the physician gave the agency nurse. e. An interim physician order, dated 12/15/2020, included an order to discontinue Vitamin B-12 500 micrograms (mcg) daily orally and an order to start a multivitamin 1 tablet daily by mouth. The POC, dated 12/16/2020 to 2/13/2021, included the order for the multivitamin 1 tablet daily by mouth, but failed to discontinue the Vitamin B-12. 3. Patient #5 had a start of care date of 7/23/2020. Review of the clinical record revealed the following: a. A POC, dated 7/23/2020 to 9/20/2020, included an order for skilled nursing services 1 to 2 times per week. An interim physician order, dated 8/31/2020, included an order to decreased skilled nursing visits to 1 to 2 times every other week. An updated POC, dated 9/1/2020, included the following: "New orders, see the IPO with date created of 9/1/2020". The updated POC failed to specify the new order the physician gave the agency nurse. b. A POC, dated 11/20/2020 to 1/18/2020, included an order for home health aide services 1 to 2 visits per week. An interim physician order, dated 1/5/2021, included an order to discontinue home health aide services due to the patient being able to complete activities of daily living tasks independently. On 1/20/21, review of the clinical record revealed a lack of an updated POC. 4. Patient #6 had a start of care date of 9/15/2020 and discharged from agency services on 11/3/2020. Review of the clinical record revealed the following: a. A POC, dated 9/15/2020 to 11/13/2020, included orders for skilled nursing services, home health aide services and PT services to evaluate and treat. b. A PT evaluation note, dated 9/16/2020, included documentation the therapist obtained a verbal physician order for PT services 1 time week 1 and then 2 times per week for 4 weeks for strengthening, transfers and gait training. The clinical record lacked an updated POC with the interim physician order for PT services, dated 9/16/2020. c. An interim physician order, dated 9/25/2020, included orders to start an Iron tablet 325 mg daily by mouth, Lasix 40 mg daily by mouth, discontinue Furosemide 20 mg daily by mouth, and for the nurse to draw a complete blood count (CBC) and Basic Metabolic Panel (BMP) on 10/9/2020. An updated POC, dated 9/29/2020, included the following: "Refer to IPO dated 9/25/2020". The medication list on the POC included the new medications, but failed to include the order for the discontinued medication and lab draws. d. A PT reassessment visit note, dated 10/5/2020, included a physician order for PT services 2 times per week for 3 weeks for strengthening, transfers and gait training. The clinical record lacked an updated POC with the interim physician order for PT services, dated 10/5/2020. e. An interim physician order, dated 10/11/2020, included an order to hold the lab draw ordered for 10/9/2020 (CBC and BMP). An updated POC, dated 10/11/2020, failed to include the order to hold lab draws on 10/9/2020. f. A PT discharge summary, dated 10/21/2020, included a physician order to discharge the patient from PT services. The clinical record lacked documentation of an updated POC with the PT discharge order. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the the end of the survey.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on agency staff interview, home visit observation and admission packet review, the agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address). The agency failed to provide this information for 2 of 2 sampled patients, with a home visit observation (Patients #1 and #3) and an agency admission packet in the home. The agency reported a census of 36 patients at the time of the survey. Failure to provide the contact information for the agency's clinical manager left the patients without the needed information to contact the agency clinical manager for any concerns about their services. Findings include: Review of the agency's admission packet identified forms that lacked the agency clinical manager's name, telephone number and/or email address. During an interview on 1/19/21 at 3:03 PM, the Administrator reported she had reviewed the admission packet and agreed the clinical manager's name and contact information was not in the admission packet. 1. Patient #1 had a start of care date of 1/7/21. On 1/20/21 at 10:10 AM, the surveyor accompanied Staff C, Registered Nurse, on a home observation visit. During the home visit, the surveyor requested review of the agency's folder kept by the patient. During review of the folder, which included all paper work given to the patient by the agency, the surveyor found no documentation identifying the name and contact information of the clinical manager. The surveyor observed no documentation including the name and contact information of the clinical manager posted anywhere in the patient's home. 2. Patient #3 had a start of care date of 1/14/21. Review of the clinical record revealed the following: A Plan of Care (POC), dated 1/14/2021 to 3/14/2021, included orders for skilled nursing and physical therapy services. On 1/21/21 at 10:55 AM, during a home visit observation with Staff L, Physical Therapist, the surveyor reviewed the admission packet left in the patient's home by agency staff. The admission packet included name and contact information for the agency's Administrator, but lacked the name and contact information for the Clinical Manager. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on clinical record review, home visit observation and staff interview, the agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 1 of 1 sampled patients with medication set up (Patient #2). The agency reported a current census of 36 patients. Failure to follow agency expectations and accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: Patient #2 had a start of care date of 9/3/2020. Observation during a home visit with Staff C, Registered Nurse, on 1/20/21 at 1:07 PM, revealed the nurse opened the locked alarmed medication dispenser in preparation of setting up the patient's medications. Staff C picked up the medication bottles from a bag the patient stores medications in, opened the bottles, used a gloved hand to place medications in the correct dispensing slots, replaced the cap on the bottles and set the bottles on the kitchen counter. While Staff C was setting up the amitriptyline, a tablet was dropped on the kitchen floor. Staff C picked up the pill from the kitchen floor with a gloved hand and threw the tablet in the trash. Staff C continued to set up the medications using the soiled glove. Staff C did not remove the soiled glove and put on clean gloves. During an interview on 1/21/21 at 10:00 AM, the Administrator confirmed Staff C, after picking the medication tablet up from the floor, should have removed the soiled gloves and put on new gloves. The above stated findings were reviewed with the agency Administrator. The agency provided no additional information prior to the end of the survey.

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 clinical record review, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions, assigned tasks and maintained pertinent current information in the patient record for 2 of 7 sampled patients (Patients #6 and #7). The agency reported a census of 36 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patient's 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: Review of the agency's policy, titled Wound Policy, dated 03/2020, identified weekly wound assessment should have the following descriptions: date of wound assessment, wound location, wound size and wound depth. Review of the agency policy, titled Documentation, dated 5/20/2020, entries will be made in a timely manner within 2 business of the visit. During an interview on 1/20/21 at 8:32 AM, the Clinical Manager reported wounds are measured at least weekly, wound measurements will include length, width and depth. 1. Patient #7 had a start of care date of 8/20/19 and a discharge date of 9/16/19. Clinical record review revealed: a. The Plan of Care (POC), dated 8/20/19 to 10/18/19, included orders for skilled nursing to complete daily dressing changes to right lower leg. b. The skilled nursing visit note, dated 8/20/19, included documentation of right lower leg wound length and width measurements but lacked documentation of wound depth measurements. c. The skilled nursing visit notes, dated 8/26 and 28/19 and 9/1/19, included: i. documentation of a blister on the left shin wound length measurement but lacked width and depth measurements; ii. documentation of right outer leg lesion wound length and width measurement but lacked depth measurement. d. The skilled nursing visit note, dated 9/4/19, included documentation of right leg wound length and width but lacked documentation of depth measurement. The clinical record lacked documentation of required wound measurements. 2. Patient #6 had a start of care date of 9/15/2020 and discharged from agency services on 11/3/2020. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 9/15/2020 to 11/13/2020, included orders for home health aide services 2 to 3 times per week. The home health aide care plan included registered nurse (RN) instructions to the home health aide to complete the task of assisting the patient with either a shower or a sponge. The home health aide visit notes, dated 9/28, 10/9, 10/26 and 10/30/2020, included instructions to the home health aide to assist the patient with a shower or sponge bath on the same line. The home health aide completing the task documented with a check mark to indicate the completion of the task, but the home health aide failed to specify which task the home health aide assisted the patient with, a shower or a sponge bath. On 1/21/21 at 8:25 AM, during an interview, the Administrator explained agency nursing staff needed to put the assigned task of shower or sponge bath on separate lines. b. A discharge comprehensive assessment visit note, dated 11/3/2020, included documentation of signature of completion, dated 11/25/2020 (22 days later). On 1/20/21 at 8:32 AM, during an interview, the Clinical Manager reported agency staff needed to complete visit notes no later than the next working day. On 1/20/21 at 3:37 PM, during an interview, the Clinical Manager explained he completed the visit note the same time as the discharge summary and OASIS (Outcome and Assessment Information Set), both signed complete on 11/4/2020. He reported he missed signing the visit note. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on patient clinical record review, agency policy review and staff interview the hospice failed to ensure all clinical entry notes included a staff signature with title for 5 of 7 sampled patients (Patients #1, #2, #3, #5 and #6). The agency reported a current census of 36 patients at the time of the survey. Failure to ensure all clinical record documentation was dated, timed and signed with staff title, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: According to the agency policy titled, Legal Aspects of Clinical Record, dated 3/18/2020, identified the nurse who signs printed or electronic records or documents are taking responsibility for the content. When a nurse signs her/his name on a patient's record, she/he should use first initial, last name, followed by RN (registered nurse), followed by the date and time handwritten documentation is completed. Electronic signatures are acceptable. During an interview on 1/21/21 at 10:00 AM the Administrator reported the staff title was entered in the computer but was not printing on the documents completed by staff. The agency will try and figure out why this is happening and they may need to contact the electronic medical record provider for assistance. 1. Patient #1 had a start of care date of 1/7/21. Clinical record review revealed the skilled nursing visit notes, dated 1/7/21 and 1/14/21, included the name of the author of the document but lacked the title of the author making the authentication of the documents incomplete. 2. Patient #2 had a start of care date of 9/3/2020. Clinical record review revealed the skilled nursing visit notes, dated 11/16, 11/23, 12/2, 12/10, 12/17, 12/23, 12/28/2020; and 1/7 and 1/14/21; included the name of the author of the document but lacked the title of the author making the authentication of the documents incomplete.3. Patient #3 had a start of care date of 1/14/21. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 1/14/21, included documentation of an electronic signature of completion, but lacked a title of the person signing the document. b. A physical therapy evaluation note, dated 1/19/21, included documentation of a handwritten signature, but lacked the title of the person completing the note. 4. Patient #5 had a start of care date of 7/23/2020. Review of the clinical record revealed the following: The skilled nursing visit notes, dated 11/16, 12/1, 12/15, 12/28/20, 1/12 and 1/14/21, included documentation of an electronic signature of completion, but lacked a title of the person signing the documents. On 1/21/21 at 8:25 AM, during an interview, the Administrator reported she thought the issue with the electronic signature not including the title for some of the nurses had something to do with one of the nurses being newer and one of the other nurses just being newly returned to work for the agency. 5. Patient #6 had a start of care date of 9/15/2020 and discharged from agency services on 11/3/2020. Review of the clinical record revealed the following: a. The skilled nursing visit notes, dated 9/15 and 10/9/2020, included documentation of an electronic signature of completion, but lacked a title of the person signing the documents. b. The physical therapy visit notes, dated 9/16, 9/23, 10/5 and 10/21/2020, included documentation of a handwritten signature, but lacked the title of the person completing the notes. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.